Every finding on record at Marlora Post Acute Rehab Hosp

Based on interview and record review, the facility failed to implement its abuse policy and procedure for one of three sampled residents (Resident1) when Resident 1 was identified to have injuries of unknown origin. This failure had the potential to place Resident 1 and all residents in the facility at risk for unrecognized abuse, ongoing harm, and an unsafe environment.Findings:During a review of Resident 1's admission Records, the admission Records indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including left knee osteoarthritis (disease in which the tissues in the joint break down over time), difficulty walking and muscle weakness.During a review of Resident 1's History and Physical (H&P), the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of the facility's radiology (x-ray medical imaging test to picture the inside of the body) results report of the left knee dated 7/20/2026, the radiology report indicated no evidence of acute fracture (broken bone), dislocation, or joint effusion (the buildup of excess fluid in or around a joint capsule) .The report indicated moderate arthritic (a condition often characterized by inflammation or swelling of one or more joints) changes of the knee without acute bony injury.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 8/15/2026, the MDS indicated Resident 1 required substantial or maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) when rolling from left to right, from sitting to lying and from lying to sitting on the side of the bed and dependent (helper does all the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) with bed to chair transfers.During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form dated 8/15/2026, the SBAR indicated on 8/15/2026 at 8:30 a.m., Resident 1 notified staff of resident's dislocated left knee requiring hospitalization based on Computed Tomography (CT - Imaging test used to detect internal injuries) scan during resident's routine appointment on 8/14/2026.During a review of the General Acute Care Hospital (GACH) Orthopedic (medical specialty focused on the diagnosis, treatment, prevention, and rehabilitation of conditions involving the musculoskeletal system) Surgery Consultation Note dated 8/14/2026, the GACH note indicated Resident 1 had a preoperative exam ( a health evaluation done before surgery) of the left knee prior to planned total knee arthroplasty (knee replacement surgery). The GACH note indicated Resident 1 remains severely limited functionally and continues to ambulate (walk) very little. The Note indicated resident was markedly deconditioned (decline in physical and mental function) and remains extremely anxious regarding her knee, walking, physical therapy, and the upcoming surgery. The Note indicated light touching or examination of the knee causes significant apprehension and distress.During a review of GACH CT scan of Resident 1's left knee dated 8/15/2026, the CT scan findings indicated Posterior subluxation of tibia with respect to femur (partial dislocation of knee joint). Impaction (compression) fracture of the lateral tibial plateau and posterior lateral femoral condyle (key bone structures that form the outside part of your knee joint). Suspect nondisplaced fracture of the fibular head (a crack in the top part of the outer leg bone near the knee).During an interview with Registered Nurse (RN) 1 on 8/27/2026 at 2:47 p.m., RN 1 stated on the morning of 8/15/2026, Resident 1 informed him of dislocated left knee as seen on CT scan from a routine pre-operative appointment at the hospital on 8/14/2026. RN 1 stated Resident 1 had no witnessed falls and that the resident required two-person assistance with mobility. RN 1 stated Resident 1 would call staff for assistance and did not attempt to move on her own due to pain and limited mobility.During a follow up interview with Registered Nurse (RN) 1 on 8/28/2026 10:28 a.m., RN 1 stated he immediately notified the Director of Nursing (DON), physician, and family member (FM) of incident involving left knee injury of unknown cause. RN 1 stated he coordinated the transfer of Resident 1 to the hospital on 8/15/2026 at 12:30 p.m. for further evaluation. RN 1 stated for any injuries of unknown origin, staff must report to appropriate personnel following the chain of command so administration can investigate cause of injury right away. RN 1 stated not following proper procedures can potentially place Resident 1's safety at risk.During concurrent interview and record review on 8/28/2026 at 10:42 a.m. with the Director of Nursing (DON), the incident report electronically sent to State agency on 8/16/2026 at 9:36 p.m. was reviewed with the DON. The DON stated RN 1 informed her of Resident 1's left knee injury of unknown origin on 8/15/2026 at 10:43 a.m. The DON stated she conducted an onsite investigation and then subsequently reported the incident to the State agency on 8/16/2026. The DON stated that there were no witnessed falls or reported incidents leading up to Resident 1's left knee injury. The incident report sent by the DON indicated The injury could have occurred during routine daily patient care, including participation in therapy sessions. The DON stated that the protocol for reporting injuries of unknown source and unusual occurrence included notification of appropriate agencies and administrator immediately and to continue with investigations. The DON stated she reported this incident to the State agency by electronic mail due to unsuccessful attempts at faxing documents. The DON stated there were no calls made or any other forms of communication attempted, and that no other outside agencies were notified of the incident involving Resident 1's left knee injury.During a follow up interview on 8/28/2026 at 12:10 p.m., with the DON, the DON stated that she was aware of facility's abuse reporting and investigating policies and federal regulations to report all possible abuse including injuries of unknown cause immediately or within two hours of discovery. The DON stated that it was important to report incidents involving injuries of unknown origin to appropriate agencies within the time frame to protect residents from further harm. The DON stated if abuse reporting and investigating policies and procedures were not followed, situations can potentially worsen or get complicated leading to unsafe environment for residents.During an interview on 8/28/2026 at 12:15 p.m., with the Administrator (ADM), the ADM stated the DON notified him of the incident involving Resident 1's left knee injury of unknown source on 8/15/2026 around 11:00 a.m. The ADM stated the incident was investigated as an unusual occurrence rather than an abuse case, which was why it was not reported immediately or within the required two-hour window. The ADM stated Resident 1's injury could potentially be related to the resident's underlying disease process, although the facility could not confirm this. The ADM stated injuries of unknown origin may signal possible abuse and were required to be reported within two hours of discovery. He stated that failing to report such incidents within the mandated timeframe could allow potential abuse to continue.During a review of the facility's policies and procedures (P&P) titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised 8/25/2025, the P&P indicated All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. 2. Incidents resulting physical harm, notify local law enforcement immediately or as soon as possible but no later than 2 hours. Provide written notice of the incident within 2 hours to the state agency, ombudsman, and local law enforcement. 5. Immediately is defined as: a. within two hours of an allegation involving abuse or result in physical harm/serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in physical harm/serious bodily injury. 8. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents.During a review of the facility's policies and procedures (P&P) titled Unusual Occurrence Reporting dated 2001, the P&P indicated that As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors. 2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations.

The facility failed to ensure one of three sampled resident's (Resident 1) medical record did not contain Resident 7's document.This failure is a breach of privacy and confidentiality.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 8/29/2022 with diagnoses including epilepsy (brain disorder that causes repeated unprovoked seizures [sudden abnormal rush of electrical activity to the brain]). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 6/3/2026, the MDS indicated Resident 11 ability to think was intact. During a review of Resident 7's admission Record, the admission Record indicated the facility admitted Resident 7 on 8/4/2026 with diagnoses including left hand contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion).During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7's ability to think was moderately impaired. During a concurrent interview and record review on 8/24/2026 at 12:19 p.m., with the Director of Nursing (DON), Resident 1's overflow medical chart was reviewed. Resident 7's Dental progress Notes were noted in Resident 1's overflow chart. The DON stated Resident 7's record should not be in Resident 1's chart. The DON stated records need to be accurate and having the wrong resident's information in Resident 1's chart violated the Health Insurance Portability and Accountability Act of 1996 (rule that establishes national standards to protect individuals' medical records and other identifiable health information). During a review of the facility's policy titled, Resident Medical Record Organization, 4/24/2025, the policy indicated it was the policy of the facility to ensure each residents' medical record was organized. During a review of the facility's policy titled, Residents Rights, undated, the policy indicated federal and state laws guarantee the residents' right to confidentiality. Unauthorized access or disclosure of resident information is prohibited.

Based on interview and record review the facility failed to implement infection prevention policies and procedures (evidence-based practices designed to prevent the spread of infections in healthcare settings, primarily following CDC guidelines) for one of one resident (Resident 81) when the facility failed to:1. Ensure Resident 81 Covid-19 (infectious disease resulting in mild to moderate respiratory illness) vaccine (medications used to prevent diseases usually given by injection or by mouth) was administered within 90 days after Resident 81 agreed to receive it. This failure had the potential to result in staff and residents contracting COVID-19 which can cause serious illness, hospitalization, and death.Findings: During a review of Resident 81's admission Record, the admission Record indicated Resident 81 was admitted to the facility on [DATE] with diagnosis including acute respiratory failure (lungs cannot release enough oxygen [vital gases for life] into your blood), dependence on supplemental oxygen, acute pulmonary edema (life-threatening buildup of fluid in lungs), and chronic kidney disease (progressive damage and loss of kidney function).During a review of Resident 81's Minimum Data Set ([MDS] a resident assessment tool), dated 1/16/2026, the MDS indicated Resident 81 cognition was intact.During a review of Resident 81's Covid-19 Vaccine Information and Declination Form, the form indicated Resident 81 consented to vaccination on 10/15/2025.During a concurrent interview and record review on 3/11/2026 at 9:09 a.m., with Infection Prevention Nurse (IPN) 1, Resident 's 81's Immunization records and consents were reviewed. IPN 1 stated Resident 81's vaccination was administered on 3/6/2026 and Resident 81 consented to receive the vaccine on 10/15/2025. IPN 1 stated the vaccination should not have been administered 5 months later.During a review of the facility's Policy and Procedure (P&P) titled, Vaccination of Residents, revised 12/20/2024, the P&P indicated if the resident is unvaccinated and needs additional vaccine doses the required or recommended vaccine will be administered within ninety days when consented.

Based on interview and record review, the facility failed to ensure two of four sampled residents' (Resident 1 and 79) had current and accurate Advance Directives ([AD]-written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) correctly in their medical records when:The facility failed to obtain a copy of Resident 1's AD despite documentation of acknowledgement, confirming and documenting the resident's wishes when the resident was deemed capable after another individual had signed the form. The facility failed to Provide written information and follow through to complete the AD acknowledgement/Physician Orders for Life-Sustaining Treatment ([POLST]- a medical order that helps give people with serious illness more control over their care during a medical emergency) for Resident 79.These failures had the potential to result in care being provided that was inconsistent with the residents' wishes and could compromised the residents' rights to make decisions regarding their medical care during emergencies, end of life, and changes in condition.Findings: 1. 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 Intervertebral disc degeneration (the natural wear and tear of the cushiony pads between your backbones), acute pulmonary edema (a dangerous, sudden buildup of fluid inside the lungs that makes it feel like you are drowning) and type 2 diabetes mellitus ( a long-term condition where the body cannot use sugar for energy properly, causing it to build up in the blood). The admission Record also indicated Resident 1's family members were listed as emergency contacts #1 and #2 and did not identify any family member as the resident's power of attorney (POA- a legal document that lets you pick a trusted person to make decisions on your behalf). During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated Resident 1 had the capacity (ability) to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated [DATE], the MDS indicated Resident 1's cognitive (functions your brain uses to think, pay attention, process information, and remember things) was moderately impaired. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort to complete the task) with eating, oral hygiene, maximal assistance (helper does more than half the effort to complete task) with toileting hygiene, and showering. During a concurrent interview and record review on [DATE] at 2:42 p.m., with the Social Service Director (SSD), Resident 1's ADA dated [DATE] was reviewed. without verifying supporting documentation and allowed the family to complete the ADA. The SSD stated the facility had not obtained a copy of the resident's AD after the acknowledgement, for about two months after the admission. The SSD stated the facility failed to obtain the ADA from the resident after the physician assessed the resident and determined the resident was capable on [DATE]. The SSD stated it was her responsibility to ensure the AD was documented, available, and completed as required to honor the residents' wishes regarding care and treatment. During an interview on [DATE], a.m., with the Director of Nursing (DON), the DON stated completion of the AD should have been completed sooner not approximately 2 months later. The DON stated completion of the AD is essential to ensure the resident's wishes are honored and to guide care and treatment decisions during emergency situations. During a review of the facility's Policy and Procedure (P&P) titled, Advance Directives, revised [DATE], the P&P indicated, If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. If the resident becomes able to receive and understand this information later, he or she will be provided with the same written materials as described above, even if his or her legal representative has already been given the information. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 2. During a review of Resident 79's admission Record, the admission Record indicated, Resident 79 was initially admitted to the facility on [DATE] and last readmission was on[DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 79's H&P, dated [DATE], the H&P indicated, Resident 79 could make needs known but could not make medical decisions. During a review of Resident 79's MDS, dated [DATE], the MDS indicated Resident 79 was dependent and required dependent assistance (Helper does all of the effort) from two or more staff for, hygiene, shower/bath, dressing, bed mobility, transfer, and maximal assistance (Helper does more than half the effort) from one staff for eating. During a concurrent interview and record review on [DATE], at 10:33 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 79's Physician Orders for Life-Sustaining Treatment (POLST), dated [DATE] was reviewed. The POLST indicated, Resident 79 had an order for Do Not Attempt Resuscitation (DNR- a medical order written by a doctor to instruct health care providers NOT to do cardiopulmonary resuscitation (CPR) if breathing stops or the heart stops beating). The POLST indicated, comfort-focused treatment only. The POLST indicated, Resident Representative (RR) elected no AD. RNS 1 stated, Resident 79 was Full Code (FC- a directive indicating that all possible life-saving measures will be used to revive the resident whose heart or breathing has stopped) before, but recently changed to DNR after being admitted to hospice (compassionate care for people who are near the end of life provided at the person's home or within a health care facility). During a concurrent interview and record review on [DATE], at 10:45 a.m., with RNS 1, Resident 79's Order Summary Report (OSR), dated [DATE] was reviewed. The OSR indicated, attempt cardiopulmonary resuscitation (CPR- an emergency lifesaving procedure performed when the heart stops beating), provide full treatment, and provide long-term artificial nutrition was ordered on [DATE]. RNS 1stated, the staff should have followed up with Resident 79's Primary Care Physician (PCP) to reflect recent changes in POLST from the hospice. RNS 1 stated, there are two conflicting orders regarding Resident 79's code status. RNS 1 stated, Resident 79 would be at risk of being treated as FC against his/her wish. During a concurrent interview and record review on [DATE], at 11:36 a.m., with the Social Service Director (SSD), Resident 79's Advance Directive (AD) Acknowledgement, dated [DATE] was reviewed. The AD Acknowledgement indicated, there was no name of Resident Representative (RR) who consented verbally via phone. The AD Acknowledgement indicated, written materials were given to RR and there were no signatures from witnesses. The SSD stated, there was no evidence that written materials regarding the right to accept or refuse medical treatments were provided to RR and Resident 79. The SSD stated, the residents and RR might not be fully informed of their rights and to have their wishes honored if AD Acknowledgement was not done correctly and incompletely. The SSD stated, AD Acknowledgement would be invalid and incomplete if there was missing information. The SSD stated, the staff, including herself, should ensure that the residents and RR fully understood how they want to precede care and treatment as they wish. During an interview on [DATE], 12:47 p.m., with the Director of Nursing (DON), the DON stated, AD and POLST should be available for all residents regardless. The DON stated, the SSD and staff should have ensured the completion of POLST and provided written information regarding AD. The DON stated, any verbal or telephone consent should be signed by two witnesses to be valid. The DON stated, AD and POLST were important to honor residents' wishes and the guideline for how to treat residents in emergency situation. The DON stated, the staff should have followed up with both hospice and the PCP to clarify the order to prevent confusion during the emergency. During a review of Resident 79's Care Plan Report (CPR) titled, POLST: Requested for CPR with full treatment and artificial nutrition via tube feeding, revised on [DATE], the CPR Goal indicated, Resident 79 will be cared for with respect and dignity and will be comfortable during the end-of-life process through [DATE]. The CPR Interventions indicated, keep POLST document in chart specifying resident's wishes and provide RR and resident with educational material regarding AD as needed. During a review of the facility's Policy and Procedure (P&P) titled, Advance Directives, revised 12/2016, the P&P indicated, Policy Interpretation and Implementation: 1. the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 2.Written information will include a description of the facility's policies to implement advance directives and applicable state law .17. The Interdisciplinary Team will conduct ongoing review of the resident's decision-making capacity and communicate significant changes to the resident's legal representative. Such changes will be documented in the care plan and medical record . 19. Changes or revocations of a directive must be submitted in writing to the Administrator. The Administrator may require new documents if changes are extensive. The Care Plan Team will be informed of such changes and/or revocations so that appropriate changes can be made to the resident assessment (MDS) and care plan. During a review of the facility's Policy and Procedure (P&P) titled, Advance Healthcare Directives/POLST, revised 12/2024, the P&P indicated, Purpose: To provide residents with the opportunity to make decisions regarding their healthcare and treatment options . Policy Interpretation and Implementation: Once POLST is executed a Licensed nurse will contact the residents' primary care physician and inform him/her of the residents' healthcare decisions and obtain orders to support these decisions. Physician orders to withhold or withdraw treatment may be taken over the telephone, with two (2) licensed nurses' signatures.

Based on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion (ROM, full movement potential of a joint) for two of five sampled residents (Residents 6 and 8) with ROM concerns by failing to: 1.Ensure Resident 6's left shoulder and left elbow were objectively (unbiased, based on facts) measured and assessed after orthopedics (specialty area in medicine referring to the management of the muscles, bones, and their connective structures) cleared Resident 6 for left shoulder and left elbow ROM exercises. 2.Ensure Resident 6's left wrist and left-hand ROM limitations were objectively measured during the Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation, dated 9/13/2025. 3.Ensure a licensed physical therapist (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) or OT assessed Resident 6's left shoulder and left elbow prior to establishing a Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) program for left shoulder and left elbow passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises. 4.Ensure RNA provided ROM exercises to Resident 8's both hips and both ankles as ordered by the physician. 5.Ensure Resident 8's ROM limitations of both knees were objectively measured during the PT Evaluation, dated 12/12/2025. These deficient practices had the potential for Residents 6 and 8 to experience further decline in ROM resulting in contracture (loss of motion of a joint associated with stiffness and joint deformity) development and have a decline in physical functioning, mobility (ability to move), and activities of daily living (ADL, basic activities such as eating, dressing, toileting).Findings:1. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including a left humeral shaft fracture (break in the long bone of the upper arm), muscle weakness, and polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain).During a review of Resident 6's History and Physical (H&P) Note, dated 9/12/2025, the H&P indicated Resident 6 was transferred to the hospital for surgery of the left humerus after sustaining a fall at the facility. The H&P indicated Resident 6 had surgery for the left humerus on 9/9/2025 and was re-admitted to the facility on [DATE] for skilled care (high level medical or rehabilitative care provided by licensed professionals), PT, and OT.During a review of Resident 6's Orthopedic Consultation Progress Note (Ortho Note), dated 10/6/2025, the Ortho Note indicated the visit was Resident 6's first orthopedic follow up appointment since surgery to the left arm on 9/9/2026. The Ortho Note indicated Resident 6 was non-weight bearing (NWB, restriction in which a person is not allowed to put any weight through the operated body part) to the left arm and was able to participate in ROM exercises to the left shoulder and left elbow with PT and OT. During a review of Resident 6's Joint Mobility Screening assessment (JMA, a brief assessment of a resident's ROM in both arms and both legs), dated 10/31/2025, the JMA indicated Resident 6's left elbow had minimal ROM loss (less than 25 percent loss) and Resident 6's left shoulder had severe ROM loss (greater than 50 percent loss). The JMA portion of the assessment titled Comments indicated Resident 6 had loss of motion in the left elbow and left shoulder. The JMA indicated recommendations for Resident 6 to continue with the RNA program. During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 1/26/2026, the MDS indicated Resident 6 had moderate cognitive (mental action or process of acquiring knowledge and understanding) impairment. The MDS indicated Resident 6 required set up/clean up assistance (helper sets up or clean up) for eating and oral hygiene and was dependent (helper does all the effort) with toileting hygiene, bathing, dressing, personal hygiene, rolling to both sides, and transfers. The MDS indicated Resident 6 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in one arm.During an observation and interview on 3/9/2026 at 10:24 am with Resident 6 in Resident 6's room, Resident 6 was lying in bed with the left elbow bent and the left wrist and hand resting on her stomach. Resident 6 stated her left shoulder was broken but did not recall when. Resident 6 reached across the body with the right arm, grabbed her left arm, and used the right arm to assist raising the left arm to less than shoulder height. Resident 6 bent the left elbow upwards towards the body but could not fully straighten the arm. Resident 6 was unable to lift the left wrist upwards or close the fingers of the hand into a fist.During a concurrent interview and record review on 3/11/2026 at 10:14 am with the Director of Rehabilitation (DOR), the DOR stated the facility monitored for changes in joint ROM by JMAs conducted by the Rehabilitation Department (Rehab) upon admission and quarterly and by staff report. The DOR stated PTs and OTs used goniometers (instrument used for the precise measurement of angles) to measure joint mobility to objectively (unbiased, based on facts) determine a resident's baseline ROM and detect changes in joint ROM. The DOR reviewed Resident 6's H&P, 9/12/2025, and confirmed Resident 6 had surgery for the left humerus on 9/9/2025 and was re-admitted back to the facility on 9/12/2025. The DOR reviewed Resident 6's Ortho Note, dated 10/6/2025, and confirmed Resident 6 was cleared by the orthopedic physician to begin post-op (after surgery) left shoulder and left elbow ROM exercises. The DOR reviewed Resident 6's JMA, dated 10/31/2025, and confirmed Resident 6 had minimal ROM loss at the left elbow which meant less than 25 percent loss and severe ROM loss at the left shoulder which meant greater than 50 percent loss. The DOR stated Resident 6's baseline ROM of the left shoulder and left elbow after surgery were not determined because the ROM limitations were not measured with a goniometer. The DOR stated that Resident 6's left shoulder and left elbow ROM impairments should have been measured using a goniometer because it was the first opportunity to record Resident 6's baseline ROM after receiving orthopedic clearance on 10/6/2025. The DOR stated JMA ROM loss indicators such as minimal and severe ROM loss were partially subjective (information, feelings, or opinions that arise from an individual's personal perspective rather than external, verifiable facts), included a wide range of variability (tendency of something to change or differ, not constant), did not indicate in which direction the joint was limited, and could not accurately detect subtle changes in ROM. The DOR stated lack of objective ROM measurements had the potential to negatively impact the staff's ability to detect changes such as improvements or declines in Resident 6's ROM. During an interview on 3/12/2026 at 11:29 am with the Director of Nursing (DON), the DON stated the facility monitored changes in ROM by staff report, observations during daily care, and JMAs done quarterly and annually by Rehab. The DON stated it was important for staff to objectively measure ROM during ROM evaluations to ensure the facility had an accurate assessment of a resident's joints since it affected their ability to effectively monitor changes and provide the appropriate services to address any declines. 2. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including a left humeral shaft fracture, muscle weakness, and polyneuropathy.During a review of Resident 6's H&P, dated 9/12/2025, the H&P indicated Resident 6 was transferred to the hospital for surgery of the left humerus after sustaining a fall at the facility. The H&P indicated Resident 6 had surgery for the left humerus on 9/9/2025 and was re-admitted to the facility on [DATE] for skilled care, PT, and OT.During a review of Resident 6's OT Evaluation and Plan of Treatment (OT Eval), dated 9/13/2025, the OT Eval indicated Resident 6's left arm ROM was impaired. The OT Eval indicated Resident 6 had minimal loss of motion in the left wrist and the left hand.During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 had moderate cognitive impairment. The MDS indicated Resident 6 required set up/clean up assistance for eating and oral hygiene and was dependent with toileting hygiene, bathing, dressing, personal hygiene, rolling to both sides, and transfers. The MDS indicated Resident 6 had functional limitations in ROM in one arm.During a concurrent interview and record review on 3/11/2026 at 10:14 am with the DOR, the DOR stated the facility monitored for changes in joint ROM by JMAs conducted by the Rehab upon admission and quarterly and by staff report. The DOR stated PTs and OTs used goniometers to measure joint mobility to objectively determine a resident's baseline ROM and detect changes in joint ROM. The DOR stated any limitations in joint ROM observed in an OT or PT evaluation should be measured with a goniometer and documented in the evaluation because it was an objective way of establishing a resident's ROM baseline and monitoring for changes in ROM. The DOR reviewed Resident 6's OT Eval, 9/13/2025, and confirmed Resident 6's ROM of left wrist and left hand were impaired and had minimal loss of motion. The DOR stated Resident 6's ROM of the left wrist and left hand should have been measured with a goniometer since they were impaired but were not. The DOR stated Resident 6's baseline ROM of the left wrist and left hand were not determined due to lack of objective measurements in the OT evaluation which in turn affected staff's ability to monitor and detect any changes in ROM.During an interview on 3/12/2026 at 11:29 am with the DON, the DON stated the facility monitored changes in ROM by staff report, observations during daily care, and JMAs done quarterly and annually by Rehab. The DON stated it was important for staff to objectively measure ROM during ROM evaluations to ensure the facility had an accurate assessment of a resident's joints since it affected their ability to effectively monitor changes and provide the appropriate services to address any declines. 3. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including a left humeral shaft fracture, muscle weakness, and polyneuropathy.During a review of Resident 6's H&P, 9/12/2025, the H&P indicated Resident 6 was transferred to the hospital for surgery of the left humerus after sustaining a fall at the facility. The H&P indicated Resident 6 had surgery for the left humerus on 9/9/2025 and was re-admitted to the facility on [DATE] for skilled care, PT, and OT.During a review of Resident 6's OT Evaluation and Plan of Treatment (OT Eval), dated 9/13/2025, the OT Eval indicated Resident 6's left shoulder and left elbow were not assessed due to Resident 6's left shoulder surgery.During a review of Resident 6's JMA, dated 9/13/2025, the JMA indicated Resident 6's left elbow and left shoulder were not tested due to Resident 6's left humerus surgery. During a review of Resident 6's Ortho Note, dated 10/6/2025, the Ortho Note indicated the visit was Resident 6's first orthopedic follow up appointment since surgery to the left arm on 9/9/2026. The Ortho Note indicated Resident 6 was NWB to the left arm and was able to participate in ROM exercises to the left shoulder and left elbow with PT and OT. During a review of Resident 6's Order Summary Report, the Order Summary Report indicated a physician's order, dated 10/9/2025, for RNA to provide PROM exercises to Resident 6's left arm to tolerable range on the left elbow and shoulder, five times a week. During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 had moderate cognitive impairment. The MDS indicated Resident 6 required set up/clean up assistance for eating and oral hygiene and was dependent with toileting hygiene, bathing, dressing, personal hygiene, rolling to both sides, and transfers. The MDS indicated Resident 6 had functional limitations in ROM in one arm.During an observation of an RNA session on 3/10/2026 at 2:05 pm, Resident 6 was lying in bed with the head of bed elevated. Resident 6 repeatedly stated her left shoulder was broken but did not recall when. Restorative Nursing Assistant 2 (RNA 2) assisted with PROM exercises to Resident 6's left shoulder, elbow, wrist, and hand. RNA 2 fully bent and was unable to fully straighten Resident 6's left elbow. RNA 2 raised Resident 6's left arm upwards and to the side to less than shoulder height for 15 repetitions. Resident 6 reported pain to the left shoulder with PROM exercises. RNA 2 stated Resident 6's participation and tolerance to left shoulder ROM exercises varied daily due to pain. During a concurrent interview and record review on 3/11/2026 at 10:14 am with the DOR, the DOR stated the purpose of the RNA program was to maintain and improve a resident's functional level and ROM. The DOR stated PT and OT formally assessed residents prior to writing RNA orders to determine what type of exercises to prescribe and to ensure an RNA program was appropriate and safe based on the resident's needs. The DOR reviewed Resident 6's H&P, 9/12/2025, and confirmed Resident 6 had surgery for the left humerus on 9/9/2025 and was re-admitted back to the facility on 9/12/2025. The DOR reviewed Resident 6's OT Eval, dated 9/13/2025, and confirmed OT did not assess Resident 6's left shoulder and elbow due to surgery. The DOR reviewed Resident 6's JMA, dated 9/13/2025, and confirmed OT did not assess Resident's left elbow and shoulder due to surgery. The DOR reviewed Resident 6's Ortho Note, dated 10/6/2025, and confirmed orthopedics cleared Resident 6 to participate in ROM exercises to the left shoulder and left elbow. The DOR reviewed Resident 6's physician's orders and confirmed there was a physician's order, dated 10/9/2025, for RNA to provide PROM exercises to Resident 6's left arm to tolerable range on the left elbow and shoulder, five times a week. The DOR confirmed PT and/or OT did not assess Resident left's shoulder and elbow prior to establishing an RNA program for left shoulder and elbow PROM exercises but should have. The DOR stated PT and/or OT should have formally assessed Resident 6's left shoulder and elbow by requesting a formal evaluation or performing a JMA before ordering RNA for PROM exercises to the left shoulder and elbow, particularly because Resident 6 had surgery to the left humerus on 9/9/2025. The DOR stated if an RNA program was established prior to assessing a resident for appropriateness and needs, it could cause harm or injury to the residents and a decline in ROM. During an interview on 3/12/2026 at 11:29 am with the DON, the DON stated Rehab determined which residents were appropriate for an RNA program, the types of exercises RNA should perform with a resident, and the frequency of RNA services. The DON stated a licensed therapist must assess a resident prior to establishing an RNA program to ensure RNA services were appropriate and safe for the resident. The DON stated if an assessment was not done prior to establishing an RNA program, it could cause harm or injury to the residents. 4. During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including senile degeneration of the brain (progressive decline in cognitive function), dementia (decline in mental ability severe enough to interfere with daily life), and peripheral vascular disease (reduced circulation of blood to a body part due to a narrowed or blocked blood vessel).During a review of Resident 8's Order Summary Report, the Order Summary Report indicated a physician's order, dated 12/8/2025 for RNA to provide PROM exercises to Resident 8's both legs, five times a week. During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8 had severe cognitive impairment for daily decision making. The MDS indicated Resident 8 was dependent with eating, oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, rolling to both sides, and transfers. The MDS indicated Resident 8 had functional limitations in ROM in both legs.During an observation and interview of Resident 8's RNA session on 3/10/2026 at 10:24 am in Resident 8's room, Resident 8 was lying in bed. Resident 8's both legs were bent at the hips and knees and rotated to the right side of the bed. RNA 1 stated Resident 8's both legs were contracted and very stiff. After assisting with PROM to Resident 8's both arms, RNA 1 stood on the left side of the bed and assisted with PROM exercises to Resident 8's right knee. RNA 1 did not assist with PROM exercises to Resident 8's right hip and right ankle. RNA 1 moved to the right side of the bed and attempted to assist Resident 8 with PROM exercises to Resident 8's left knee but stopped after one repetition. RNA 1 stated she stopped assisting with left knee PROM exercises because the left knee felt very stiff and was scared to cause pain or injury. RNA 1 did not attempt PROM exercises to Resident 8's left hip and left ankle.During an interview on 3/10/2026 at 10:42 am with RNA 1, RNA 1 confirmed Resident 8 had RNA orders for PROM exercises to Resident 8's both legs which meant assisting Resident 8 with ROM exercises to the entire leg, including the hips, knees, and ankles. RNA 1 confirmed she did not assist with ROM exercises to Resident 8's both hips and both knees as ordered because she forgot. RNA 1 stated Resident 8 required encouragement and assistance with ROM exercises to both legs because Resident 8's joints were very stiff and contracted. RNA 1 stated she should have assisted Resident 8 with both hip and both ankle ROM exercises as ordered but did not. RNA 1 stated Resident 8 could have a decline in ROM if RNA exercises were not provided as ordered.During an interview on 3/10/2026 at 11:15 am with the DOR, the DOR stated the purpose of the RNA program was to maintain and improve a resident's functional level and ROM. The DOR stated Rehab determined the types of exercises RNAs were to perform when creating an RNA program. The DOR stated if an RNA order was written for ROM exercises to both legs, it was expected the RNA provide ROM to the entire leg, which included the hips, knees, and ankles. The DOR stated if RNA did not provide RNA services as ordered, it could potentially result in a decline in ROM and ADLs.During an interview on 3/12/2026 at 11:29 pm with the DON, the DON stated it was important for RNA to provide exercises as ordered to ensure the residents in the facility maintained their level of function and to prevent potential declines in mobility, ADLs, and contracture development.5. During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including senile degeneration of the brain, dementia, and peripheral vascular disease.During a review of Resident 8's PT Evaluation and Plan of Treatment (PT Eval), dated 12/12/2025, the PT Eval indicated Resident 8's ROM in both knees were impaired.During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8 had severe cognitive impairment for daily decision making. The MDS indicated Resident 8 was dependent with eating, oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, rolling to both sides, and transfers. The MDS indicated Resident 8 had functional limitations in ROM in both legs.During a concurrent interview and record review on 3/11/2026 at 10:14 am with the DOR, the DOR stated the facility monitored for changes in joint ROM by JMAs conducted by the Rehab upon admission and quarterly and by staff report. The DOR stated PTs and OTs used goniometers to measure joint mobility to objectively determine a resident's baseline ROM and detect changes in joint ROM. The DOR stated any limitations in joint ROM observed in an OT or PT evaluation should be measured with a goniometer and documented in the evaluation because it was an objective way of establishing a resident's ROM baseline and monitoring for changes in ROM. The DOR reviewed Resident 8's PT Eval, 12/12/2025, and confirmed Resident 8's ROM of both knees were impaired. The DOR stated Resident 8's ROM of both knees should have been measured with a goniometer since they were impaired but were not. The DOR stated Resident 8's baseline ROM of both knees were not determined due to lack of objective measurements in the PT evaluation which in turn affected staff's ability to monitor and detect any changes in ROM.During an interview on 3/12/2026 at 11:29 am with the DON, the DON stated the facility monitored changes in ROM by staff report, observations during daily care, and JMAs done quarterly and annually by Rehab. The DON stated it was important for staff to objectively measure ROM during ROM evaluations to ensure the facility had an accurate assessment of a resident's joints since it affected their ability to effectively monitor changes and provide the appropriate services to address any declines. During a review of the facility's job description titled, Restorative Care Nurse, revised 10/2020, the job description indicated one of the duties and responsibilities of the Restorative Care Nurse was to assist residents with OT and PT exercises as directed. During a review of the facility's P/P titled Specialized Rehabilitative Services, revised 12/2009, the P/P indicated a licensed professional can either discontinue treatment or initiate a maintenance program which either nursing or restorative aides would implement to assure the resident maintained his or her functional and physical status once a resident has met his or her care plan goals. During a review of the facility's Policy and Procedure (P/P) titled Resident Mobility and ROM, revised 7/2017, the P/P indicated resident would not experience an avoidable reduction in ROM and residents with limited ROM would receive treatment and services to increase and/or prevent a further decrease in ROM. The P/P indicated documentation of the resident's progress toward the goals and objectives will include attempts to address any changes or decline in the resident's condition or needs.During a review of the facility's P/P titled Rehab Screening and JMAs, revised 5/2025, the P/P indicated the purpose of the Rehab Screening and JMAs were to identify residents with functional changes and/or changes in ROM and allow those residents to receive therapy services if declines or improvements were present and skilled services were required.

Based on interview and record review, the facility failed to ensure one resident receiving hemodialysis ([HD]a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) resident's (Resident 11) blood pressure was not taken in the left upper extremity where Resident 11's arteriovenous (AV) shunt (a direct connection between an artery and a vein, bypassing the capillary network, which can be natural or surgically created for medical access) was located.These deficient practices had the potential to result in clotting (process that prevents excessive bleeding when a blood vessel is injured), damage, or inaccurate high readings.Findings:During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (ESRD -irreversible kidney failure) and dependence on renal dialysis.During a review of Resident 11's Minimum Data Set (MDS - a resident assessment tool), dated 2/19/2026, the MDS indicated Resident 11's cognition (ability to think) was intact. The MDS indicated Resident 11 needed set up assistance when eating, oral hygiene and substantial assistance (helper does more than half the effort) with toileting hygiene.During a review of Resident 11's Order Detail, the order indicated, starting 11/10/2025, no blood pressure on left upper extremity with AV shunt.During a concurrent observation and interview on 3/10/2026 at 2 p.m., with Licensed Vocational Nurse (LVN) 1, at Resident 11's bedside, there was no signage indicating not measure Resident 11's blood pressure on Resident 11's Left upper extremity. LVN 1 stated Resident 11 did not have signage at the bedside indicating not to take Resident 11's BP on the left upper extremity. During a concurrent interview and record review on 3/10/2026 at 2 p.m. with LVN 1, Resident 11's blood pressure readings, 2/1/2026 to 3/9/2026, were reviewed and LVN 1 confirmed and stated Resident 11's blood pressure was taken on the left upper arm on several occasions. LVN 1 stated Resident 11's blood pressure should not be measured on the left upper arm because it can cause a clot. During an interview on 3/12/2026 at 7:48 a.m., with the Director of Nursing (DON), the DON stated blood pressure should not be taken from the arm with the AV shunt because it can cause a clot. During a review of the facility's policy and procedure (P&P) titled, End-Stage Renal Disease, Care of a Resident with revised 9/2010, the P&P indicated Residents with ESRD will be cared for according to currently recognized standards of care and standards. The P&P indicated not to use access arm to take blood pressure.

Based on interview and record review, the facility failed to provide medically related social services (professional interventions provided by social workers to help residents manage the emotional, social, and financial impacts of illness) for two of six sampled residents (Resident 27 and Resident 49) as evidence by:A. Failing to ensure Resident 27 was seen by an ophthalmologist (a medical doctor specializing in eye and vision care, qualified to perform complex surgeries and treat severe eye diseases) as requested.B. Failing to ensure Resident 49 did not miss a Nerve Conduction Study (NCS-a test that measures how fast an electrical impulse moves through the nerve) and Electromyography (EMG- measures muscle electrical activity to identify nerve or muscle damage) procedure on [DATE].This failure had the potential to result in delay in the delivery of care and services.Findings:A. During a review of Resident 27's admission record, the admission record indicated Resident 27 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and blindness on left eye.During a review of Resident 27's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 27 had the capacity (ability) to understand and make decisions.During a review of Resident 27's Minimum Data Set (MDS-a resident assessment tool), dated [DATE], the MDS indicated Resident 27 required moderate assistance (Helper does less than half the effort) from one staff for toilet hygiene, dressing, transfer, maximal assistance (Helper does more than half the effort) from one staff for shower, personal hygiene, bed mobility, transfer, toilet hygiene, dressing, and eating.During an interview on [DATE], at 10:25 a.m., with Resident 27 in her room, Resident 27 stated, she was blind in her left eye and worried about her right eye vision. Resident 27 stated, she was admitted to the facility on 1/2026, but no one helped her to be seen by an ophthalmologist Resident 27 stated, she was very worried about her right eye, because her the facility staff from her previous did not really help her to see an ophthalmologist and she ended up losing her vision on left eye.During a concurrent interview and record review on [DATE], at 10:12 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 27's Progress Notes (PN), dated from 1/2026 to 3/2026 were reviewed. The PN indicated, there was no documentation regarding Resident 27 being seen by an ophthalmologist. RNS 1 stated, she was not aware of Resident 27's concern and agreed that Resident 27 should be seen by a specialist since she had DM and poor control of blood sugar levels that could lead to blindness. RNS 1 stated, the staff should have communicated with the Social Service Director (SSD) to arrange the appointment for Resident 27.During an interview on [DATE], at 11:40 a.m., with the Social Services Director (SSD), the SSD stated, she was not aware of Resident 27's concern regarding her vision. The SSD stated, she could not recall that Resident 27 expressed her concern during her room visits and assessments. The SSD stated, she would arrange the ophthalmologist appointment if she knew about her current concerns and conditions. The SSD stated, it was important to accommodate Resident 27's concern to preserve her right eye vision with specialty care.During a review of Resident 27's Care Plan Report (CPR) titled, Resident 27 has impaired (damaged) visual function related to blindness on left eye, revised on [DATE], the CPR Goal indicated, Resident 27 would show no decline in visual function through review date of [DATE]. The CPR Interventions indicated, arrange consultation with eye care practitioners as required.During a review of Resident 27's Order Summary Report (OSR), dated [DATE], the OSR indicated, annual eye exam with follow up as needed ordered on [DATE].B. During a review of Resident 49's admission record, the admission record indicated Resident 49 was initially admitted to the facility on [DATE] and last readmission was on [DATE] with diagnoses including quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury) and generalized muscle weakness.During a review of Resident 49's H&P, dated [DATE], the H&P indicated, Resident 49 had the capacity to understand and make decisions.During a review of Resident 49's MDS, dated [DATE], the MDS indicated Resident 49 required dependent assistance (Helper does all of the effort) from two or more staff for transfer, shower, toilet hygiene, lower body dressing, and maximal assistance (Helper does more than half the effort) from one staff for upper body dressing, personal hygiene, bed mobility, eating.During an interview on [DATE], at 11:31 a.m., with Resident 49 in her room, Resident 49 stated, she missed important appointments on [DATE] because the nursing staff did not prepare the required documentation for her appointments. Resident 49 stated, no one rescheduled the appointments for her.During a concurrent interview and record review on [DATE], at 10:17 a.m., with RNS 1, Resident 49's Progress Notes (PN), dated [DATE] was reviewed. The PN indicated, Resident 49 refused to go for the NCS and EMG procedures on [DATE]. The PN did not indicate a reason for refusal by Resident 49 and did not indicate a information about rescheduling the appointments for Resident 49. RNS 1 stated, the staff should have notified the Primary Care Physician (PCP) and followed up with the reason for refusal and rescheduled. RNS 1 stated, Resident 49 had generalized muscle weakness and quadriplegia. RNS 1 stated, NCS and EMG procedures were important to evaluate Resident 49's current status.During a concurrent interview and record review on [DATE], 11:50 a.m., with the SSD, Resident 49's Order Summary Report (OSR), dated [DATE] was reviewed. The OSR indicated, Nerve Conduction Study/EMG Procedure on [DATE] with appointment time at 10:30 a.m. was ordered on [DATE]. The SSD stated, she did not know Resident 49 refused to go. The SSD stated, it was important to find out the reason Resident 49 refused to go to the appointments, and encourage Resident 49 to go to specialty appointment because it would be more difficult to reschedule the appointment and Resident 49 missed an opportunity to get treatment.During an interview on [DATE], at 12:57 p.m., with the DON, the DON stated, the SSD should be proactive with assisting the residents. The DON stated it was SSD's responsibility to assist residents with all aspects of their lives. The DON stated, it was important to ensure specialty consult appointments were made in timely manner and the staff should have assisted the residents to go to appointments without any difficulty. The DON stated, the staff should have identified the residents' needs and arranged necessary services.During a review of the facility's Policy and Procedure (P&P) titled, Ancillary Services, revised 12/2016, the P&P indicated, Policy: Routine and emergency ancillary services such as dental, eye, podiatry, psychiatry, psychology, optometry, ophthalmology and other services are available to meet the residents' health needs in accordance with the resident's assessment and plan of care. Policy Interpretation and Implementation: 6. Social services or designee will assist residents with appointments, referrals, transportation arrangemen1s, and for reimbursement of services under the state plan, if eligible. 7. order/s for ancillary services will be relayed to the provider by social services or designee.During a review of the facility's P&P titled, Referrals, Social Services, revised 2001, the P&P indicated, Policy Statement: Social services personnel shall coordinate most resident referrals with outside agencies. Policy Interpretation and Implementation:1. Social services shall coordinate most resident referrals. Exceptions might include emergency or specialized services that are arranged directly by a physician or the nursing staff . 3. Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician. 4. Social services will document the referral in the resident's medical record . 6.Social services will help arrange transportation to outside agencies, clinic appointments, etc., as appropriate.During a review of the facility's P&P titled, Job Description: Social Worker, revised 10/2020, the P&P indicated, Duties and Responsibilities: Assist in obtaining resources from community social, health and welfare agencies to meet the needs of the resident. Ensure that each resident receives necessary care and services to obtain and maintain the highest practical physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care.

Based on interview and record review, the facility failed to ensure medical records for two of five sampled residents (Residents 6 and 8) were accurately documented and readily accessible: 1.For Resident 6, the facility failed to:a.Ensure Resident 6's orthopedic (specialty area in medicine referring to the management of the muscles, bones, and their connective structures) consultation note was in the medical record and readily accessible.b.Ensure the physician's order, dated 12/10/2025, reflecting Resident 6's left arm weightbearing restriction (guidance from a physician limiting the amount of weight a person can put through a specific arm or leg after surgery) was changed from non-weight bearing (NWB, restriction in which a person is not allowed to put any weight through the operated body part) to weightbearing as tolerated (WBAT, a person is medically cleared to place as much weight through the affected arm or leg to the point of comfort or tolerance) as ordered by the consulting orthopedic physician on 11/3/2025 to accurately reflect Resident 6's current weightbearing status. 2.For Resident 8, the facility failed to ensure Resident 8's right-hand splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) assessment was in the medical record and readily accessible. These deficient practices had the potential to delay and negatively affect the delivery of necessary care and services.CROSS-REFERENCE TO F684 Findings: 1. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including a left humeral shaft fracture (break in the long bone of the upper arm), muscle weakness, and polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain). During a review of Resident 6's History and Physical (H&P) Note, dated 9/12/2025, the H&P indicated Resident 6 was transferred to the hospital for surgery of the left humerus after sustaining a fall at the facility. The H&P indicated Resident 6 had surgery for the left humerus on 9/9/2025 and was re-admitted to the facility on [DATE] for skilled care (high level medical or rehabilitative care provided by licensed professionals), Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) and Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities).During a review of Resident 6's OT Evaluation and Plan of Treatment (OT Eval), dated 9/13/2025, the OT Eval indicated Resident 6's left arm ROM was impaired at the wrist and the hand, and the left shoulder and elbow ROM were not assessed due to Resident 6's left humerus surgery.During a review of Resident 6's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated Resident 6 was discharged from OT services per physician or Case Manager.During a review of Resident 6's Orthopedic Consultation Progress Note (Ortho Note), dated 10/6/2025, the Ortho Note indicated the visit was Resident 6's first orthopedic follow up appointment since surgery to the left arm on 9/9/2026. The Ortho Note indicated Resident 6 was NWB to the left arm and was able to participate in ROM exercises to the left shoulder and left elbow with PT and OT. The Ortho Note indicated Resident 6 was to follow up with orthopedics in four weeks. During a review of Resident 6's Order Summary Report, the Order Summary Report indicated a physician's order, dated 10/6/2025, for Resident 6 to follow up with orthopedics on 11/3/2025 at 9:45 am.During a review of Resident 6's Ortho Note, dated 11/3/2025, the Ortho Note indicated Resident 6 presented to the orthopedic appointment three months after undergoing surgery of the left humerus. The Ortho Note indicated Resident 6's left arm was WBAT. The Ortho Note indicated Resident 6 could participate in ROM and strengthening exercises to the left shoulder, elbow, wrist, and fingers and instructed Resident 6 to follow up with orthopedics through her Health Maintenance Organization (HMO, type of insurance plan that limits coverage to doctors and facilities within a specific network).During a review of Resident 6's Order Summary Report, the Order Summary Report indicated a physician's order, dated 12/10/2025, for Resident 6's left arm to be NWB.During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 1/26/2026, the MDS indicated Resident 6 had moderate cognitive (mental action or process of acquiring knowledge and understanding) impairment. The MDS indicated Resident 6 required set up/clean up assistance (helper sets up or clean up) for eating and oral hygiene and was dependent (helper does all the effort) with toileting hygiene, bathing, dressing, personal hygiene, rolling to both sides, and transfers. The MDS indicated Resident 6 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in one arm.During an observation and interview on 3/9/2026 at 10:24 am with Resident 6 in Resident 6's room, Resident 6 was lying in bed with the left elbow bent and the left wrist and hand resting on her stomach. Resident 6 stated her left shoulder was broken but did not recall when. Resident 6 reached across the body with the right arm, grabbed her left arm, and used the right arm to assist raising the left arm to less than shoulder height. Resident 6 bent the left elbow upwards towards the body but could not fully straighten the arm. Resident 6 was unable to lift the left wrist upwards or close the fingers of the hand into a fist.During a concurrent interview and record review on 3/10/2026 at 2:50 pm with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated a licensed nurse was responsible for accepting a resident's paperwork and implementing new physician orders and recommendations when a resident returned to the facility from a consultation appointment. LVN 1 stated if follow up appointments were recommended by the consulting physician, the licensed nurse or the Assistant Director of Nursing (ADON) scheduled the follow up appointment based on the physician recommendations, updated the physician orders, and placed all consultation notes in the EMR. LVN 1 reviewed Resident 6's physician's orders and Ortho Note, dated 10/6/2025, and confirmed Resident 6 was supposed to follow up with Orthopedics on 11/3/2025 per physician's orders, dated 10/6/2025, but was unable to confirm if Resident 6 went to the scheduled orthopedic appointment because she could not locate the Ortho Note, dated 11/3/2025. LVN 1 stated Resident 6's Ortho Notes were supposed to be in the resident's electronic medical record (EMR) but were not. LVN 1 stated she was unsure if orthopedics made any additional recommendations for follow up or updated Resident 6's left arm restrictions because she could not locate the Ortho Note. LVN 1 stated it was important that consultation notes were readily accessible and scanned into the EMR to ensure staff were aware of any recommendations, instructions, follow-up appointments, and changes to the plan of care. During a concurrent interview and record review on 3/10/2026 at 3:09 pm with the ADON, the ADON stated a licensed nurse was responsible for accepting a resident's paperwork and implementing new physician orders and recommendations when a resident returned to the facility from a consultation appointment. The ADON stated if follow up appointments were recommended by the consulting physician, the licensed nurse scheduled the follow up appointment based on the physician recommendations, contacted the Transportation Coordinator to arrange transportation for the scheduled appointment, and placed all consultation notes in the EMR. The ADON reviewed Resident 6's clinical record and confirmed Resident 6 had a follow-up orthopedic appointment scheduled for 11/3/2025 but did not know if Resident 6 went to the appointment because she could not find the Ortho Note, dated 11/3/2025. The ADON stated Resident 6's Ortho Note, dated 11/3/2025, should be scanned into the EMR but was not.During a follow up interview on 3/11/2026 at 9:45 am, the ADON stated she looked extensively for Resident 6's Ortho Note, dated 11/3/2025, but was unable to locate it. The ADON stated she called Resident 6's orthopedic clinic and asked the clinic to fax Resident 6's Ortho Note, dated 11/3/2025, to the facility because the facility was unable to locate it. The ADON reviewed Resident 6's Ortho Note, dated 11/3/2025, and confirmed the Ortho Note indicated Resident 6's left arm weightbearing status was changed from NWB to WBAT. The ADON confirmed the Ortho Note, dated 11/3/2025, recommended Resident 6 begin ROM and strengthening exercises for the left arm, and instructed Resident 6 to follow up with orthopedics through her HMO. The ADON reviewed Resident 6's physician's orders and Ortho Notes, dated 10/6/2025 and 11/6/2025, and confirmed Resident 6's physician order, dated 12/20/2025, which indicated Resident 6's left arm was NWB was inaccurate as the Ortho Note, dated 11/3/2025, indicated Resident 6's left arm weightbearing status was upgraded to WBAT. The ADON stated Resident 6's left arm weightbearing status was likely not changed on the physician's order because the Ortho Note, dated 11/3/2026, was missing and staff was unaware of the change and recommendations. The ADON stated the case manager typically followed up with scheduling follow up appointments for residents with HMO and was unsure if a follow up ortho appointment was scheduled as recommended by the physician since the Ortho Note was missing. The ADON stated it was important that consultation notes were readily accessible and in the resident's EMR to ensure the facility provided the appropriate care and services and followed up with any recommendations and orders given by the consulting physician. The ADON stated it was important to accurately document Resident 6's weightbearing status to prevent unnecessary restrictions and allow Resident 6 to progress in strength and ROM which improved ADLs and reduced the risk of decline. During a concurrent interview and record review on 3/11/2026 at 9:59 am with the Case Manager (CM), the CM stated she was responsible for obtaining insurance authorization (health insurance requirement where providers must obtain approval from the insurance plan before a specific treatment, medication, or service is covered) and scheduling follow up appointments for residents with HMOs. The CM stated that once staff, typically a licensed nurse, became aware of a recommendation for follow up consultation appointments, she was either given the resident's consultation note or notified directly by staff of the resident's follow up instructions and recommendations. The CM stated once she was notified or given the resident's consultation note, she contacted the resident's HMO immediately and/or within the week to verify authorization and schedule the appointment. The CM reviewed Resident 6's Ortho Note, dated 11/3/2025, and confirmed she never received the Ortho Note and was not notified by staff of any recommendations for Resident 6 to follow up with orthopedics through her HMO. The CM stated the Ortho Note, dated 11/3/2026, was required to schedule Resident 6's appointment and should have been in the EMR but was not. The CM stated the follow up appointment should have been scheduled immediately or generally within a week of receipt of Resident 6's orthopedic consultation follow up instructions and recommendations but was not because she was never notified by staff and the Ortho Note was not in the EMR. The CM stated inaccessible consultation notes could result in missed follow up appointments and instructions, delay in care, and ADL decline.During a concurrent interview and record review on 3/11/2026 at 10:14 am with the Director of Rehabilitation, the DOR reviewed Resident 6's therapy notes and confirmed Resident 6 was evaluated by OT on 9/11/2025 and discharged from OT services on 9/27/2025 due to lack of insurance coverage for skilled services. The DOR stated Resident 6 no longer required skilled therapy services (services that require specialized training and experience of a licensed therapist or therapy assistant) at the time she was discharged from OT services because Resident 6 had reached her highest level of functioning due to the NWB and ROM restrictions to the left arm. The DOR stated staff typically informed the Rehabilitation Department (Rehab) if a resident's weightbearing or activity restrictions changed after a resident returned from a follow up orthopedic appointment and updated the physician's order to reflect the resident's current weightbearing status. The DOR stated if any changes in a resident's weightbearing status occurred, Rehab would re-assess the resident and/or modify the plan of care. The DOR reviewed Resident 6's physician's orders and Ortho Notes, dated 10/6/2025 and 11/3/2025, and confirmed Resident 6's physician order, dated 12/20/2025, which indicated Resident 6's left arm was NWB was inaccurate as the Ortho Note, dated 11/3/2025, indicated Resident 6's left arm weightbearing status was upgraded to WBAT. The DOR stated Resident 6's left arm weightbearing status was likely not changed on the physician's order because the Ortho Note, dated 11/3/2025, was missing and staff were unaware of the change and recommendations. The DOR stated staff must accurately document a resident's weightbearing status in the physician's orders and keep consultation notes readily accessible to ensure staff were aware of any changes to a resident's care plan, including weightbearing and activity restrictions, which directly affected the resident's progress in therapy and ability to perform ADLs.During an interview on 3/12/2026 at 11:29 am with the Director of Nursing (DON), the DON stated consultation notes should always be in the EMR and readily accessible. The DON stated inaccessible consultation notes could result in missed appointments and a delay in necessary care and services. The DON stated inaccurate documentation of a resident's weightbearing status could result in lack of progression and/or decline in a resident's level of function. 2. During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including senile degeneration of the brain (progressive decline in cognitive function), dementia (decline in mental ability severe enough to interfere with daily life), and peripheral vascular disease (reduced circulation of blood to a body part due to a narrowed or blocked blood vessel).During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8 had severe cognitive impairment for daily decision making. The MDS indicated Resident 8 was dependent with eating, oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, rolling to both sides, and transfers. The MDS indicated Resident 8 had functional limitations in ROM in both legs.During a review of Resident 8's Rehab Screen/Recommendations (Rehab Screen), dated 12/8/2025, the Rehab Screen indicated the DOR referred Resident 8 to OT to assess Resident 8's right hand.During a review of Resident 8's Order Summary Report, the Order Summary Report indicated a physician's order, dated 2/25/2026 for RNA to apply a hand roll to Resident 8's right hand for four hours, every day, seven times a week or as tolerated to prevent a decline in ROM and skin integrity. During an observation on 3/10/2026 at 10:24 am of Resident 8's Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain any progress made after therapy intervention to maintain their function) session in Resident 8's room, Resident 8 was laying in bed. RNA 1 assisted with passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to Resident 8's both arms and both legs. At the end of the session, RNA 1 applied a splint to Resident 8's right hand.During a concurrent record review and interview on 3/11/2026 at 2:11 pm with the Director of Rehabilitation (DOR), the DOR stated the purpose of splints was to improve or maintain a resident's ROM and prevent contractures. The DOR stated a licensed PT or OT must assess a resident's need for splints if indicated. The DOR stated the licensed therapist must determine the splint wear tolerance and schedule by periodically assessing the splint for safety, comfort or need for modification. The DOR stated that after the therapist assessed a resident for the correct type of splint and established the wear tolerance, the therapist transitioned the splinting plan of care to nursing, specifically the RNA program and documented the assessments, precautions, and wear time (length of time and frequency a person can tolerate wearing the splint for safety, comfort, and maximal benefits) in the EMR. The DOR reviewed Resident 8's physician's orders and confirmed Resident 8 had an RNA order to apply a hand roll to Resident 8's right hand for four hours, seven days a week. The DOR stated a hand roll was considered a splint and required a formal assessment by a licensed therapist to determine the appropriate fit and wear time. The DOR stated splinting assessments should always be documented in the therapy evaluation and/or a progress note and filed in a binder titled Rehab Screenings in the therapy gym. The DOR reviewed Resident 8's clinical record, therapy notes, and the Rehab Screening binder in the therapy gym and could not find Resident 8's therapy assessment for the right-hand splint. During a concurrent interview and record review on 3/11/2026 at 3:41 pm with the DOR and Occupational Therapist 1 (OT 1), OT 1 stated she assessed and issued Resident 8 a right splint but could not recall when.During a concurrent interview and record review on 3/11/2026 at 3:41 pm with the DOR and Occupational Therapist 1 (OT 1), OT 1 stated she assessed and issued Resident 8 a right splint after the DOR referred Resident 8 to OT for a splint evaluation but could not recall when. OT 1 stated she recalled initially trialing Resident 8's right hand with a rolled-up towel and eventually progressed Resident 8 to a right-hand splint as his tolerance for the splint and ROM improved. OT 1 stated all splint assessments should either be in the therapy evaluation or notes, in the Rehab Screening binder, or in her personal binder. OT 1 reviewed Resident 8's clinical record, therapy notes, Rehab Screening binder, and her personal binder and could not find Resident 8's assessment for the right-hand splint. The DOR and OT 1 stated it was important splint assessments were readily accessible to ensure staff were aware of treatments provided and any recommendations and/or precautions indicated. OT 1 stated she recalled initially trialing Resident 8's right hand with a rolled up towel and eventually progressed Resident 8 to a right-hand splint as his tolerance for the splint and ROM improved. OT 1 stated all splint assessments should either be in the therapy evaluation or notes, in the Rehab Screening binder, or in her personal binder. OT 1 reviewed Resident 8's clinical record, therapy notes, Rehab Screening binder, and her personal binder and could not find Resident 8's assessment for the right-hand splint. The DOR and OT 1 stated it was important splint assessments were readily accessible to ensure staff were aware of treatments provided and any recommendations and/or precautions indicated.During an interview on 3/12/2026 at 11:29 am with the DON, the DON stated all assessments and services provided should be readily accessible and in the EMR. The DON stated it was important for splint assessments to be readily accessible to ensure staff can clearly identify which type of splint was provided to the residents and be aware of any special instructions or safety precautions associated with its use.During a review of the facility's Policy and Procedure (P/P) titled Charting and Documentation, revised 2001, the P/P indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The P/P indicated the medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The P/P indicated documented in the medical record would be objective, complete, and accurate.

Based on interview and record review the facility failed to implement infection control policies and procedure (P&P) when:The facility failed to provide documented evidence of all employees, including physicians, Annual Influenza ([Flu] highly contagious respiratory infection) vaccine (medications used to prevent diseases usually given by injection or by mouth) status and the provision of education on benefits and potential side effects and offering of the 2025 to 2026 flu vaccine. The facility failed to ensure one of two residents' (Resident 39) foley catheter drainage bag (collects urine drained from the bladder via a tube) was kept off the floor. These failures had the potential to result in staff and residents contracting infectious diseases which can cause serious illness, hospitalization, and death. Findings: a. During a concurrent interview and record review on 3/11/2026 at 9:15 a.m., with Infection Prevention Nurse (IPN 1), the facility's Staff Vaccination Status, updated 3/5/2026, was reviewed. IPN 1 stated there was no documented evidence for physician or licensed practitioners' education on benefits and side effects was provided and the offering of 2025 to 2026 flu vaccine. IPN 1 stated the roster did not include physicians and it should include everyone that has direct access to the residents. During an interview on 3/12/2026 at 7:48 a.m. with the Director of Nursing (DON), the DON stated staff need to be educated and offered the current annual flu vaccine because its mandated. During a review of the facility's policy and procedure (P&P) titled, Influenza Vaccine, revised 5/29/2025, the P&P indicated all healthcare Providers (HCP) will be provided with information regarding the requirement to receive the flu vaccine and IP will document the status of Flu vaccination of all HCP. b.During a review of Resident 39's admission Record, the admission Record indicated the facility admitted Resident 1 on 8/30/2024, and readmitted on [DATE] with diagnoses including neuromuscular dysfunction of bladder (or neurogenic bladder happens when damaged nerves stop the brain and bladder from talking, causing trouble holding or releasing urine), gastro esophageal reflux disease (GERD-a chronic condition where stomach acid frequently flows back up into the tube connecting your mouth to your stomach), and fusion of spine (a surgery that joins two or more backbones together so they grow into one solid bone). During a review of Resident 39's History and Physical (H&P), dated 5/15/2025, the H&P indicated Resident 39 had the capacity (ability) to understand and make decisions. During a review of Resident 39's Minimum Data Set (MDS- a resident assessment tool), dated 6/12/2025, the MDS indicated Resident 39's cognitive (functions your brain uses to think, pay attention, process information, and remember things) was intact. The MDS indicated Resident 39 required setup assistance with eating, oral hygiene, moderate assistance with personal hygiene, maximal assistance with toileting hygiene, showering, and dressings. During a review of Resident 39's Order Summary Report, orders as of 3/9/2026, the Order Summary Report indicated a physician order, effective 6/12/2025, for placement of an 18 French (size indicates how thick the tube is) foley catheter to drainage bag for non-patency as needed one time a day related to neuromuscular dysfunction of bladder. During a concurrent observation and interview on 3/09/2026 at 8:55 a.m., with Resident 39 in the resident's room, the resident's foley catheter drainage bag was observed touching the floor. The resident stated she had been experiencing burning and cramping sensations in her abdominal area for the previous couple of days. Resident 39 stated a staff collected a specimen the day prior and she was waiting for the results. During a concurrent observation and interview on 3/9/2026 at 9:15 a.m., in Resident 39's room with Licensed Vocational Nurse (LVN) 4, LVN 4 stated Resident 39's foley catheter drainage bag was touching the floor. LVN 4 stated this placed Resident 39 at a higher risk for a urinary tract infection ([UTI] a bacterial infection in the body's pee system, causing burning, frequent urges to pee, and pain). LVN 4 stated the drainage bag should always be kept off the floor to maintain infection control standards. During an interview on 3/12/2026 at 9:59 a.m., with the Director of Nursing (DON), the DON stated the foley catheter drainage bag should always be maintained off the floor to ensure infection control. During a review of the facility's policy and procedure (P&P), titled Catheter Care, Urinary, undated, the P&P indicated staff must Be sure the catheter tubing and drainage bag are kept off the floor for Infection control.

Based on interview and record review the facility failed to ensure one of five sampled resident's (Resident 81) influenza ([flu] highly contagious respiratory infection) and pneumococcal (bacterial infection) vaccine (medications used to prevent diseases usually given by injection or by mouth) was administered timely after Resident 81 consented to receive the vaccines. This deficient practice resulted in a delay of services and placed the residents at risk of contracting influenza or pneumococcal disease.Findings:During a review of Resident 81's admission Record, the admission Record indicated Resident 81 was admitted to the facility on [DATE] with diagnosis including acute respiratory failure (lungs cannot release enough oxygen [vital gases for life] into your blood), dependence on supplemental oxygen, acute pulmonary edema (life-threatening buildup of fluid in lungs), and chronic kidney disease (progressive damage and loss of kidney function).During a review of Resident 81's Minimum Data Set ([MDS] a resident assessment tool), dated 1/16/2026, the MDS indicated Resident 81 cognition was intact.During a review of Resident 81's Consent/Declination for Influenza vaccine and pneumococcal vaccine, the consents indicated Resident 81 consented to vaccinations on 10/15/2025.During a concurrent interview and record review on 3/11/2026 at 9:09 a.m., with the Infection Prevention Nurse (IPN) 1, Resident 's 81's Immunization records and consents were reviewed. IPN 1 stated Resident 81's vaccinations were administered on 3/5/2026 and Resident 81 consented to receive the vaccines on 10/15/2025. IPN 1 stated the vaccinations should not have been administered five months later.During an interview on 3/12/2026 at 7:48 a.m. with the Director of Nursing (DON), the DON stated vaccines should be administered within 90 days once resident consents to the vaccination.During a review of the facility's Policy and Procedure (P&P) titled, Vaccination of Residents, revised 12/20/2024, the P&P indicated if the resident is unvaccinated and needs additional vaccine doses the required or recommended vaccine will be administered within ninety days when consented.

Based on interview, and record review, the facility failed to implement it's policy and procedure (P&P) , titled Change in a Resident's Condition or Status, for reporting a change in condition for one of three sample residents (Resident 1) to the physician when Resident 1's blood glucose levels exceeded 400 per deciliter (mg/dL- a unit measure for concentration of substances, normal blood glucose range 70-99 mg/dL) on 2/6/2026, 2/8/2026, and 2/22/2026.This failure placed Resident 1 at risk for treatment and services for high glucose levels and had the potential to lead to adverse health outcomes, including dehydration, kidney failure and ketoacidosis (breakdown of fat in the body that leads to acid in the blood).Findings:During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis including Intervertebral disc degeneration (the natural wear and tear of the cushiony pads between your backbones), acute pulmonary edema (a dangerous, sudden buildup of fluid inside the lungs that makes it feel like you are drowning) and Type 2 diabetes mellitus ( [DM]- a long-term condition where the body cannot use sugar for energy properly, causing it to build up in the blood).During a review of Resident 1's History and Physical (H&P), dated 2/4/2026, the H&P indicated Resident 1 had the ability to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 1/22/2026, the MDS indicated Resident 1's cognitive (functions your brain uses to think, pay attention, process information, and remember things) was moderately impaired. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort to complete the task) with eating, oral hygiene, maximal assistance (helper does more than half the effort to complete task) with toileting hygiene, and showering.During a review of Resident 1's Order Summary Report, the Order Summary Report indicated an order initiated on 1/15/2026 and discontinued on 2/24/2026, to administer Lispro injection solution (a fast-acting, liquid medicine under the skin to manage diabetes) subcutaneously (below the skin) and to call the physician when the blood glucose was above 400 mg/dL.During a concurrent interview and record review on 3/10/2026 at 2:48 p.m. with Registered Nurse Supervisor (RNS) 1, Resident 1's Medication Administration Records (MAR), for the month of February 2026 were reviewed. RNS 1 stated Resident 1's blood glucose levels were 430 mg/dL on 2/6/2026 at 4:30 p.m., 419 mg/dL on 2/8/2026 at 4:30 p.m., and 437 mg/dL on 2/22/2026 at 4:30 p.m., and these elevated blood glucose levels represented a change of condition. RNS 1 stated the facility failed to follow its policy for change of condition, including completing a SBAR (stands for situation, background, assessment, and recommendation- four step communication tool used by health professionals to share urgent patient information quickly and accurately), notifying the physician and the resident's family regarding these elevated blood glucose readings.During an interview on 3/12/2026 at 9:59 a.m. with the Director of Nursing (DON), the DON stated staff were required to follow physician orders and the facility's change of condition protocol, including notifying the physician when the resident's BS were above 400 mg/dL per the physician's order. During a review of the facility's Policy and Procedure (P&P), titled Change in a Resident's Condition or Status, undated, the P&P indicated the nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotion/mental condition.

Based on interview and record review, the facility failed to ensure Resident 28 had an Interdisciplinary Team (IDT-group of healthcare professionals) meeting after a change of condition (COC) was identified for increasing delusions (holding a firm, false belief that is not based on reality) and paranoia (unfounded mistrust of others). This failure led to resident feeling ignored and distressed and violates his right to participate in person-centered care.Findings: During a review of Resident 28's Face Sheet, the Face Sheet indicated, Resident 28 was admitted on [DATE] with diagnoses of type 2 diabetes mellitus with hyperglycemia (chronic metabolic disease where the body cannot properly manage blood sugar levels), legal blindness (vision loss), unspecified glaucoma (eye disease that leads to blindness, if untreated), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and unspecified psychosis (a mental health condition where a person loses touch with reality, causing difficulty distinguishing what is real from what is not) not due to a substance or known physiological condition. During a review of Resident 28's History & Physical (H&P) dated 2/4/26, the H&P indicated, Resident 28 is alert, oriented, and has the capacity to understand and make decisions. During a review of Resident 28's Minimum Data Set (MDS-a resident assessment tool) dated 2/3/26, the MDS indicated, Resident 28 is able to understand others and makes self-understood. The MDS indicated, Resident 28 participates and is involved in assessment and goal setting. The MDS indicated, Resident 28 uses a wheelchair and walker for mobility and is dependent with activities of daily living (ADLs). The MDS also indicated Resident 28 has delusions. During a review of Resident 28's SBAR (stands for Situation, Background, Assessment, and Recommendation, a structured, four-step communication framework) dated 2/25/26, the SBAR indicated, new or worsening behavioral symptoms. Resident 28's change in condition as being paranoid and delusional, calling 911 multiple times. The SBAR indicated, Resident 28 exhibiting paranoid ideation, verbalizing persistent delusions that staff and/or others are attempting to poison him. Resident 28 stated, They're putting something in my food and drinks, and reports fear of consuming meals and medications. Resident 28 appears visibly distressed, anxious, and hypervigilant. Resident 28 has contacted 911 multiple times during shift, reporting belief of being poisoned. During a review of Progress Notes dated 3/9/26, the Progress Notes indicated, the facility was informed/updated of resident's current condition and behaviors related to episode of verbalization of paranoia saying that staff is poisoning his food. During a review of Resident 28's Care Plan dated 2/27/26, the Care Plan indicated diagnosis of unspecified psychosis manifested by being paranoid, has delusions that he is being poisoned causing distress, where he has called 911 multiple times. The Care Plan indicated, Goals such as to participate in making decisions for health and personal care, be assisted by family/staff in making decisions for health and personal care; to maintain normal sleep pattern. The Care Plan indicated, Interventions such as: IDT meeting with the resident, monitor episodes of paranoia and delusions as evidenced by verbalizing staff is poisoning his food every shift and record number of episodes, assess resident for behavior manifestations. During an interview on 3/11/2026 at 12:00p.m. with Resident 28, Resident 28 stated, the facility did not involve me in the second IDT meeting. Resident 28 stated he wanted to tell them I must buy my food because I am being poisoned. I cannot sleep. I look like a sick person, not enjoying. I want to know exactly what they plan for me. During an interview on 3/11/2026 at 2:40p.m. with MDS Nurse 1, MDS Nurse 1 stated the facility did not do an IDT Meeting after the second COC. MDS Nurse 1 stated usually IDT Meeting was conducted upon admission, then quarterly. MDS stated it is necessary to do IDT after COC on 2/25/26, to prevent him from having this feeling of being poisoned and to follow up to make sure this will not worsen. During a concurrent interview and record review on 3/11/26 at 3:01pm with MDS Nurse 1, Resident 28's Care Plan dated 3/11/26 was reviewed. The Care Plan indicated no documentation or Progress Notes of Care Plan Interventions such as IDT meeting with the resident, monitoring of episodes of paranoia and delusions as evidenced by verbalizing staff is poisoning his food every shift and record number of episodes, nor assessment of resident for behavior manifestations. During an interview on 3/12/26 at 8:00am with the Director of Nursing (DON), DON stated, if there is a COC, we do the Care Plan first, then IDT. We will revise CP whatever happens based on IDT. The DON stated it's important to hold an IDT Meeting; it is resident's right to be involved in planning Resident 28's care. During a review of facility's P&P titled Resident Rights, undated, the document indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: p. be informed of, and participate in, his or her care planning and treatment.

Based on interview and record review the facility failed to ensure one of one 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 originally admitted Resident 6 on 5/06/2022 and was re-admitted on [DATE] with diagnoses including schizoaffective disorder (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 1/26/2026, the MDS indicated Resident 6's cognition (ability to think and make decisions) was moderately impaired. 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 3/10/2026 at 9:56 a.m. with the Minimum Date Set Nurse (MDSN) 1, Resident 6's admission Record and Resident 6's PASARR and Resident Review Level I Screening, dated 11/12/2025 was reviewed. The MDSN 1 coordinator stated Resident 6 had a diagnosis of schizoaffective disorder. The MDSN 1 stated Resident 6's PASARR Level I Screening diagnosis of schizophrenia should have been checked (as yes). The MDSN 1 stated completing the PASARR Level 1 screening correctly was important to be able to meet the needs of the resident. During an interview on 3/12/2026 at 8 a.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, admission Criteria, revised 3/2019, the P&P indicated the facility conducts Level I PASARR screen for all admissions and readmissions. The P&P indicated all residents are screened for mental disorders per PASARR Process.

Based on observation, interview, and record review, the facility failed to implement a care plan for one of five residents (Resident 89) by failing to inform Resident 89 of the risks and consequences of refusing to take Keppra ([generic name - levetiracetam] a medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) as indicated in Resident 89's care plan.This deficient practice failed to explain to Resident 89 about the risk of seizures due to refusal of Keppra and had the potential of causing seizures, falls and hospitalization.Findings:During a review of Resident 89's admission Record, dated 3/11/2026, the admission record indicated the facility originally admitted Resident 89 on 6/16/2013 and readmitted on [DATE] with diagnoses that included epilepsy, intractable, unspecified without status epilepticus (a condition of recurrent seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] that are not fully managed by medication) and other specified disorders of bone density and structure. During a review of Resident 89's History and Physical (H&P) dated 10/26/2025, the H&P indicated Resident 89 had the capacity to understand and make decisions.During a review of Resident 89's Minimum Data Set (MDS - a resident assessment tool), dated 12/4/2025, the MDS indicated Resident 89's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was intact. The MDS indicated Resident 89 needed moderate assistance from the facility staff in performing activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as eating, oral hygiene, toileting hygiene, upper body dressing and personal hygiene, needed maximal assistance for lower body dressing and putting on/taking off footwear, and dependent on facility staff for showering. During an observation on 3/10/2026 at 4:07 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 prepared the following four medications to be administered to Resident 89. a. One tablet of glycopyrrolate (a medication used to treat chronic drooling) 1 milligram ([mg] metric unit of measurement, used for medication dosage and/or amount)b. One tablet of levetiracetam 1000 mgc. One tablet of Eliquis ([generic name - apixaban] a medication used to treat atrial fibrillation [an irregular, often rapid heart rate that starts suddenly and stops on its own], prevent clots and stroke [loss of blood flow to a part of the brain] 5 mgd. One tablet of calcium (an important supplement to maintain strong bones and teeth) 500 mg plus vitamin D (a vitamin used to treat low level of vitamin D and support bone health and absorb calcium) 5 micrograms ([mcg] metric unit of measurement, used for medication dosage and/or amount)LVN 3 stated to Resident 89 that she (LVN 3) had four medications to administer to Resident 89. LVN 3 was observed handing over one tablet of levetiracetam 1000 mg to Resident 89 and Resident 89 refused to take levetiracetam 1000 mg stating, not today. LVN 3 then continued to give one tablet of glycopyrrolate 1 mg, one tablet of Eliquis 5 mg and one tablet of calcium 500 mg plus vitamin D 5 mcg, by explaining only glycopyrrolate that it was for Resident 89's drooling symptoms. LVN 3 only offered levetiracetam 1000 mg one time to Resident 89. LVN 3 did not explain to Resident 89 about the benefits and purpose of taking levetiracetam and the risk for seizures if levetiracetam was not taken as prescribed. During a subsequent interview on 3/10/2026 at 4:07 p.m., with LVN 3, LVN 3 stated she would try to offer the medication to Resident 89 again before the end of her shift and then stated she would document medication as refused and inform the physician. LVN 3 stated she did not offer the levetiracetam three times as she should have and did not explain the risks and benefits of taking and not taking levetiracetam to Resident 89. LVN 3 stated by not taking levetiracetam, Resident 89 was placed at risk for seizures, falls and hospitalization.During a medication reconciliation review on 3/11/2026, Resident 89's Order Summary Report (a document containing a summary of all active physician orders), dated 3/11/2026 was reviewed. The order summary report indicated, but not limited to the following physician orders: Monitor for seizure activity. Notify medical doctor (MD) if noted, (Keppra) every shift Document if notes: Y = Yes; N = No, order date 5/10/2024, start date: 5/10/2024. Keppra tablet 1000 mg (levetiracetam), give 1 tablet by mouth two times a day related to epilepsy, unspecified, intractable, without status epilepticus, order date 8/29/2022, start date 8/30/2022. Apixaban tablet 5 mg, give 1 tablet by mouth two times a day related to unspecified atrial fibrillation, order date 8/29/2022, start date 8/30/2022. Glycopyrrolate oral tablet 1 mg, give 1 tablet by mouth two times a day for hypersalivation, order date 1/21/2026, start date 1/22/2026. Oscal 500-200 D3 tablet 500 mg-200 international units ([IU] a unit of measurement for mass) mg-IU (calcium carbonate-vitamin D), give 1 tablet by mouth two times a day for supplement, order date 8/29/2022, start date 8/30/2022. During a review of Resident 89's Medication Administration Record (MAR - daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 3/1/2026 to 3/11/2026, the MAR indicated, levetiracetam 1000 mg was documented as 2 = drug refused, three times. During a review of Resident 89's Care Plan dated 3/10/2026, the Care Plan indicated, Focus: Refusal of medication: Keppra; Goal: Resident will demonstrate improved compliance with medication regimen and remain free from seizure activity; Interventions: Educate resident on the importance of taking Keppra for seizure prevention, monitor resident for signs and symptoms of seizure activity.During a review of Resident 89's Care Plan dated 2/13/2026, the Care Plan indicated, Focus: Resident is at risk for clinical or social decline due to non-compliance, non-adherence, refusal of medications, 1. Oscal, 2. Apixaban, 3. Keppra, 4. Vitamin D3, 5. Glycopyrrolate; Goal: Resident right to choose will be honored daily, Resident will be informed of risks and consequences of choices that they make daily; Interventions: Establish daily routine based on input from the resident, Do not force resident to comply against their wishes when resident refuses any food, treatment, care, etc. return later and try again, re-affirm resident's rights to make their own choices, inform of risks and consequences of choices, assess resident for ability to control behavior and express needs.During a review of Resident 89's Care Plan date initiated 8/30/2022, revision date 3/5/2026, the Care Plan indicated, Focus: Resident is at risk for injury due to diagnosis of seizure disorder; Goal: Will be free from injury daily through next review for 3 months; Interventions: Padded 1/4 siderails as ordered, Medication levetiracetam as ordered.monitor for change in level of consciousness. Protected environment when having seizure. During a concurrent interview and record review on 3/11/2026 at 2:02 p.m., with Registered Nurse Supervisor (RNS) 1, the care plans dated 3/10/2026 and 2/13/2026 were reviewed. RNS 1 stated that for residents who were alert and refused to take medications, the facility nurses should have offered the medications at least three times and explained risks and benefits of the medications. RNS 1 stated the care plan was not followed with regards to explaining levetiracetam and offering at least three times. RNS 1 stated not taking seizure medication could increase the risk for seizures, falls and hospitalization. RNS 1 stated Resident 89's levetiracetam was supposed to help prevent episodes of seizure and epilepsy, and if resident refused it, the facility nurse should document the refusal, initiate a change of condition and inform physician and family member. During an interview on 3/11/2026 at 3:11 p.m., with the Director of Nursing (DON), the DON stated in the case of refusal of seizure medications, the facility nursing staff should have informed the doctor when the resident refused the medication. The DON stated facility nurses should have explained to the resident the benefits and risks of taking or not taking levetiracetam and reminded Resident 89 that levetiracetam was to prevent seizures. The DON stated there Resident 89 was at risk for seizures, injury or hospitalization due to refusal of levetiracetam. During a review of facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 12/2016, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives. is developed and implemented for each resident. The P&P indicated, The comprehensive, person-centered care plan will: m. aid in preventing or reducing decline in the resident's functional status and/or functional levels. The P&P indicated, Identifying problem areas and their causes.are the endpoint of an interdisciplinary process. a. no single discipline can manage an approach in isolation; b. The resident's physician (or primary healthcare provider) is integral in this process. Care plan interventions are chosen only after careful data gathering.benefit for the resident. The P&P indicated, The resident has the right to refuse to participate in.treatments. Such refusals will be documented.with established policies.During a review of facility's P&P titled, Medication Administration - General Guidelines, undated, the P&P indicated, If two consecutive doses of a vital medication are withheld or refused, the physician is notified.

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of five sampled residents (Residents 6) by failing to follow up with an orthopedic (specialty area in medicine referring to the management of the muscles, bones, and their connective structures) consultation appointment for Resident 6's left humerus (upper arm bone) fracture (broken bone) per consulting physician's recommendations.This deficient practice resulted in a delay of Resident 6's care and had the potential for worsening of the fracture, delayed healing, and a decline in mobility (ability to move), range of motion (ROM, full movement potential of a joint), activities of daily living (ADL, basic activities such as eating, dressing, toileting), physical comfort and psychosocial well-being. CROSS-REFERENCE TO F842 Findings: During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including a left humeral shaft fracture (break in the long bone of the upper arm), muscle weakness, and polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain). During a review of Resident 6's History and Physical (H&P) Note, dated 9/12/2025, the H&P indicated Resident 6 was transferred to the hospital for surgery of the left humerus after sustaining a fall at the facility. The H&P indicated Resident 6 had surgery for the left humerus on 9/9/2025 and was re-admitted to the facility on [DATE] for skilled care (high level medical or rehabilitative care provided by licensed professionals), Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) and Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities).During a review of Resident 6's OT Evaluation and Plan of Treatment (OT Eval), dated 9/13/2025, the OT Eval indicated Resident 6 was referred for OT services due to a decrease in strength, function, mobility, transfers (moving from one place to another), and ADL participation and an increased need of assistance from others. The OT Eval indicated Resident 6's left arm ROM was impaired at the wrist and the hand, and the left shoulder and elbow ROM were not assessed due to Resident 6's left humerus surgery.During a review of Resident 6's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated Resident 6 was discharged from OT services per physician or Case Manager.During a review of Resident 6's Orthopedic Consultation Progress Note (Ortho Note), dated 10/6/2025, the Ortho Note indicated the visit was Resident 6's first orthopedic follow up appointment since surgery to the left arm on 9/9/2026. The Ortho Note indicated Resident 6 was non-weight bearing (NWB, restriction in which a person is not allowed to put any weight through the operated body part) to the left arm and was able to participate in ROM exercises to the left shoulder and left elbow with PT and OT. The Ortho Note indicated Resident 6 was to follow up with orthopedics in four weeks. During a review of Resident 6's Order Summary Report, the Order Summary Report indicated a physician's order, dated 10/6/2025, for Resident 6 to follow up with orthopedics on 11/3/2025 at 9:45 am.During a review of Resident 6's Ortho Note, dated 11/3/2025, the Ortho Note indicated Resident 6 presented to the orthopedic appointment three months after undergoing surgery of the left humerus. The Ortho Note indicated Resident 6's left arm was weight bearing as tolerated (WBAT, a person is medically cleared to place as much weight through the affected arm or leg to the point of comfort or tolerance). The Ortho Note indicated Resident 6 could participate in ROM and strengthening exercises to the left shoulder, elbow, wrist, and fingers and instructed Resident 6 to follow up with orthopedics through her Health Maintenance Organization (HMO, type of insurance plan that limits coverage to doctors and facilities within a specific network).During a review of Resident 6's Order Summary Report, the Order Summary Report indicated a physician's order, dated 12/10/2025, for Resident 6's left arm to be NWB.During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 1/26/2026, the MDS indicated Resident 6 had moderate cognitive (mental action or process of acquiring knowledge and understanding) impairment. The MDS indicated Resident 6 required set up/clean up assistance (helper sets up or clean up) for eating and oral hygiene and was dependent (helper does all the effort) with toileting hygiene, bathing, dressing, personal hygiene, rolling to both sides, and transfers. The MDS indicated Resident 6 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in one arm.During an observation and interview on 3/9/2026 at 10:24 am with Resident 6 in Resident 6's room, Resident 6 was lying in bed with the left elbow bent and the left wrist and hand resting on her stomach. Resident 6 stated her left shoulder was broken but did not recall when. Resident 6 reached across the body with the right arm, grabbed her left arm, and used the right arm to assist raising the left arm to less than shoulder height. Resident 6 bent the left elbow upwards towards the body but could not fully straighten the arm. Resident 6 was unable to lift the left wrist upwards or close the fingers of the hand into a fist.During a concurrent interview and record review on 3/10/2026 at 2:50 pm with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated a licensed nurse was responsible for accepting a resident's paperwork and implementing new physician orders and recommendations when a resident returned to the facility from a consultation appointment. LVN 1 stated if follow up appointments were recommended by the consulting physician, the licensed nurse or the Assistant Director of Nursing (ADON) scheduled the follow up appointment based on the physician recommendations. LVN 1 reviewed Resident 6's physician's orders and Ortho Note, dated 10/6/2025, and confirmed Resident 6 was supposed to follow up with Orthopedics on 11/3/2025 per physician's orders, dated 10/6/2025, but was unable to confirm if Resident 6 went to the scheduled orthopedic appointment because she could not locate the Ortho Note, dated 11/3/2025. LVN 1 stated Resident 6's Ortho Notes were supposed to be in the resident's electronic medical record (EMR) but were not. LVN 1 stated she was unsure if orthopedics made any additional recommendations for follow up or updated Resident 6's left arm restrictions because she could not locate the Ortho Note. LVN 1 stated the lack of orthopedic follow-up as recommended could potentially result in a decline in function and a delay of necessary treatments and services such as therapy.During a concurrent interview and record review on 3/10/2026 at 3:09 pm with the ADON, the ADON stated a licensed nurse was responsible for accepting a resident's paperwork and implementing new physician orders and recommendations when a resident returned to the facility from a consultation appointment. The ADON stated if follow up appointments were recommended by the consulting physician, the licensed nurse scheduled the follow up appointment based on the physician recommendations and contacted the Transportation Coordinator to arrange transportation for the scheduled appointment. The ADON reviewed Resident 6's clinical record and confirmed Resident 6 had a follow-up orthopedic appointment scheduled for 11/3/2025 but did not know if Resident 6 went to the appointment because she could not find the Ortho Note, dated 11/3/2025. The ADON stated Resident 6's Ortho Note, dated 11/3/2025, should be scanned into the EMR but was not. During a follow up interview on 3/11/2026 at 9:45 am, the ADON stated she looked extensively for Resident 6's Ortho Note, dated 11/3/2025, but was unable to locate it. The ADON stated she called Resident 6's orthopedic clinic and asked the clinic to fax Resident 6's Ortho Note, dated 11/3/2025, to the facility because the facility was unable to locate it. The ADON reviewed Resident 6's Ortho Note, dated 11/3/2025, and confirmed the Ortho Note indicated Resident 6's left arm weightbearing status was changed from NWB to WBAT. The ADON confirmed the Ortho Note recommended Resident 6 begin ROM and strengthening exercises for the left arm, and instructed Resident 6 to follow up with orthopedics through her HMO. The ADON reviewed Resident 6's physician's orders and confirmed Resident 6's physician order, dated 12/20/2025, which indicated Resident 6's left arm was NWB was inaccurate as the Ortho Note, dated 11/3/2025, indicated Resident 6's left arm weightbearing status was upgraded to WBAT. The ADON stated Resident 6's left arm weightbearing status was likely not changed on the physician's order because the Ortho Note, dated 11/3/2026, was missing and staff was unaware of the change and recommendations. The ADON stated the case manager typically followed up with scheduling follow up appointments for residents with HMO and was unsure if a follow up ortho appointment was scheduled as recommended by the physician. The ADON stated it was important to follow up with orthopedics as recommended to ensure the residents received the care and services they needed. The ADON stated lack of orthopedic follow up as recommended could result in delayed care and unnecessary ROM and weightbearing restrictions limiting a resident's ability to progress in function resulting in a functional decline.During a concurrent interview and record review on 3/11/2026 at 9:59 am with the Case Manager (CM), the CM stated she was responsible for obtaining insurance authorization (health insurance requirement where providers must obtain approval from the insurance plan before a specific treatment, medication, or service is covered) and scheduling follow up appointments for residents with HMOs. The CM stated that once staff, typically a licensed nurse, became aware of a recommendation for follow up consultation appointments, she was either given the resident's consultation note or notified directly by staff of the resident's follow up instructions and recommendations. The CM stated once she was notified or given the resident's consultation note, she contacted the resident's HMO immediately and/or within the week to verify authorization and schedule the appointment. The CM reviewed Resident 6's Ortho Note, dated 11/3/2025, and confirmed she never received the Ortho Note and was not notified by staff of any recommendations for Resident 6 to follow up with orthopedics through her HMO. The CM stated the Ortho Note, dated 11/3/2026, was required to schedule Resident 6's appointment and should have been in the EMR but was not. The CM stated the follow up appointment should have been scheduled immediately or generally within a week of receipt of Resident 6's orthopedic consultation follow up instructions and recommendations but was not because she was never notified by staff and the Ortho Note was not in the EMR. The CM stated lack of orthopedic follow up as recommended could lead to the resident experiencing pain, delayed healing, and lack of progress in ADLs. During a concurrent interview and record review on 3/11/2026 at 10:14 am with the Director of Rehabilitation (DOR), the DOR reviewed Resident 6's therapy notes and confirmed Resident 6 was evaluated by OT on 9/13/2025 and discharged from OT services on 9/27/2025 due to lack of insurance coverage for skilled services. The DOR stated Resident 6 no longer required skilled therapy services (services that require specialized training and experience of a licensed therapist or therapy assistant) at the time she was discharged from OT services because Resident 6 had reached her highest level of functioning due to the NWB and ROM restrictions to the left arm. The DOR stated staff typically informed the Rehabilitation Department (Rehab) if a resident's weightbearing or activity restrictions changed after a resident returned from a follow up orthopedic appointment and Rehab would in turn re-assess the resident and/or modify the plan of care. The DOR stated he was unaware and was never informed by staff that Resident 6's weightbearing status to the left arm was changed to WBAT and that Resident 6 was cleared for ROM and strengthening exercises to the left arm after returning from Resident 6's follow up orthopedic appointment on 11/3/2025. The DOR stated lack of orthopedic follow up as recommended could result in a delay in care, lack of progression in ADLs and mobility, and functional decline. During an interview on 3/12/2026 at 11:29 am with the Director of Nursing (DON), the DON stated the charge nurse was responsible for accepting a resident's paperwork and implementing new physician orders when a resident returned to the facility from a consultation appointment. The DON stated if follow up appointments were recommended by the consulting physician, the charge nurse contacted the case manager to verify authorization, schedule the follow up appointment based on the physician recommendations, updated the order in the chart, and arranged transportation. The DON stated lack of orthopedic follow up as recommended could result in inappropriate or delay of necessary care and services and negatively impact a resident's ability to progress in function, ROM, and ADLs.During a review of the facility's job description titled, Charge Nurse/Nurse Supervisor, revised 10/2020, the job description indicated two of the nursing care functions of the Charge Nurse/Nurse Supervisor was to communicate with the primary care physician and members of the comprehensive care planning team regarding the status of residents, follow up on critical labs, order requests, and physician notifications and assist in coordinating nursing services with other resident services to ensure the continuity of the residents' plan of care. The P/P indicated one of the duties and responsibilities of the Charge Nurse/Nurse Supervisor was to arrange for diagnostic and therapeutic services as ordered by the physician and in accordance with established facility procedures. The P/P indicated two of the charting and documentation functions of the Charge Nurse/Nurse Supervisor was to complete and file required recordkeeping forms/charts and perform routine charting duties as required and in accordance with established charting and documentation policies and procedures. During a review of the facility's job description titled, Case Manager/Discharge Planner, dated 7/2024, the job description indicated two of the specific job functions included obtaining continued authorization for placement and treatment of managed care patients and negotiating with service providers, payers, and members of the facility's care team to meet the patient's care needs and assists in arranging for services. During a review of the facility's P/P titled, Quality of Care, revised 8/2009, the P/P indicated each resident shall be care for in a manner that promoted and enhanced quality care. The P/P indicated health services must be timely, equitable, integrated, and efficient.

Based on interview and record review the facility failed to ensure one out of one sampled resident (Resident 11) with a nephrostomy tube (thin, flexible catheter inserted through the back into the kidney to drain urine directly into an external bag) had documented evidence of assessing and monitoring of the urine for signs and symptoms of infection.The deficient practice had the potential to result in urinary tract infections ([UTI] an infection in the bladder/urinary tract).Findings:During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was admitted to the facility on [DATE] with diagnoses including artificial openings of urinary tract status (covers the presence of surgically created, permanent, or temporary, urinary diversion), obstructive and reflux uropathy (dangerous blockage of urine flow).During a review of Resident 11's Minimum Data Set (MDS - a resident assessment tool), dated 2/19/2026, the MDS indicated Resident 11's cognition (ability to think) was intact. The MDS indicated Resident 11 needed set up assistance when eating, oral hygiene and substantial assistance (helper does more than half the effort) with toileting hygiene.During a review of Resident 11's Order summary, the order summary dated 11/10/2025 indicated to provide nephrostomy care every shift.During a review of Resident 11's Care Plan titled, Alteration in bowel and bladder manifested by nephrostomy, initiated 7/5/2025, the care plan intervention indicated to monitor for signs and symptoms of UTI , blood in the urine, sedimentation [physical process where suspended particles settle out of a fluid, dysuria [pain on urination], and flank pain).During a concurrent interview and record review on 3/10/2026 at 3:50 p.m., with MDS nurse (MDSN)1, Resident 11's care plan was reviewed. MDSN 1 stated the care plan should have been implemented and it indicated monitoring urine for signs and symptoms of UTI. MDSN 1 stated there was no documentation of any assessment of urine characteristics in the drainage bag noted in Resident 11's medical records.During an interview on 3/12/2026 at 7:48 a.m., with the Director of Nursing (DON), the DON stated it was important to monitor the urinary drainage to detect any problems.During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, revised 9/2014, the P&P indicated to check the urine for unusual appearance and urine characteristic need to be documented in the resident's medical record.

Based on interviews and record review, the facility failed to ensure a physician assessed one of three sampled residents (Resident 1) within 72 hours after admission.This failure resulted in a delayed physician assessment which placed Resident 1's health status and safety at risk for timely medical interventions.Findings:During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis including Intervertebral disc degeneration (the natural wear and tear of the cushiony pads between your backbones), acute pulmonary edema (a dangerous, sudden buildup of fluid inside the lungs that makes it feel like you are drowning) and Type 2 diabetes mellitus ( a long-term condition where the body cannot use sugar for energy properly, causing it to build up in the blood). During a review of Resident 1's History and Physical (H&P), dated 2/4/2026, the H&P indicated Resident 1 had the ability to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 1/22/2026, the MDS indicated Resident 1's cognitive (functions your brain uses to think, pay attention, process information, and remember things) was moderately impaired. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort to complete the task) with eating, oral hygiene, maximal assistance (helper does more than half the effort to complete task) with toileting hygiene, and showering. During a concurrent interview and record review on 3/10/2026 at 3:21 p.m. with Registered Nurse Supervisor (RNS) 1, Resident 1's H&P, dated 2/4/2026 and Progress notes, for the month of January and February 2026 were reviewed. RNS 1 stated the facility admitted Resident 1 on 1/15/2026 and the physician conducted an in-person visit on 2/4/2026, approximately three weeks later, and there was no documentation that the medical director evaluated the resident within the required time frame. RNS 1 stated the physician is expected to see the resident within three days after admission to complete an assessment and evaluation.During an interview on 3/12/2026 at 9:59 a.m. with the Director of Nursing (DON), the DON stated the facility failed to ensure the physician to see the resident in person within 3 days after admission.During a review of the facility's Policy and Procedure (P&P), titled Physician Documentation, undated, the P&P indicated 'History and Physical Examination': a patient evaluation including a written report of a physical examination shall be provided by the attending physician within 72 hours following admission.

Based on interview and record review the facility failed to ensure one of one resident (Resident 6) was followed up by a psychologist (medical doctor who can diagnose and treat mental health conditions) as ordered by the resident's primary physician. This failure resulted in Resident 6 not receiving a psychology follow-up while in the facility to attain mental and psychosocial well-beingFindings:During a review of Resident 6's admission Record (Face Sheet), the admission Record indicated the facility originally admitted Resident 6 on 5/06/2022 and was re-admitted on [DATE] with diagnoses including schizoaffective disorder (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 1/26/2026, the MDS indicated Resident 6's cognition (ability to think and make decisions) was moderately impaired. 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 a review of Resident 6 physician orders, dated 9/12/2025, the physician's order indicated a psychological (psych) evaluation and follow up treatment. During a review of Resident 6's Care Plan titled Behavior dated 1/30/2026, the Care Plan indicated Monitor behavior and notify Medical Doctor (MD) if it interferes with functioning, psych consult as orderedDuring a concurrent interview and record review on 3/10/2026 at 3:43 p.m., with the Minimum Date Set Nurse (MDSN) 1, Resident 6's care plan for behavior was reviewed. The MDSN 1 stated Resident 6 needed behavioral services and maybe a psychology follow up. During a concurrent interview and record review on 3/11/2026 at 11:15 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 6's behavior care plan was reviewed. LVN 1 stated the resident required a follow up with psychology based on Resident 6 behavior and ongoing verbal repetition of past traumatic events. During an interview with the Director of Nursing (DON) on 3/12/2026 at 8:00 a.m. the DON stated if the resident has psychiatric symptoms, the resident should be referred to psych, requires an interdisciplinary team (a group of professionals from diverse fields working together to achieve shared, patient-center goals) meeting, the care plan should be updated, and behavior should be monitored. The DON stated a psych follow-up was important to assist the resident with what he/she are experiencing mentally. During a review of the facility's Policy and Procedure (P&P) titled, Behavioral Health Services dated 2001, the P&P indicated the facility will provide and residents will receive behavior health services as needed to attain or maintain highest practicable mental, physical, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to:1. Ensure one of five residents' (Resident 36's) instructions for holding parameters on medication bubble pack (sealed card containing individual, daily, or weekly doses of medication in clear, push-through plastic bubbles) for amlodipine (a medication used to treat hypertension [HTN - high blood pressure] and heart conditions) matched with physician's order, before medication administration during medication pass observation. 2. Ensure one of five residents (Resident 62's) polyethylene glycol powder (a medication in powder form used to treat constipation after being dissolved in a specific amount of water) was dissolved in the correct volume of water, in accordance with physician's order and manufacturer's specifications while preparing for administration during medication pass observation.These deficient practices increased the risk of medication errors for Residents 36 and 62 and had the potential to result in abnormal heart rate, abnormal blood pressure, swallowing difficulty and stomach discomfort.Findings: 1. During a review of Resident 36's admission Record, dated 3/10/2026, the admission record indicated the facility admitted Resident 36 on 1/21/2026 with diagnoses that included but not limited to unspecified polyneuropathy (a condition where multiple peripheral nerves throughout the body are damaged), essential (primary) hypertension and paroxysmal atrial fibrillation (an irregular, often rapid heart rate that starts suddenly and stops on its own).During a review of Resident 36's History and Physical (H&P) dated 2/4/2026, the H&P indicated Resident 36 had the capacity to understand and make decisions.During a review of Resident 36's Minimum Data Set (MDS - a resident assessment tool), dated 1/28/2026, the MDS indicated Resident 36's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was moderately impaired. The MDS indicated Resident 36 needed moderate assistance from facility staff in performing activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as eating, oral hygiene, upper body dressing and personal hygiene, and needed maximal assistance for toileting hygiene, showering, lower body dressing and putting on or taking off footwear. During a concurrent observation and interview on 3/10/2026 at 8:37 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 prepared and administered the following five medications to Resident 36. LVN 2 stated she (LVN 2) checked Resident 36's blood pressure on 3/10/2026 around 8:36 a.m., and Resident 36's blood pressure reading was 126/78 (systolic blood pressure [SBP - measures the pressure in the arteries when the heart contracts to pump blood] at 126) and (diastolic blood pressure [DBP - measures the pressure in the arteries when the heart muscle relaxes between beats] at 78 and heart rate (HR) was at 68 beats per minute. During a record review on 3/10/2026 at 8:37 a.m., during medication administration, the pharmacy label on morning medication bubble pack for Resident 36's amlodipine 5 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount) was reviewed. The pharmacy label indicated, Amlodipine besylate 5 mg, take one tablet by mouth daily for HTN. Hold if SBP less than 110 or Pulse less than 60. a. One tablet of amlodipine 5 mg with medication card label that indicated, hold if SBP less than 110 or Pulse less than 60.b. Two capsules of gabapentin (a medication used to treat nerve pain) 300 mgc. One tablet of carvedilol (a medication used to treat high blood pressure and heart conditions) 25 mg, with medication card label that indicated, hold if SBP less than 110 or Pulse less than 60.d. One patch of lidocaine (a medication used to treat localized pain) 5 percent ([%] a unit used to show potency or strength of medication)e. One capsule of docusate sodium (a medication used to treat constipation) 100 mg During a medication reconciliation review on 3/10/2026, Resident 36's Order Summary Report (a document containing a summary of all active physician orders), dated 3/10/2026 was reviewed. The order summary report included the following physician orders: Amlodipine besylate tablet 5 mg, give 1 tablet by mouth one time a day for HTN, hold if SBP less than 110, order date 2/21/2026, start date 2/22/2026. Carvedilol tablet 25 mg, give 1 tablet by mouth two times a day for hypertension, hold if SBP less than 110 or Pulse less than 60, order date 1/21/2026, start date 1/22/2026. Colace capsule (docusate sodium), give 1 capsule by mouth two times a day for bowel management, hold for loose stools, order date 1/21/2026, start date 1/22/2026. Gabapentin capsule 300 mg, give 2 capsules by mouth in the morning for neuropathy, order date 1/21/2026, start date 1/22/2026. Lidoderm Patch 5% (lidocaine), apply to bilateral knees topically in the morning for pain management and remove per schedule, order date 2/12/2026, start date 2/13/2026. During an interview on 3/10/2026 at 12:15 p.m., with LVN 2, LVN 2 stated the pharmacy label on Resident 36's amlodipine 5 mg medication bubble pack and the physician order in the electronic medical record (eMAR) should always match and align to ensure that Resident 36 was receiving the medication based on correct parameters. LVN 2 stated the pharmacy label indicated to hold amlodipine 5 mg if Resident 36's pulse or heart rate was less than 60, but the physician order instructed to hold amlodipine 5 mg only if Resident 36's SBP was less than 110. LVN 2 stated this discrepancy could place Resident 36 at risk for high or low blood pressure and high or low heart rate. During an interview on 3/11/2026 at 3:43 p.m., with the Director of Nursing (DON), the DON stated facility nurses should be checking for right resident, right medication name, right dose, right frequency, right time, right parameters, etc. before medication administration. The DON stated that the physician order in eMAR and pharmacy label should match for instructions and if there was a change in order, there should be a label alerting change in directions and facility nurse should refer to the physician order in the chart. DON stated there was a risk that amlodipine could have been inadvertently held because of pharmacy label instructions whereas the physician's order was only to hold the medication based on SBP. DON stated this placed the resident at risk for abnormal changes in heart rate. 2. During a review of Resident 62's admission record, dated 3/10/2026, the admission record indicated the facility originally admitted Resident 62 on 2/5/2025 and readmitted on [DATE] with diagnoses that included enterocolitis due to recurrent clostridium difficile (a severe, often hospital-acquired infection causing inflammation of the colon [colitis] or small intestine [enteritis], triggered by antibiotic-induced disruption of normal gut flora) and unspecified noninfective gastroenteritis (an infection causing vomiting, diarrhea, abdominal cramps, and fever, typically lasting 1-3 days) and colitis (inflammation of the inner lining of the colon).During a review of Resident 62's H&P dated 3/15/2025, the H&P indicated Resident 62 had the capacity to understand and make decisions.During a review of Resident 62's MDS dated [DATE], the MDS indicated Resident 62's cognition was intact. The MDS indicated Resident 62 was independent in performing ADLs such as oral hygiene, needed setup or clean-up assistance from the facility staff for ADLs such as eating, toileting hygiene, upper body dressing, lower body dressing, putting on or taking off footwear and personal hygiene, and needed supervision assistance for showering. During a concurrent observation and interview on 3/10/2026 between 9:03 a.m., and 9:25 a.m., with LVN 2, LVN 2 prepared and administered the following nine medications to Resident 62. LVN 2 checked Resident 62's blood pressure using a manual blood pressure monitor and stated Resident 62's blood pressure reading was 122/76 (SBP at 122 and DBP at 76) and HR was at 64. During a concurrent observation and interview on 3/10/2026 at 9:15 a.m., with LVN 2, LVN 2 was observed measuring one capful of polyethylene glycol's cap and dropped it in a cup of water and stared stirring it with a spoon. The cup looked like it was one-half to three-fourth of the way filled with water which was less than four ounces ([oz] a unit of measurement for volume) or 120 milliliters ([mL] a unit of measurement for volume). Surveyor asked LVN 2 to indicate the volume of water that was being used to dissolve polyethylene glycol powder. LVN 2 stated it was 30 mL, then stated she (LVN 2) was not sure and needed to measure the water using one oz medicine cup. LVN 2 stated the water measured to 100 mL. LVN 2 stated one capful was 17 grams ([gm] a unit of measurement for mass) of polyethylene glycol and was supposed to be dissolved in four oz which would be 120 mL. LVN 2 then added 20 mL to the water cup with 100 mL to bring the water to 120 mL for polyethylene glycol powder. a. One tablet of amlodipine 10 mg, with indication to hold if SBP was less than 110 b. One capsule of celecoxib (a medication used to treat pain and inflammation) 200 mg c. One tablet of vitamin B12 (a vitamin used to treat low level of vitamin B12 and support nerve cell health)1000 micrograms ([mcg] a unit of measurement for mass)d. One capsule of gabapentin 300 mge. One tablet of oxybutynin chloride (a medication used to treat overactive bladder symptoms) extended release 10 mgf. One tablet of multivitamin g. One capsule of docusate sodium 250 mgh. One tablet of losartan (a medication used to treat high blood pressure) 50 mg with indication to hold if SBP less than 110 or HR less than 60i. 17 gm of polyethylene glycol powder dissolved in four to eight ounces of water During a medication reconciliation review on 3/10/2026, Resident 62's Order Summary Report, dated 3/10/2026, was reviewed. The order summary report indicated, but not limited to the following physician orders: Amlodipine besylate oral tablet 10 mg, give 1 tablet by mouth one time a day for HTN, Hold if SBP less than 110, order date 3/12/2025, start date 3/13/2025. Celebrex oral capsule 200 mg (celecoxib), give 200 mg by mouth one time a day for pain, order date 3/21/2025, start 3/22/2025. Cyanocobalamin oral tablet 1000 mcg, give 1 tablet by mouth one time a day for vitamin B12 deficiency, order date 3/12/2025, start date 3/13/2025. Docusate sodium oral capsule 250 mg, give 1 capsule by mouth one time a day for constipation, hold for loose stool, order date 1/24/2026, start date 1/25/2026. Gabapentin capsule 300 mg, give 1 capsule by mouth three times a day for diabetic neuropathy, order date 5/2/2025, start date 5/2/2025. Losartan potassium oral tablet 50 mg, give 1 tablet by mouth two times a day for HTN hold if SBP less than 110 or Pulse less than 60, order date 3/6/2026, start date 3/7/2026. Multivitamin oral tablet, give 1 tablet by mouth one time a day for supplement, order date 3/12/2025, start date 3/13/2025. Oxybutynin chloride ER oral tablet extended release 24-hour 10 mg, give 1 tablet by mouth one time a day for overactive bladder, order date 7/29/2025, start date 7/30/2025. Polyethylene Glycol 3350 Powder, give 17 grams by mouth one time a day for constipation, mix in 4 to 8 ounces of fluid. If no bowel movement (BM) in past 72 hours 17 gram = 1 scoop, order date 3/12/2025, start date 3/13/2025. During an interview on 3/10/2026 at 12:15 p.m., with LVN 2, LVN 2 stated polyethylene glycol powder should have been dissolved in the volume of water specified by manufacturer and physician's order to prevent the risk of difficulty in swallowing for Resident 62. LVN 2 stated there was a risk that Resident 62 could have received improperly dissolved medication. During an interview on 3/11/2026 at 3:33 p.m., with the DON, the DON stated polyethylene glycol powder usually should be mixed with eight ounces of water or juice to dissolve the powder. The DON stated if the order indicated four to eight oz, then it would be okay to use that volume. The DON stated there was a risk of not following manufacturer's specifications, and polyethylene glycol would not be effective and there would be a risk of swallowing discomfort and difficulty for the resident. The DON stated if polyethylene glycol was not administered in proper dosage, then the medication might not be effective for resident's bowel management. During a review of facility's policy and procedure (P&P) titled, VII. Preparation for Medication Administration - Medication Administration - General Guidelines, undated, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The P&P indicated, Prior to administration, the medication and dosage schedule on the resident's Medication Administration Record (MAR) is compared with the medication label. If the label and MAR are different.the physician's orders are checked for the correct dosage schedule. The P&P indicated, Medications are administered in accordance with written orders of the attending physician.

Based on observation, interview, and record review, the facility failed to:1. Ensure one of five residents (Resident 36's) five (5) medications that included amlodipine (a medication used to treat hypertension [HTN - high blood pressure]), gabapentin (a medication used to treat nerve pain), carvedilol (a medication used to treat HTN), lidocaine patch (a medication applied on skin to treat localized pain) and docusate sodium (a medication used to treat constipation) were secured and not left unattended on bedside cart with the resident during medication pass observation.2. Ensure that the discarded medications in two of two inspected medication carts (Station 1 Morning Medication Cart 1 also known as split cart and Station 2 Medication Cart 4) were stored in a closed-lid container and/or disposed of in an irretrievable, safe and secure manner.These deficient practices failed to destroy the unidentifiable discarded medications and secure Resident 36's prepared medications, resulting in an unsafe and unsecure environment for medication storage in medication carts and Resident 36's room, increasing the risk of medication self-administration without supervision for Resident 36, and had the potential to result in medication errors and/or incorrect ingestion, and retrieval and/or misuse of discarded medications. Findings:1. During a review of Resident 36's admission Record dated 3/10/2026, the admission record indicated the facility admitted Resident 36 on 1/21/2026 with diagnoses that included but not limited to unspecified polyneuropathy (a condition where multiple peripheral nerves throughout the body are damaged), essential (primary) hypertension and paroxysmal atrial fibrillation (an irregular, often rapid heart rate that starts suddenly and stops on its own).During a review of Resident 36's History and Physical (H&P) dated 2/4/2026, the H&P indicated Resident 36 had the capacity to understand and make decisions.During a review of Resident 36's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 1/28/2026, the MDS indicated Resident 36's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was moderately impaired. The MDS indicated Resident 36 needed moderate assistance from the facility staff in performing activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as eating, oral hygiene, upper body dressing and personal hygiene, and needed maximal assistance (helper does all the effort) for toileting hygiene, showering, lower body dressing and putting on or taking off footwear.During a concurrent observation and interview on 3/10/2026 at 8:37 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 prepared five medications for Resident 36 outside of Resident 36's room. LVN 2 stated she (LVN 2) checked Resident 36's blood pressure on 3/10/2026 around 8:36 a.m., and Resident 36's blood pressure reading was 126/78 (systolic blood pressure [SBP - measures the pressure in the arteries when the heart contracts to pump blood] at 126) and (diastolic blood pressure [DBP - measures the pressure in the arteries when the heart muscle relaxes between beats] at 78 and heart rate (HR) was at 68 beats per minute. LVN 2 entered Resident 36's room and placed the following five medications on Resident 36's bedside cart in front of her (Resident 36). Resident 36 was observed requesting juice instead of water to take with her (Resident 36's) medications. LVN 2 turned around, left the medications unattended and unsecured with Resident 36, walked to the medication cart and brought juice for Resident 36.1. One tablet of amlodipine 5 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount) with medication card label that indicated, hold if SBP less than 110 or Pulse less than 60.2. Two capsules of gabapentin 300 mg3. One tablet of carvedilol 25 mg, with medication card label that indicated, hold if SBP less than 110 or Pulse less than 60.4. One patch of lidocaine 5 percent ([%] a unit used to show potency or strength of medication)5. One capsule of docusate sodium 100 mgDuring an interview on 3/10/2026 at 12:15 p.m. with LVN 2, LVN 2 stated she recalled that she turned away to go to the medication cart when Resident 36 requested to receive juice instead of water. LVN 2 stated she left the medications unattended with Resident 36 which increased the risk that resident could have pocketed or taken medications incorrectly.During an interview on 3/11/2026 at 3:05 p.m. with the Director of Nursing (DON), the DON stated it was always important to secure meds and medications should not be left unattended with the residents. The DON stated if the medications went out of sight without supervision, you don't know what will happen. The DON stated if the residents took medication without supervision, there was a risk of not knowing what the resident would do if they took the medication or if they took them correctly. DON stated LVN should have taken the medications with them to the medication cart and returned with the juice.2a. During a concurrent observation and interview on 3/10/2026 at 3:04 p.m. with LVN 1 of Split Cart Station 1 Morning Medication Cart 1, the medication cart contained one red container with an open lid filled with a few unidentified white tablets of different shapes and sizes in the bottom drawer such that the medications were retrievable. LVN 1 stated, these tablets were probably medications that were refused or dropped on the floor and then discarded. LVN 1 stated they should have been in a closed bin and not retrievable because it would not be safe and had a risk of misuse.2b. During a concurrent observation and interview on 3/10/2026 at 3:38 p.m. with LVN 6 of Station 2 Medication Cart 4, the medication cart contained one red container with an open lid filled with a few unidentified tablets and capsules with varied shapes, sizes and colors, such as yellow, white, orange and pink, in the bottom drawer such that the medications were retrievable. LVN 6 was observed trying to close the lid and could not close. LVN 6 stated, it was not safe to have such a bin because anyone could go through the bin and retrieve medications for misuse. LVN 6 stated it was not in the medication cart on the day before and it was possible that these meds were placed in the red bin after they were refused. LVN 6 stated she would discard the red bin at the end of her shift.During an interview on 3/11/2026 at 3:22 p.m. with the DON, the DON stated the red bins were used to discard refused medications or for discarding capsule shells, for example, if a capsule needed to be opened and the shell needed to be discarded. The DON stated it would be safe if the red bins were closed. The DON stated the nursing staff should have added liquid or water to dissolve the discarded medications to ensure they were irretrievable and to prevent risk of misuse and inadvertent administration. During a review of the facility's policy and procedures (P&P) titled, Medication Storage in the Facility - Storage of Medications, undated, the P&P indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The P&P indicated, Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of .for medication disposal and reordered.if current order exists. Medication storage areas are kept clean, well lit, and free of clutter and extreme temperatures.During a review of the facility's P&P titled, Drug Disposition - Procedure for Disposal, undated, the P&P indicated, Discontinued or outdated non-controlled drugs are to be stored in a secured area designated for that purpose until picked up by the pharmaceutical waste disposal service or the pharmacy personnel. During a review of the facility's P&P titled, Medication Administration - General Guidelines, undated, the P&P indicated, During administration of medications.all other sides closed. No medications are kept on top of the cart. The resident is always observed after administration to ensure that the dose was completely ingested.

Based on interview and record review, the facility failed to ensure a resident, who had diagnoses of congestive heart failure ([CHF] a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), chronic obstructive pulmonary disease with acute exacerbation ([COPD] a chronic lung disease causing difficulty in breathing), chronic respiratory failure (a long-term condition where the lungs cannot supply enough oxygen to the blood or remove enough carbon dioxide) and dependence on supplemental oxygen (O2) was not administered a narcotic (a substance used to treat moderate to severe pain by binding to opioid receptors in the central nervous system)-analgesic (a drug or agent used to relieve pain, acting as a painkiller); Hydrocodone-Acetaminophen ([Norco] used for pain relief) concurrently with benzodiazepines (a class of prescription drugs that slow down the central nervous system ([CNS] a complex of nerve tissues that controls the activities of the body) used for anxiety [a feeling of fear, dread, and uneasiness]), a sedative medication Diazepam, an antipsychotic medication Olanzapine (used to treat mental health condition including schizophrenia [a disorder characterized by disruptions in thought processes, perceptions, and emotional responsiveness] and bipolar disorder [a disorder characterized by extreme mood swings]), and an anti-anxiety medication Buspirone Hydrochloride (used to treat anxiety) for one of four sampled residents (Resident 2) who became unresponsive and stopped breathing. The facility failed to: 1. Ensure licensed nurses recognized the increased effect of CNS depressants (drugs that slow down brain activity, reducing arousal and stimulation leading to relaxation, drowsiness and slowed reflexes), Diazepam, Olanzapine, Buspirone Hydrochloride, in combination with Norco, causing Resident 2's oversedation (a condition resulting in a decreased level of consciousness that interferes with a patient's proper assessment, recovery, and essential bodily functions like breathing) and affecting Resident 2's ability to breathe. On 11/1/2025 after concurrent administration of Norco, Diazepam, Olanzapine and Buspirone Hydrochloride, Resident 1 became unresponsive, was without a pulse and stopped breathing. 2. Ensure licensed nurses monitored the black box warning for Buspirone HCL as ordered by the physician on 10/31/2025 to avoid concomitant (occurring at the same time) administration of benzodiazepines and narcotics which could result in Resident 2's profound sedation, respiratory depression, coma, and death. 3. Ensure the Director of Staff Development (DSD) provided training to licensed vocational nurses, who administered medications in the facility, on black box warnings and use of narcotics-analgesics concurrently with psychotropic medications. 4. Ensure licensed nurses followed the facility's Policy and Procedure (P&P) titled, Administering Medications dated 1/2024, which indicated If .a medication has been identified as having potential adverse consequences (a negative or harmful result) for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medications will contact the prescriber, attending physical, or facility medical director to discuss concerns. These deficient practices resulted in Resident 2 experiencing a cardiac arrest (when the heart suddenly and unexpectedly stops beating) on 11/1/2025, transfer to a General Acute Care Hospital (GACH) 2 where Resident 2 was intubated (having a breathing tube inserted through the mouth or nose into the windpipe to maintain an open airway and assist breathing, often through a mechanical ventilator [a medical treatment using a machine to support or take over a patient's breathing]) and admitted to the intensive care unit ([ICU] a hospital department that provides constant, specialized medical care to critically ill patients with life-threatening conditions). On 11/3/2025 Resident 2 experienced an acute hypoxic hypercapnic respiratory failure (a life-threatening condition where the body has both too little O2 and too much carbon dioxide [a colorless odorless gas] in the blood) and died later the same day. On 11/21/2025 at 5:45 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 called in the presence of the facility's Administrator (ADM) and Director of Nursing (DON) due to the facility's failure to recognize the increased effect of the concurrent administration of sedative, anti-anxiety, psychotropic, and narcotic- analgesic medication, leading to Resident 2's oversedation, CNS depression and subsequent respiratory arrest (when a person stops breathing or their breathing becomes too weak to sustain life). These deficient practices placed 31 other residents, who were receiving narcotics and psychotropic medications, at increased risk for oversedation, CNS depression, respiratory failure and cardiac arrest. On 9/10/2025, the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on 9/10/2025 at 3:40 p.m., in the presence of the facility's DON and ADM.On 11/23/2025, the facility submitted an acceptable IJ Removal Plan ([IJRP] intervention to immediately correct the deficient practice) after onsite verification of the IJRP's implementation through observation, interview, and record review, the IJ was removed on 11/23/2025 at 12:54 p.m., in the presence of the facility's ADM and DON. The facility's IJRP included the following immediate actions: 1. On 11/2220/25, the DON provided 1:1 training with LVN 1 on the following. 2. Drug interactions between narcotics (a substance used to treat moderate to severe pain by binding to opioid receptors in the central nervous system) and benzodiazepines drugs. 3. Indication for use of narcotic medications, side effects, drug interactions, dosage and black box warnings (the strongest warning issued by the U.S. Food and Drug Administration for a prescription drug, indicating there is a reasonable association between the drug and a serious hazard that may result in death or serious injury). 4. The location of the medication information (Drug Reference Handbook). 5. Initiating a change of condition (COC) and notification to the physician for any medication adverse effects or signs and symptoms of opioid overdose. HOW TO IDENTIFY OTHER RESIDENTS: On 11/21/2025 and 11/22/2025, DON and ADON reviewed current residents with orders for narcotic medications. There were 50 residents with narcotic orders. The DON and/or ADON will obtain an order for the 50 residents with narcotic orders to monitor or s/s of and side effects every shift and to document in the Medication Administration Record (MAR). On 11/22/2025, the facility's Pharmacy Consultant conducted a medication review of residents with orders for narcotics, benzodiazepine, and psychotropic (used to treat mental disorders including antidepressants, antipsychotics sedative, anti-anxiety and narcotics) medications for possible drug interactions. There were 31 residents with orders for both narcotics and benzodiazepines/psychotropic medications. The Pharmacist Consultant's recommendations will be communicated to the physician and orders will be carried out by 11/22/25. On 11/22/2025, the Clinical team which includes the DON, ADON, Quality Assurance (QA) Nurse, Nursing Supervisor, and Licensed Nurses reviewed 31 residents with orders for narcotic, benzodiazepines and psychotropic drugs for s/s of drug overdose. SYSTEMIC CHANGES: On 11/21/2025 and 11/22/2025, the DON and DSD conducted an in-service training with licensed nurses on the following topics: 1. Drug interactions between benzodiazepines, sedative, anti-anxiety and psychotropic drugs. 3. Indication of narcotic medications, side effects, drug interactions, dosage and black box warnings. 4. The location of the medication information (Drug Reference Handbook). 5. Initiating COC and notification to the physician for any medication adverse effects or signs and symptoms of oversedation and/or CNS depression due to concurrent administration of narcotic-analgesics, sedatives, anti-anxiety and psychotropics. On 11/22/2025, Pharmacy Consultant conducted an in-service with the licensed nurses on the possible drug interaction of medications when given together such as benzodiazepine, and psychotropic medications. The remaining licensed nurses will be provided in-service by the DON/Designee on the first day of returning to work. On 11/22/2025 the Quality Assurance Committee met with the Medical Director, ADM, Pharmacy Consultant, DON, DSD, ADON, and QA Consultant to discuss the deficient practices identified and the corrective action to prevent re-occurrence of the deficient practices. On 11/21/2025 and 11/22/2025, the DSD and the QA Nurse Consultants initiated the knowledge competencies with licensed nurses on the following: 1. The location of the medication's information (Drug Reference Handbook). 2. Initiating COC and notification to the physician for any medication adverse effects or signs and symptoms of opioid overdose. The DSD and/or DON will continue to provide in-service training and complete knowledge competencies until all licensed nurses have gone through the training and competencies by 11/24/2025. The In-service and knowledge competencies will be completed by the licensed nurses on leave on their first day of returning to work. The DSD will incorporate the knowledge competency with the licensed nurses' orientation program; this will be completed during the new hire orientation then annually and as needed. The DSD and the DON will provide quarterly in-services with the licensed nurses on the following: 1. The location of the medication's information (Drug Reference Handbook). 2. Initiating COC and notification to the physician for any medication adverse effects or signs and symptoms of opioid overdose. MONITORING PROCESS: The DON will track any trends or concerns related to side effects, and drug interactions identification; this will be communicated to the QA & A Committee for further evaluation and recommendations monthly. If it is determined that we have accomplished the objectives in the POC (plan of correction) above and the results are successful, then the facility will consider the matter resolved. The QA & A committee will continue to review until such time that the deficiency has been proven to be resolved for three consecutive months and/or advised by the QA & A Committee.Findings: During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including CHF, COPD, chronic respiratory failure, and dependence on supplemental O2. During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool) dated 8/21/2025, the MDS indicated Resident 2 had moderate cognitive impairment (the ability to think and reason). During a review of Resident 2's Progress Note dated 10/19/2025, the Progress Note indicated Resident 2 had an unwitnessed fall at 10:30 p.m., 911 was called, and paramedics transported Resident 2 to a General Acute Care Hospital (GACH) 1 at 11:05 p.m. During a review of Resident 2's Paramedic Incident Report dated 10/19/2025, the Paramedic Incident Report indicated Resident 2 had shortness of breath (SOB) for one hour and his lung sounds revealed rhonchi (a continuous, low-pitched, rattling lung sounds that often resemble snoring or gurgling caused by airflow obstruction). The Paramedic Incident Report indicated Resident 2 was transported to a GACH 1 emergency department, where he was until 10/31/2025. During a review of the GACH 1's Plan and Goals for admission dated 10/31/2025, the Plan and Goals for admission indicated, Physician (MD) 2, a pulmonary specialist (a physician specializing in the respiratory system, including the lungs, airways, and blood vessels), recommended to decrease Resident 2's sedative medications (a class of medications that slows down the central nervous system to relieve anxiety or induce sleep) polypharmacy (the simultaneous use of multiple drugs to treat a single ailment or condition) as it was likely the culprit (the cause of a problem) of Resident 2's recurrent respiratory failure. During a review of Resident 2's Physician's Order dated 10/31/2025, the Physician's Order indicated to readmit Resident 2 to the facility. During a review of Resident 2's Physician's Order dated 10/31/2025, the Physician's Order indicated the following orders: 1. Buspirone HCL oral tablet 10 mg twice a day for anxiety manifested by verbalizing persistent worry regarding his health and living circumstance. 2. Monitor the black box warning for Buspirone HCL that indicated concomitant (occurring at the same time) use of benzodiazepines and narcotics may result in profound sedation, respiratory depression, coma, and death. The black box warning indicated to reserve concomitant prescribing of these drugs for use in patients whom alternative treatment options are inadequate, to limit dosages and durations to the minimum required, and to follow patients for signs and symptoms (s/s) of respiratory depression and sedation every shift. 3. Diazepam 7.5 - milligram ([mg] a unit of dose measurement) three times a day for anxiety. 4. Norco 7.5 mg/325 mg every six hours as needed for moderate to severe pain. 5. Olanzapine 10 mg twice a day for a psychotic disorder (a serious mental illness characterized by a loss of contact with reality) related to a panic disorder (an anxiety disorder characterized by recurrent, unexpected panic attacks [sudden episodes of intense fear accompanied by physical symptoms like a pounding heart, sweating, and dizziness]). 6. Olanzapine 15 mg at bedtime for a psychotic disorder. 7. Administer O2 at three liters ([L] a unit of measurement) per minute via a nasal cannula (a medical device that delivers supplemental O2 through a lightweight tube with two prongs that rest in the nostrils) at all times. During a review of Resident 2's Medication Administration Audit Report (MAAR) dated 11/2025, the MAAR indicated the following medication was administered to Resident 2 on 11/1/2025: 1. LVN 1 administered Norco 7.5 mg-325 mg to Resident 2 at 8:30 a.m. 2. LVN 1 administered Buspirone HCL 10 mg to Resident 2 at 8:50 a.m. 3. LVN 1 administered Diazepam 7.5 mg to Resident 2 at 8:50 a.m. 4. LVN 1 administered Olanzapine 10 mg to Resident 2 at 8:50 a.m. During a review of Resident 2's Progress Note dated 11/1/2025, the Progress Note indicated at 9:07 a.m., Certified Nursing Assistant (CNA) 1 made LVN 1 aware that Resident 2 was unresponsive. The Progress Note indicated upon entering Resident 2's room, LVN 1 noted Resident 2 was sitting up in bed, unresponsive to verbal commands, diaphoretic (profuse sweating), and still breathing. The Progress Note indicated a code blue (signifies a patient requires immediate resuscitation, most often due to cardiac or respiratory arrest) was called but before the crash cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations) arrived, Resident 2 stopped breathing. The Progress Note indicated Cardiopulmonary resuscitation ([CPR] an emergency treatment that's done when someone's breathing or heartbeat has stopped) began at 9:09 a.m., 911 was called, and CPR continued until 9:20 a.m., until paramedics arrived and took over CPR. The Progress Note indicated Resident 2's pulse returned, and he was transferred to a GACH 2 at 9:27 a.m. During a review of Resident 2's Paramedic Incident Report dated 11/1/2025, the Paramedic Incident Report indicated paramedics arrived to the facility at 9:13 a.m., and were informed that Resident 2 received Norco 7.5 mg/325 mg at 8:30 a.m. The Paramedic Incident Report indicated upon arrival Resident 2 had altered level of conciseness (ALOC) with pinpoint pupils (abnormally constricted pupils that could be caused by opioid use, other medications, brain injuries, certain infections, or other medical conditions) and his Glascow Coma Scale ([GCS] a neurological assessment tool used to rate a person's level of consciousness based on their eye opening, verbal, and motor responses) was 3 (normal score being 15, and 3 being the lowest possible score indicating a coma). The Paramedic Incident Report indicated paramedics administered one dose of Narcan 2 mg via inhalation at 9:31 a.m., while enroute to the GACH but it did not yield positive result and Resident 2 remained with ALOC. The Paramedic Incident Report did not indicate the nursing staff informed the paramedics of the other medications Resident 2 received. During a review of the GACH's Emergency Department (ED) record dated 11/1/2025 and timed at 9:39 a.m., the ED record indicated upon arrival to the ED Resident 2 had agonal respirations (gasping, shallow, irregular breaths that occur when the brainstem is trying to compensate for a lack of O2) at six breaths per minute (normal respiration 12 to 20 breaths per minute for a healthy adult). The ED record indicated in the field, Resident 2 presented with pinpoint pupils and received Narcan with no change in level of consciousness. The ED record indicated Resident 2 was intubated shortly after arrival for airway protection. During a review of the GACH's Discharge summary dated [DATE], the Discharge Summary indicated Resident 2 was brought to the ED and was intubated due to acute hypoxic hypercapnic respiratory failure (a life-threatening condition where the body has both too little oxygen and too much carbon dioxide [a naturally occurring, colorless, odorless gas] in the blood). During a review of the GACH Discharge summary dated [DATE], the Discharge Summary indicated on 11/3/2025 Resident 2 was admitted to the ICU where a bronchoscopy (a medical procedure where a thin, flexible tube called a bronchoscope is inserted through the nose or mouth to examine the airways and lungs) was done. The bronchoscopy showed Resident 2's left side mainstem bronchus (one out of the two large airway branches that carry air to the lungs) was completely blocked by mucus (a slimy substance secreted by mucous membranes and glands for lubrication and protection). The GACH Discharge Summary indicated Resident 2 was extubated (to remove a tube of artificial ventilation) on 11/1/2025 and transferred to the ward (a lower level of care due to a stable condition). The GACH 2's Discharge Summary indicated on 11/3/2025 in the a.m. (time unknown) Resident 2 had hypoxic hypercapnic respiratory failure but improved with aggressive suctioning (a procedure that uses negative pressure to remove bodily fluids, gases, or secretions to maintain a clear airway) and was transferred to the telemetry unit (a hospital floor where patients are continuously monitored for cardiac and vital signs). The GACH 2's Discharge Summary indicated on 11/3/2025, at 5:16 p.m., Resident 2 became more somnolent (sleepy and drowsy) with labored (done with great effort and difficulty) breathing that was not improving with aggressive suctioning, and Resident 2 presented without a gag reflex (an involuntary, protective reflex triggered by touching the back of the throat, which causes the throat muscles to contract and the soft palate to lift) and hypercapnic respiratory failure (when the lungs cannot remove enough carbon dioxide from the blood, causing it to build up). The GACH 2's Discharge Summary indicated comfort measures (a type of care focused on relieving pain and other symptoms, rather than curing an illness) were pursued at 5:43 p.m., and Resident 2 was pronounced dead at 7:20 p.m. During an interview on 11/19/2025 at 9:17 a.m., LVN 1 stated she gave Resident 2 Norco 7.5 mg/325 mg at approximately 8:30 a.m., and at approximately 9 a.m., she gave him Diazepam, Buspirone HCL, Olanzapine. LVN 1 stated at that time Resident was awake, alert, and oriented. LVN 1 stated at 9:05 a.m. to 9:10 a.m., CNA 1 stood outside Resident 2's doorway and reported to her that something was wrong with Resident 2. LVN 1 stated when she went into Resident 2's room he was sitting up in bed and was observed with shortness of breath (SOB). LVN 1 stated Resident 2 was unresponsive to verbal stimuli (a word phrase, or other language pattern [spoken, written, or signed] that acts as a trigger or cue) and was leaning forward trying to catch his breath. LVN 1 stated she called a code blue due to Resident 2's unresponsiveness, but he still had a pulse at that time. LVN 1 stated one minute later, after the code blue was called, Resident 2 was no longer breathing and had no pulse. LAN 1 stated she flattened his bed, placed a board under him, and Registered Nurse (RN) 1 began compressions (the manual pushing of a person's chest to simulate a heartbeat, helping to pump blood and oxygen throughout the body). LVN 2 stated someone from the team (unknown) called 911 and CPR continued until paramedics arrived. Paramedics took over CPR and transferred Resident 2 to GACH 2. During an interview on 11/20/2025 at 1:08 p.m., LVN 1 stated she did not recall what Olanzapine was indicated for when she administered it to Resident 2 at 9 a.m., with Diazepam, Buspirone and Norco medications on 11/1/2025. LVN 1 stated the side effects of Norco and Diazepam could cause drowsiness or depression of respirations. LVN 1 stated she was not aware of the interactions between Diazepam, Norco, and Buspirone, but stated she followed the physician's orders. LVN 1 stated she was not familiar with the black box warning for Buspirone, and she monitors side effects, but does so toward the end of her shift. During an interview on 11/19/2025 at 9:36 a.m., the facility's Pharmacy Consultant (PC) stated the combination of Norco 7.5 mg/325 mg and Diazepam 7.5 mg that Resident 2 received, had a high risk for oversedation and respiratory failure due to CNS depression since the combination had a synergistic (a term to describe an interaction between two or more drugs where their combined effect is greater than the sum of their individual effects) effect to it. The PC stated Buspirone HCL, narcotics, Buspirone HCL and benzodiazepines, or all three combined, could contribute to CNS depression resulting in respiratory failure. The PC stated the combination of Norco, Diazepam, and Olanzapine could also synergistically and consequently cause a drug overdose, presenting as altered mental status (AMS), comatose, unresponsiveness, labored breathing and/or low breaths per minute. The PC stated ideally, when LVN 1 administered Norco to Resident 2, she should have conducted a follow up assessment thirty minutes to an hour later and prior to giving any other medications to determine whether it was safe to give other medications to Resident 2. The PC stated, since Diazepam and Olanzapine were new medications prescribed to Resident 2, and not something they routinely gave to Resident 2 at the facility; there should have been extra precautions and monitoring taken. The PC stated knowing Resident 2's history and tolerance of medications prior to administering a combination like Diazepam and Norco was important, but as a pharmacist he would not recommend to give these medications concurrently due to the high risk of oversedation and CNS depression. The PC stated pinpoint pupils were a cholinergic (parasympathetic nervous system [part of the nervous system that controls involuntary body functions when at rest, such as digestion, heart rate, and breathing response which decreases the heart rate, increases pupil constriction, and increased digestion and urination]) response from narcotic, oversedation, labored breathing, and respiratory distress (the difficulty or inability to breathe, characterized by symptoms like SOB, rapid or noisy breathing, and sweating). The PC stated Resident 2 had a history of COPD so if he had respiratory depression and was intubated, his recovery would be more difficult because he was elderly and did not have the strength. The PC stated staff should have reported to the paramedics that Resident 2 received benzodiazepines concurrently with narcotic-analgesic because flumazenil ([Romazicon] an intravenous [IV] in the vein] medication that acts as a specific antidote [drugs used to counteract or neutralize the effects of another substance, such as an anesthetic, narcotic, poison, or toxin] to reverse the sedative effects of benzodiazepines) could have been administered to Resident 2 to act as a reverse agent. During an interview on 10/19/2025 at 10:38 a.m., Resident 2's physician stated he did not recall if he ordered Olanzapine or Diazepam for Resident 2, but any new psychiatric and/or psychotropic medications prescribed for Resident 2 was likely transcribed from the GACH 1's discharge summary because 93% of the time he does not prescribe psychiatric medications. Resident 2's physician stated Resident 2 displayed a lot of anxiety and was being seen by a psychiatrist. Resident 2's physician stated s/s of suspected oversedation included not responding to stimuli (verbal, physical [light, sound, touch, pain, temperature, smells, tastes, irritants]), a slow respiratory rate less than 5-10 breaths per minute, and constricted pupils (pinpoint pupils). Resident 2's physician stated pinpoint pupils, and decreased response would go along with the sedatives/narcotics mix, and that combination of medications could cause decreased responsiveness and decreased respiratory rate. Resident 2's physician stated he was aware that Resident 2 was transferred to GACH 2 on 11/1/2025 but stated he did not know the details of what happened to Resident 2. During an interview on 11/19/2025 at 11:18 a.m., the DON stated Resident 2 was not taking Diazepam or Olanzapine prior to his hospitalization on 10/19/2025. The DON stated if she was not familiar with a drug or how it interacted with other medications, she would look it up to avoid possible reactions, and/or clarify the order with physician. The DON stated side effects of narcotics and benzodiazepines both include depression of respirations, AMS/ALOC and confusion. The DON stated she would be cautious giving Resident 2 Norco and Diazepam concurrently and would check the resident's respirations since both medications were CNS depressants. The DON stated Buspirone HCL, narcotics and/or benzodiazepines combined could place Resident 2 at an increased risk for CNS depression. The DON stated there was a black box warning for Buspirone HCL on Resident 2's Medication Administration Record (MAR), but it was not signed off by LVN 1 to acknowledge that she read it prior to administering the medications to Resident 2. During an interview on 11/19/2025 at 12:39 p.m., with the DSD, the DSD stated she was responsible for training staff in medication administration but stated in the past one year and six months to two years that she had worked at the facility, she had not trained staff on black box warnings, or use of narcotics concurrently with psychotropic medications. The DSD stated if licensed nurses were not familiar with a drug, they should call the doctor or pharmacist. During an interview on 11/21/2025 at 9:48 a.m., the psychiatric Nurse Practitioner (NP) stated Diazepam 7.5 mg was a large dose and he was not aware that Resident 2 was prescribed Diazepam or Olanzapine. The NP stated Resident 2 received Buspirone and Norco together without issues in the past because his tolerance of the medications was high. The NP stated the combination of Olanzapine, narcotic-analgesic, and Diazepam could have a sedative effect, and the narcotic pain medication and benzodiazepine should be spaced out at least one hour from each other and not given concurrently. The NP stated if he would have known Resident 2 was prescribed Olanzapine, he would have adjusted the dose because 10 mg twice a day and 15 mg at night was a lot. The NP stated, he would have clarified the indication for Olanzapine's use because Resident 2 did not have a diagnosis to support the prescription of that medication. The NP stated he would have also adjusted the dose of the Diazepam to be lower, because Norco and Diazepam were both CNS depressants. During a review of the National Library of Medicine's drug information on hydrocodone bitartrate and acetaminophen usage warning, revised on 10/6/2025, the National Library of Medicine's drug information indicated concomitant use of narcotics with benzodiazepines or other central nervous system depressants such as antipsychotics may result in profound sedation, respiratory depression, coma, and death. The National Library of Medicine's drug information warning indicated serious, life-threatening, or fatal respiratory depression has been reported with the use of narcotics, even when used as recommended and that respiratory depression, if not immediately recognized and treated, may lead to respiratory arrest and death. The National Library of Medicine's drug information indicated management of respiratory depression may include close observation, supportive measures, and use of narcotics antagonists (a substance which interferes with or inhibits the physiological action of another substance), depending on the patient's clinical status. The National Library of Medicine's drug information indicated narcotics can cause sleep-related breathing disorders including central sleep apnea (CSA, a sleep disorder where the brain temporarily fails to send signals to the muscles that control breathing, causing repeated pauses in breathing during sleep) and sleep-related hypoxemia. https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl. During review of facility's P/P titled Administering Medications dated 1/2024, the P/P indicated If a dosage is believed to be inappropriate for a resident, or a medication has been identified as having potential adverse consequences (a negative or harmful result) for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medications will contact the prescriber, attending physical, or facility medical director to discuss concerns.

Based on interview and record review the facility failed to ensure four out of eight sampled residents (Resident 6, Resident 26, Resident 29, and Resident 30) were free of a significant medication error. The facility failed to: 1. Ensure the licensed nurses checked Resident 6's heart rate prior to administering Amiodarone on as ordered 13 times from 10/1/2024 to 10/31/2024, and 13 times from 11/1/2024-11/20/2024. 2. Ensure Resident 26's Mexiletine (medication for the treatment of life-threatening heart disease including ventricular arrhythmias [an irregular heartbeat], such as sustained ventricular tachycardia [a rapid, irregular heartbeat], a life-threatening arrhythmia [an irregular heartbeat) 150 milligrams ([mg] a unit of weight measurement) was administered every eight hours as prescribed by the cardiologist (heart doctor [MD 2]). 3. Ensure Resident 26's medication Mexiletine 150 mg, was available for administration on 10/20/2024 to receive at 4 pm as ordered and scheduled. 4. Ensure the Quality Assurance Performance Improvement ([QAPI] a group who takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) identified and acted to correct the error in Mexiletine administration Resident 26 per facility's policy and procedure titled Adverse Consequences and Medication Errors dated 2/2023. 5. Ensure Resident 26 received Mexiletine on 10/20/2024 at 4 p.m. and on 11/8/2024, 11/26/2024 and 12/2/2024 at 8:00 a.m., 4 p.m. and 12:00 a.m. as ordered and not in less than eight hours between doses as ordered. 6. Ensure licensed vocational nurse (LVN 2) communicated Resident 26's late administration of Mexiletine to LVN 5 from oncoming shift, who would be administering the next dose to Resident 26 to prevent Mexiletine administration in less than eight hours. 7. Ensure licensed nurses monitored Resident 26 for Mexiletine adverse effects, including cardiac arrhythmias, when LVN 1 missed administering dose of Mexiletine on 10/20/2024 at 4 p.m. as ordered and scheduled. 8. Ensure the licensed nurses did not administer Midodrine to Resident 29 when the resident's systolic blood pressure ([SBP] the pressure of blood against the blood vessel walls when the heart contracts and pumps blood. It's the top number in a blood pressure reading) was greater than 130 as ordered by the physician and indicated in Resident 29's untitled Care Plan initiated on 10/6/2023. 9. Ensure the licensed nurses check Resident 30's blood pressure and pulse rate before administering Amiodarone as ordered. 10. Ensure the licensed nurses followed the facility's policy and procedure titled, Administering Medications to act upon the physician's orders to administer medication as ordered to minimize the risk of adverse consequences (an undesired effect of a drug) including chest pain and palpitations [a skipped, irregular, or extra heartbeat]) to Resident 6, 26, 29 and 30. These deficient practices resulted in: 1. Resident 26 missing one dose of Mexiletine on 10/20/2024 which can cause worsening cardiac arrhythmia. Resident 26 complained of feeling severe palpitations and feeling scared when he did not receive the ordered/scheduled dose. 2. Resident 26 was placed at high risk for liver toxicity (a condition that occurs when the liver is damaged by a harmful substance, such as a chemical, medication, supplement, or alcohol) and fatal (deadly) arrhythmias due to receiving Mexiletine in less than eight hours between doses. 3. Residents 6, 11, 20, 26, 30, 43, 51, and 70 who were receiving antiarrhythmic (used to treat irregular heart rhythm) medications were placed at risk to not receive medication as ordered resulting in potential worsening of cardiac arrhythmia. 4. Residents 6, 29, and 30 were placed at risk for low heart rate and low blood pressure (the pressure of blood on the walls of the arteries as the heart pumps blood around your body) when a physician's parameters (specific instructions that you can measure before medication administration) for administration of Amiodarone, Midodrine (used to treat low blood pressure) and Amlodipine Besylate (blood pressure medication) were not followed. On 12/6/2024 at 9:17 a.m., an Immediate Jeopardy ([IJ] a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Director of Nursing (DON) and the facility's Administrator (ADMIN) due to the facility's failure to prevent significant medication errors. On 12/7/2024 at 8:05 a.m., the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on 12/7/2024 at 12:50 p.m., in the presence of the DON and ADMIN. The IJRP included the following immediate actions: a. Resident 26 was seen by MD 2 on 12/6/2024. The DON spoke to MD 2 and informed him Resident 26 missed a dose of Mexiletine on 10/20/2024 and was given a late dose on 11/8/2024, 11/26/2024 and 12/2/2024. b. On 12/6/2024, the DON provided one on one (1:1) training to the Licensed Vocational Nurses (LVNs) who documented Mexiletine's late and missed administration The DON discussed the importance of making sure medications are available, the process of when to reorder medications, and process if dose was late or missed, physician notification, monitoring of residents for adverse effect for missing medications and development of change of condition Situation, Background, Assessment, Recommendation ([SBAR] a significant change in a resident's health that requires attention) and care plan. c. On 12/6/2024, the DON provided one on one counseling and in-service (staff training and education) with LVN 2 in failing to administer the Mexiletine dose as scheduled and as ordered by the physician on 11/8/2024, the possible adverse effects of late administration (beyond 1-hour-before and 1-hour-after the scheduled time) and notification to the physician and monitoring of resident and/or responsible party if the schedule of the medication dose needs to be altered or changed, such as d. On 12/4/2024, the DON provided a phone 1:1 counseling and in-service with involved LVN 3 in failing to administer the Mexiletine dose on 11/26/24 and on 12/2/24 as scheduled and as ordered by the physician, and about the adverse effects of late administration including the process if the medication dose schedule needs to be altered or change such as notification to the physician. The DON will provide in-person counseling and in-service upon return to work of LVN 3 who failed to administer Mexiletine dose on 11/26/2024 and 12/2/2024. e. The facility's contracted Pharmacy Consultant initiated an in-service with thirteen LVNs on 12/6/2024 regarding administration of medications, the adverse effects of missing the dose and/or late medication administration. In-services will continue until all twenty-five LVNs have participated (remaining 12 LVNs) by 12/16/2024. f. The facility contracted Pharmacy Consultant is scheduled to do a Medication Regimen Review (MRR, a process that evaluates a patient's medications to identify and address issues that could be clinically significant) for Residents receiving antiarrhythmic medications including Residents 6, 11, 20, 26, 30, 43, 51 and 70 on 12/6/2024. g. The facility's Medical Director will initiate an in-service training with the seven LVNs on 12/06/2024 on the importance of administering antiarrhythmic medications as ordered and at the specified time; the adverse effects of not administering medications or late administration, and adverse effects of overdosing on medications when administered medication too close between doses . The Medical Director will continue to conduct the in-service until the remaining eighteen LVNs have participated by 12/16/2024. (Cross reference: F580, F726) Findings: 1. During a review of Resident 6's Admission Record, the Admission Record indicated Resident 6 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including type 2 diabetes (a condition that occurs when the body doesn't use insulin properly, leading to high blood sugar levels), supraventricular tachycardia (SVT, an abnormally rapid heart rate and occurs when electrical impulses in the heart are out of sync [not happened at the same time], causing the heart to beat at least 100 beats per minute [bpm] and sometimes as high as 300 bpm), and heart failure. During a review of Resident 6's Minimum Data Set ([MDS] a resident assessment tool) dated 9/25/2024, the MDS indicated Resident 6 had severe impairment of cognitive (a condition that makes it difficult for a person to remember things, learn, concentrate, make decisions, or understand the meaning of things) skills for daily decision making. During a review of Resident 6's untitled Care Plan initiated on 5/2/2019 and revised on 11/15/2022, the Care Plan indicated Resident 6 had heart disease and was at risk of SVT with a goal for Resident 6 not to have any chest pain. The Care Plan interventions included for Resident 6 receiving her Amiodarone (a medication that prevents and treats arrhythmia) medication as ordered. During a review of Resident 6's Physician's Order Listing Report, the Physician's Order Listing Report indicated an order was placed on 10/5/2022 for Amiodarone tablet 200 mg, one tablet by mouth once daily, hold if pulse (heart rate) is less than 60. During a review of Resident 6's Medication Administration Record (MAR), the MAR indicated Not Applicable (NA) was documented 14 times from 10/1/2024 to10/31/2024 and 13 times from 11/1/2024-11/30/2024 instead of Resident 6's pulse reading which should have been checked and documented before the administration of Amiodarone The MAR indicated Amiodarone was marked as given. 2. During a review of Resident 26's Admission Record, the Admission Record indicated Resident 26 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of ventricular tachycardia ([VT] is a type of irregular heartbeat that occurs when the heart's lower chambers beat too fast. VT is defined as a heart rate of more than 100 beats per minute with at least three irregular heartbeats in a row) and with a cardiac pacemaker (a small, battery-powered device surgically placed under the skin of the chest that signals the heart to beat when the heartbeat is too slow or irregular). During a review of Resident 26's MDS dated [DATE], the MDS indicated Resident 1 had moderate cognitive impairment and had no behaviors of rejecting care such as medications. During a review of Resident 26's History and Physical (H&P) report dated 9/26/2024, the H&P indicated Resident 26 had the capacity to understand and make decisions. During a review of Resident 26's H&P/ Admission Notes from a General Acute Care Hospital (GACH) dated 2/15/2024, Resident 26 was transferred to the GACH for an automatic implantable cardioverter defibrillator ([AICD] is a small device that's surgically implanted in the chest to monitor and correct an irregular heartbeat, or arrhythmia) interrogation (assessment of AICD because it engaged four times due to Resident 26's high heart rate). The GACH's record indicated Resident 26's electrocardiogram ([ECG] non-invasive test that measures the electrical activity of the heart) in the Emergency Department dated 2/15/2024, indicated the resident had SVT. During a review of Resident 26's GACH's MAR dated 2/15/2024- 2/24/2024 Resident 26 was started on Mexiletine 150 mg every eight hours on 2/22/2024 due to Resident 26's heart rate remaining elevated even after treatment with only Amiodarone 200 mg three times a day. During a review of Resident 26's Physician's Order Summary Report (from the facility), the Physician's Order Summary Report indicated the following orders dated 9/20/2024: a. Amiodarone Tablet 200 mg, one tablet twice a day for arrhythmia, hold for heart rate less than 60. b. Mexiletine oral capsule 150 mg, one capsule every eight hours for arrhythmia (administer at midnight, 8 a.m., and 4 p.m.). During a review of Resident 26's untitled Care Plan initiated on 9/21/2024, the care plan indicated there was a Black Box Warning (the most serious warning that the U.S. Food and Drug Administration [FDA-a US federal agency that protects public health by regulating the safety of many products] can issue for a prescription drug) for the use of Mexiletine with a goal for Resident 26 to not experience side effects with the use of Mexiletine. The care plan indicated there was a Black Box Warning that indicated there was a risk of acute (severe and sudden) liver injury with the use of Mexiletine. Resident 26's care plan initiated 9/22/2024 indicated Resident 26 had altered cardiovascular (the heart [cardio] and the blood vessels ([vascular]) status related to arrhythmia with a goal for Resident 26 to be free from complications of cardiac problems. The Care Plan interventions included monitoring Resident 26's vital signs (measurements of the body's essential functions) and notifying the physician of any significant abnormalities. During a review of Resident 26's MAR, the MAR indicated the following: a. From10/1/2024 to 10/31/2024 Resident 26 did not receive his scheduled 4 p.m. dose of Mexiletine 150 mg on 10/20/2024. The MAR indicated to see progress notes for the reason Resident 26's 4 p.m. dose of Mexiletine was not administered. A review of the Medication Administration Progress Notes for 10/20/2024 at 3:34 p.m., indicated awaiting medication delivery. b. The MAR indicated NA was documented instead of a pulse reading six times in the month of October 2024 and NA was documented 13 times instead of Resident 26's pulse reading for November 2024 before the administration of Amiodarone 200 mg Resident 26's pulse was not checked before administration of Amiodarone 200 mg as ordered. During a review of Resident 26's Medication Administration Audit Report for 11/1/2024 to 12/4/2024, the Medication Administration Audit Report indicated the resident's midnight dose for 11/8/2024 was given at 5:12 a.m., on 11/8/2024, which was five hours and 12 minutes later than scheduled and dose of Mexiletine ordered for 8:00 a.m. was given at 7:45 a.m. on 11/8/2024, which was two hours and 33 minutes after the last dose was given at 5:12 a.m. During a review of Resident 26's Medication Administration Audit Report for 11/1/2024 to -12/4/2024, the Medication Administration Audit Report indicated the resident's midnight dose on 11/26/2024 was given at 3:02 a.m., which was three hours and two minutes later and nine hours 38 minutes after the last dose given on 11/25/2024 at 5:24 p.m. The Medication Administration Audit Report indicated the resident's Mexiletine dose scheduled at 8:00 a.m. was given at 7:46 a.m., which was four hours and 44 minutes after the dose given at 3:02 a.m. During a review of Resident 26's Medication Administration Audit Report for 11/1/2024 to -12/4/2024, the Medication Administration Audit Report indicated the resident's midnight dose on 12/2/2024 was given at 2:42 a.m., which was two hours and 42 minutes later than scheduled and ordered and the 8:00 am. dose was given at 7:51 a.m., which was five hours and 9 minutes apart from the dose given at 2:42 a.m. instead of the ordered eight hours between doses. During a review of Resident 26's SBAR Communication Form dated 12/4/2024, the SBAR indicated Resident 26 informed LVN 10 he received a late dose of Mexiletine on 12/2/2024. Resident 26's primary care physician (MD 3) was informed two days later, on 12/4/2024 at 6:39 p.m., regarding the late dose administration on 12/2/2024. During a review of Resident 26's medical record and SBAR form from 10/2024 through 12/2024, the medical record and SBAR form did not indicate MD 3 was notified of Resident 26's missed dose of Mexiletine on 10/20/2024 or receiving the late doses on 11/8/2024 and 11/26/2024. During a review of the Manufacturers Insert for Mexiletine, revised on 1/2023, the Manufacturers Insert indicated Mexiletine was indicated for the treatment of documented ventricular arrhythmias, such as sustained ventricular tachycardia, that in the judgement of the physician were life-threatening. The peak (when the level of the drug in the patient's body is the highest) blood levels of Mexiletine were reached in two to three hours after intake. In most patients, the time it takes for Mexiletine's action in the body to reduce by half is approximately 10 to 12 hours. During an interview on 12/3/2024 at 10 a.m., Resident 26 stated he had a pacemaker placed in January 2024 and he was not receiving his heart medicine (Mexiletine) on time. Resident 26 stated he was supposed to get a midnight dose of Mexiletine and sometimes it would be after 2 a.m. without receiving the medication so he had to go hunt down the nurses to get his medications. During an interview on 12/4/2024 at 4 p.m., Resident 26 stated he missed a dose of Mexiletine in October 2024 (10/20/2024) because the facility did not order it in time from the pharmacy and his heart was beating out of control and he felt scared. Resident 26 stated he was very sensitive to how his heartbeat felt and when his medications were given late, he felt his heart beating differently and just did not feel good. Resident 26 stated there was an instance on 11/8/2024 where his midnight dose of medication was given at around 5 a.m., and then the 8 a.m. dose was given around 7 a.m. Resident 26 stated it was very scary for him because the doses were very close to each other. Resident 26 stated he did not like to complain so he just took the medication like the nurse said but deep down inside he was nervous because MD 2 told him, he could die if he did not take Mexiletine as prescribed. During an interview on 12/4/2024 at 4:15 p.m., LVN 5 stated Resident 26 was taking antiarrhythmic medications (Mexiletine and Amiodarone) for his history of VT, arrhythmia, and having a pacemaker. LVN 5 stated the nurses had to monitor Resident 26's heartrate and ensure it was not below 60 bpm when administering these medications. LVN 5 stated the Black Box warning for Mexiletine indicated Mexiletine can cause acute liver injury and Mexiletine should be reserved for residents with life threatening ventricular arrhythmias. LVN 5 stated it was very important to abide by the administration scheduled/ordered times for Resident 26's Mexiletine (8 a.m., 4 p.m., and midnight) and nurses were allowed only one hour before or after a scheduled administration time to give medication. LVN 5 stated if you gave Mexiletine too close to the next dose it could suddenly drop the blood pressure or heart rate too low. During an interview on 12/4/2024 at 4:20 p.m., MD 3 stated it was important to administer antiarrhythmics such as Mexiletine as ordered (every eight hours) for effectiveness. During an interview on 12/4/2024 at 4:24 p.m., the facility's Pharmacy Consultant (PC) stated antiarrhythmic medications were high risk medications and were managed closely by cardiologists. The PC stated it was important to give Mexiletine every eight hours as ordered because of the pharmacokinetics (the movement of drug into, through, and out of the body) of the medication to maintain therapeutic effects (the response(s) after a treatment of any kind, the results of which are judged to be useful or favorable). The PC stated it was important not to miss any doses of Mexiletine because it could cause worsening of arrhythmias. The PC stated if a dose was given within four hours of the next dose it would be considered a double dose and there was a risk for toxicity (the degree to which a substance can harm an organ). The PC stated that too much of the medication given could cause liver toxicity, a different cardiac arrhythmia and a too close or missed dose could worsen a cardiac arrythmia and was potentially life threatening. The PC stated the facility nurses should notify the physician of a late or missed dose right away. During an interview on 12/4/2024 at 4:51 p.m., the facility's Quality Assurance Consultant (QAC) stated the time documented on the Medication Administration Audit Report as administered was the time the nurse gave the medication. During an interview on 12/5/2024 at 8:05 a.m., Resident 26 stated he felt stressed in the facility because MD 2 made it clear to him that the Mexiletine needed to be taken every eight hours to be effective and that was why he would have to get out of bed, get dressed, and go look for the nurse when his midnight dose was late. Resident 26 stated he was fearful he would suffer from a massive heart attack or some other issue if he didn't get his medication as ordered ad scheduled. During an interview on 12/5/2024 at 8:20 a.m., the Director of Nursing (DON) stated the facility policy was to remove the pill out of the bubble pack (how the medication is dispensed from the pharmacy), give the medication to the resident, and then immediately document the medication administration and time in the resident's MAR. During an interview on 12/5/2024 at 10:29 a.m., MD 2 stated a missed dose or late dose of Mexiletine had the potential to cause a worsening of cardiac arrhythmia. During an interview on 12/5/2024 at 3:04 p.m., LVN 5 stated the computer system the licensed staff used to document medication administration did not have an alert that would inform her that the nurse from the shift prior gave the medication to the resident late. LVN 5 stated the only way to know the nurse from the prior shift did not give the medication or if it was administered late was if the nurse informed her (LVN 5). LVN 5 stated LVN 2 did not report to her that Mexiletine was administered late (12 a.m. dose given at 5:12 a.m.) on 11/8/2024 and that was why she gave the scheduled dose at 7:45 a.m. LVN 5 stated a late dose or a missed dose of medication was considered a medication administration error and the nursing staff should notify the physician of the missed or late dose, and the resident needed to be monitored and assessed for any changes in condition due to the late or missed dose. LVN 5 stated a check mark on the MAR meant the medication was given and it was important to follow the physician's orders for parameters because the vital signs could go below the normal range (BP reference range is less than 120 systolic and less than 80 diastolic [bottom number]) and heart rate normal range between 60 and 100 BPM) and that would not be good for the resident. LVN 5 stated there was an option to choose on the MAR that indicated NA but that should never be used and the actual vital sign should have been documented. During an interview on 12/5/2024 at 3:22 p.m., the DON stated the importance of following physician's orders for Mexiletine was the resident could develop problems or irregularities in heart rate if the physician's orders were not followed. The DON stated the doses given on 11/8/2024 for Resident 26's Mexiletine at 5:12 a.m. and 7:45 a.m. were considered a double dose and Resident 26 should have been monitored for adverse reactions. The DON stated the physician should have been notified of the late and missed doses of Mexiletine and Resident 26 should have been monitored for adverse reactions for three days. During a concurrent interview and record review on 12/5/2024 at 3:30 p.m., with the DON, the Administration Progress Note for Resident 26 dated 10/20/2024 was reviewed. The DON stated Resident 26's Mexiletine was not given because the facility was awaiting delivery of the Mexiletine from the pharmacy. The DON stated it was facility's process to order medications 3 to 5 days prior to running out so there would not be any missed doses, but it does not appear the Mexiletine was ordered in time. The DON stated arrhythmias were a life-threatening condition and the facility should always have the necessary antiarrhythmic medications available in the facility. The DON stated it was important to follow physician's orders for parameters relating to the BP and pulse because it was important for the nurses to know if they must hold (not administer) the medication, so the blood pressure or pulse did not drop causing weakness, dizziness, or the potential for the loss of consciousness. The DON stated nurses should never document NA instead of measuring and documenting the actual vital sign. 3. During a review of Resident 29's Admission Record, the Admission Record indicated Resident 29 was admitted to the facility 9/27/2023 with diagnoses of hypotension (low blood pressure) and atrial fibrillation ([AFib], a rapid irregular heartbeat). During a review of Resident 29's MDS dated [DATE], the MDS indicated Resident 29 had moderate cognitive impairment. During a review of Resident 29's Physician's Order Summary Report, the Physician's Order Summary Report indicated Resident 29 had an order dated 9/27/2023 for Midodrine 2.5 mg three times a day for hypotension, hold if SBP is greater than 130. During a review of Resident 29's untitled Care Plan initiated on 10/6/2023, the Care Plan indicated Resident 29 had hypotension related to heart disease with a goal to maintain Resident 29's blood pressure within an acceptable range as determined by the physician with interventions that included giving Midodrine as ordered. During a review of Resident 29's MAR, the MAR indicated NA was documented 14 times from 10/1/2024 to 10/31/2024 and 13 times from 11/1/2024 to 11/30/2024 instead of the pulse reading before the administration of Midodrine 2.5 mg tablet. The MAR indicated Midodrine 2.5 mg tablet was administered without Resident 29's pulse being checked first. The MAR indicated that Midodrine 2.5 mg tablet was given to Resident 29 on the following dates when Resident 29's SBP was above130: a. On 10/3/2024 6 a.m. for BP 133/63. b. On 10/4/2024 6 a.m. for BP 138/67. c. On 11/7/2024 10 p.m. for BP 149/54. d. On 11/17/2024 6 a.m. for BP 147/63. e. On 11/28/2024 6 a.m. for BP 131/69. During an interview on 12/6/2024 at 1:10 p.m., the Director of Staff Development (DSD) stated she was unsure why nurses were documenting NA on the MAR instead of the actual pulse rate and/or blood pressure reading because that was not the facility's policy. The DSD stated if the pulse rate and/or blood pressure reading was not documented, it was not measured, it was not done. The Director of Staff Development (DSD) stated if Resident 29's Midodrine was given when Resident 29's SBP was greater than 130, there was a risk for an increase in blood pressure which could place the resident at the risk of stroke [blood vessel bursting, causing bleeding and brain tissue damage]), heart attack, and chest pain. 4. During a review of Resident 30's Admission Record, the Admission Record indicated Resident 30 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of AFib and congestive heart failure ([CHF] a chronic condition that occurs when the heart can't pump enough blood to meet the body's needs). During a review of Resident 30's Physician's Order Summary Report, the Physician's Order Summary Report indicated an order dated 9/22/2024 for Amiodarone 200 mg, one tablet twice a day for CHF, hold if heart rate is less than 60 and the order dated 9/23/2024 for Amlodipine Besylate (blood pressure medication) 10 mg tablet daily for hypertension ([HTN] high blood pressure), hold if SBP is less than 110 bpm. The order for Amlodipine administration parameter was updated on 10/25/2024 indicating to hold the medication if the resident's pulse rate was less than 60 bpm. During a review of Resident 30's untitled Care Plan initiated on 9/23/2024, the Care Plan indicated Resident 30 was at risk for cardiac distress (a group of heart-related symptoms that can quickly become life-threatening, including shortness of breath, chest pain, and feeling of a pounding heartbeat) related to heart failure with a goal for Resident 30 to be free from cardiac distress. The Care Plan interventions included monitoring the pulse rate and blood pressure, and administering medications as ordered. During a review of Resident 30's MDS dated [DATE], the MDS indicated Resident 30 was moderately cognitively impaired. During a review of Resident 30's MAR, for the administration of Amlodipine Besylate 10 mg tablet, the MAR indicate the following: a. There was NA documented seven times between 10/1/2024 to 10/31/2024 instead of the having Resident 30's documented blood pressure reading. b. There was NA documented three times between 10/1/2024 to 10/31/2024 instead of Resident 30's documented pulse rate. c. There was NA documented 16 times between 11/1/2024 to11/30/2024 instead of Resident 30's documented blood pressure and pulse rate readings. d. There was NA documented seven times between 11/1/2024 to 11/30/2024 instead of the resident's pulse rate. During an interview on 12/6/2024 at 2:29 p.m., the director of nursing (DON) stated medication administration errors were not part of their current QAPI program and issues were not identified by the QAPI team prior to learning about the deficiencies related to missed doses of medication, late administration of medication, and not following physician's orders during medication administration. The DON stated if they had been aware of the medication errors, they would have been added to the QAPI program to prevent the errors from occurring again. During a review of the facility's policy and procedure (P/P) titled Administering Medications undated, the P/P indicated medications were to be administered in accordance with prescriber orders, including any required time frame. Medication administration times were determined based on the resident need and benefit and not staff convenience. Factors that were considered for medication administration time included enhancing optimal therapeutic effect of the medication. Medications were to be administered within one hour of their prescribed time. Vital signs were to be checked if necessary for each resident prior to administering medications. The individual administering the medication was to document the date and time the medication was administered in the resident's medical record. The P/P indicated medication errors were to be documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. During a review of the facility's P/P titled Documentation of Medication Administration dated 11/2022, the P/P indicated administration of medication was to be documented immediately after the medication was given. During a review of the facility's P/P titled Adverse Consequences of Medication Errors dated 2/2023, the P/P indicated a medication error was defined as the preparation or administration of drugs which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards. Examples of medication errors included the medication being given at the wrong time or a drug is ordered but not administered. A significant medication error is determined as one that is life threatening. The physician was to be promptly notified of any significant error. The resident was to be monitored for 24 to 72 hours after a significant medication error. The significant medication error was to be communicated to the oncoming shift as needed to alert staff of the need for continued monitoring.

Based on interview, and record review, the facility failed to ensure residents were free from rough handling for one of three residents (Resident 1). Certified Nursing Assistant 1 (CNA 1) was observed by CNAs 2 and 3 firmly holding Resident 1's face with a soiled rubber glove while providing care to Resident 1. This deficient practice violated Resident 1's rights and resulted in disrespect and had a high risk for mental anguish. Findings: During a review of Resident 1's Admission Record (Face Sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 9/7/2018, the MDS indicated Resident 1 had cognitive (thought process) problems, impaired decision-making, and was sometimes able to make needs known and sometimes able to understand others. According to the MDS, Resident 1 required extensive assistance of one-person physical assist with bed mobility, transferring, locomotion on and off the unit, and with eating and personal hygiene. During a review of Resident 1's care plan titled, Activities of Daily Living (ADLs [self-care activities such as eating, personal hygiene, dressing, and bathing]), dated 6/8/2018, the care plan indicated Resident 1 required assistance in activities of daily living including personal hygiene, dressing, and bathing related to dementia and Alzheimer's disease. The goal was for Resident 1 to be able to maintain dignity and self-esteem. The staffs' interventions were to encourage independent functions by providing cues, assist in ADLs, explain the task prior to starting the task, use adequate assistance during care, promote dignity and handle gently when giving care. During a review of Resident 1's Nursing Progress Notes (NPN), dated 9/22/2018 and timed at 8:18 a.m., the NPN indicated on 9/22/2018 at approximately 5:50 a.m. while changing Resident 1 adult brief (diaper), Resident 1 became agitated, kicking, screaming, and scratched CNA 1 on the face. During an interview on 10/10/2018 at 10:22 a.m., the Administrator (ADM) stated he was informed during the overnight shift 11 p.m. to 7 a.m. on 9/22/2018, CNA 1 rough handled Resident 1. The ADM stated CNA 1 was no longer an employee at the facility. During an interview on 10/10/2018 at 11:40 a.m., CNA 2 stated during the shift he was assigned to provide care for Resident 1. CNA 2 stated Resident 1 was mildly agitated, and he requested help from another coworker to clean Resident 1. CNA 2 stated CNA 3 assisted him (CNA 2) to clean and change Resident 1's adult brief. CNA 2 stated CNA 1 also volunteered to assist with Resident 1's care because she CNA 1 had a good relationship with the resident. CNA 2 stated during care, CNA 1 grabbed Resident 1's face to tell her, Calm Down because Resident 1 was resistant to care. CNA 2 stated CNA 3 moved CNA 1's hand away from Resident 1's face and asked CNA 1 to leave the room. During an interview on 10/10/2018 at 12:45 p.m., CNA 3 stated CNA 2 asked for assistance to change Resident 1's adult brief. CNA 3 stated Resident 1 was agitated and was screaming, and not cooperative with her care. CNA 3 stated CNA 1 came into Resident 1's room and helped change the resident. CNA 3 stated while putting on gown and an adult brief for Resident 1, CNA 1 turned the resident aggressively to get the brief on her and firmly grabbed Resident 1's face with a soiled rubber glove on her hand and squeezed Resident 1's cheeks together. CNA 3 stated she pulled CNA 1's hand away from Resident 1's face and said, No! That is not ok. CNA 3 stated CNA 1 laughed and walked out of Resident 1's room, and they (CNA 2 and CNA 3) finished changing Resident 1. During an interview on 10/11/2018 at 11:03 a.m., Registered Nursing supervisor (RN 1) stated Resident 1 was screaming while CNAs 1, 2, and 3 were changing her adult brief. RN 1 stated Resident 1 was screaming so loudly it prompted RN 1 to check on the resident, upon entering the room, CNAs 1, 2, and 3 were almost finished with Resident 1's care. RN 1 stated CNA 3 reported the incident a few minutes later. RN 1 stated she interviewed CNA 1 about holding Resident 1's face and CNA 1 acknowledged holding her face to help her calm down. RN 1 stated the incident was reported to the facility's Administrator (ADM) right away and an incident report was completed. During a review of the facility's Abuse Investigation Reporting form, dated 9/22/2018, the report indicated Resident 1 was deemed by her physician as not having the capacity to understand and make decisions and physically needs total assistance to perform ADLs. The Abuse Investigation Reporting form indicated CNA 1's employment was terminated due to CNA 1 confirming holding Resident 1 by the mouth and telling the resident to calm down. The abuse investigation reporting indicated CNA 1's actions were considered reasonably unnecessary and inappropriate. During a review of the facility's policy and procedures (P/P) titled, Preventing Resident Abuse, revised on 9/1/2016 indicated the facility's goal was to achieve and maintain an abuse free environment. The abuse prevention/ intervention program includes but is not limited to assisting or rotating staff working with difficult or abusive residents. Helping staff to deal appropriately with stress and emotions. Training staff to understand and manage a resident's verbal or physical aggression. Monitoring staff on all shifts to identify inappropriate behaviors toward residents such as using derogatory language, rough handling of residents, and ignoring residents while giving care. Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues. Encouraging all personnel, residents, family members, visitors to report any signs of suspected incidents of abuse to facility management immediately. During a review of the facility's P/P titled, Abuse Prevention and Prohibition Program dated 1/1/2017, the P/P indicated each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property.

Based on record review and interview, the facility failed to notify a resident's physician when there was a continuous change of condition (COC) with difficulty in breathing and adhere to its policy and procedure which indicated that the attending physician would be notified immediately in the event a resident had a change of condition and if the condition continued to deteriorate to call 911 (emergency services) for one of three sampled residents (Resident 1). (Crossed referenced to F684). This deficient practice of not reporting Resident 1's continuous COC resulting in a delay in diagnosis, care and treatment and the resident's family member (FM 1) calling 911 (emergency services) for Resident 1 to be transfer red to a general acute care hospital (GACH). Resident 1 was readmitted to the GACH within 24 hours of admission to the skilled nursing facility (SNF) after experiencing a change of condition (COC). In the emergency department (ED) Resident 1 required an emergency intubation ((ET) a tube placed in the trachea for air exchange) and was admitted into the intensive care unit ((ICU) a unit for residents who requires a higher level of care (critical care)) for further care and treatment. Findings: A review of Resident 1's GACH Discharge Summary prior to admission to the SNF, dated 11/15/19 indicated Resident 1 had an acute hypoxic [MEDICAL CONDITION] (fluid build-up in the air sacs of the lungs), septic shock (wide spread infection), obstructive sleep apnea (complete or partial obstruction during sleep) requiring continuous positive airway pressure (([MEDICAL CONDITION]) continuous positive airway pressure a treatment for [REDACTED]. A review of Resident 1's GACH medications and treatments indicated the following were administered at the GACH: 1. [MEDICATION NAME] (a medication that relax muscles in the airway to increase air flow to the lungs) 3 milliliters (ml-a unit of measure) nebulizer ((neb)-a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) every 4 to 6 hours while awake and when necessary for shortness of breath (SOB) or wheezing (a [MEDICATION NAME] sound made when breathing). 2. [MEDICATION NAME] (a drug that loosens and thins mucus) 10% 2 ml neb every 4 hours while awake. 3. [MEDICAL CONDITION] (positive airway pressure breathing device to treat sleep apnea/ delivers pressurized air to regulate the breathing pattern). A review of Resident 1's skilled nursing facility (SNF) Admission Record indicated Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 1's admission vital signs included a blood pressure (BP) of 130/70 (unit of measurement) (normal reference range (NRR) is 139/70-120/70), heart rate 84 beats per minute (bpm) (NRR is 60-100 bpm) and respiratory rate of 21 breaths per minute (bpm) (NRR is 12-20 bpm). Resident 1's pulse oximeter (an electronic device that measures the saturation of oxygen carried in the red blood cells) measured at 95% (NRR is 95-100%) on room air with clear breath sounds in both lungs, no cough and regular respirations. Resident 1 was alert and oriented to person and place with verbal coherent communication and the ability to understand others. Resident 1's neurological status (mental state) was within normal limits. The medication list was obtained from the GACH transfer form and the admission orders [REDACTED]. A review of Resident 1's SNF Order Summary Report dated 11/15/19 indicated the following orders: 1. Oxygen 2-3 liter per minute (LPM) via nasal cannula (a plastic tube for oxygen infusion) continuous. 2. [MEDICATION NAME] (([MEDICATION NAME]) medication used to remove excess fluid from the body) and Losartan potassium (blood pressure medication) each once a day for hypertension (high blood pressure (HTN)). 3. Lubriprostone (used to treat irritable bowel syndrome) 24 micrograms (mcg) one capsule two times a day for [MEDICAL CONDITION] (A [MEDICAL CONDITION] disease of the liver resulting in scarring and liver failure). 4. [MEDICATION NAME] HCL (medication to help control blood sugar levels) 1000 milligrams (mg) one tablet two times a day for diabetes (high blood sugar level). 5. Simivastatin (cholesterol lowering medication) 40 mg tablet at bedtime for HLD (hypersensitivity lung disease). 6. [MEDICATION NAME] (allergy medication) 1 tablet every 24 hours as needed for allergy. A review of Resident 1's physician telephone orders, dated 11/16/19 and noted at 5:53 a.m., indicated the following orders: 1. Discontinue [MEDICATION NAME], losartan, Lubiprostone and [MEDICATION NAME]. 2. Accu-check (blood sugar monitoring) before meals and at hour of sleep and cover with regular insulin ((a short acting, form of the hormone) the body uses insulin to process blood sugar). A review of Resident 1's History and Physical (H/P), dated 11/16/19, within 24 hours of admission indicated the resident had decreased breath sounds and the resident did not have the capacity to understand and make decisions. A review of Resident 1's Medication Administration Record (MAR) of the physician's orders [REDACTED]. 1. [MEDICATION NAME]-[MEDICATION NAME] Solution (used to enlarge airways in the lungs) 3 ml inhale orally via nebulizer every 4 hours for shortness of breath (sob)/ wheezing every 4 hours while awake and/or every 6 hours as needed 2. [MEDICATION NAME] 10% 2 ml neb every 4 hours while awake to loosen secretions 3. Oxygen (O2) 2-3 LPM via nasal cannula continuous three times a day 4. Monitor oxygen saturation (the percentage of oxygen is in the blood) every shift three times a day 5. [MEDICATION NAME] (a synthetic drug used to relieve rheumatic and allergic conditions and to treat [MEDICAL CONDITION]) 20 mg one time a day for [MEDICAL CONDITION] 6. Accu-checks (blood sugar monitoring) before meals and at bedtime cover with regular insulin for diabetes mellitus ((DM) high blood sugar) 7. [MEDICATION NAME] ((an insulin) a hormone that works by lowering levels of glucose in the blood) Solution 100 units/ml 10 at bedtime for DM 8. [MEDICATION NAME] HCL 500 mg two times a day for DM 9. [MEDICATION NAME] 40 mg one tablet a day for high blood pressure (HTN) 10. [MEDICATION NAME] (a medication used to treat high blood pressure) extended release (XR-the drug takes longer to clear from the body) 25 mg one time a day [MEDICAL CONDITION] 11. Losartan Potassium) 50 mg one time a day for HTN 12. [MEDICATION NAME] HCL (a medication designed to raise the blood pressure) 2.5 mg every 8 hours for orthostatic (change in position from lying down to standing) low blood pressure 13. Lubiprostone 24 mcg two times a day for [MEDICAL CONDITION] (scarring of the liver) 14. Apixaban 2.5 mg two times a day for [MEDICAL CONDITION] (blood clot prevention) 15. [MEDICATION NAME] 40 mg at bedtime for HLD (abnormally high concentration of fats in the blood) 16. Aspirin 81 mg one time a day for stroke prevention A review of Resident 1's Medication Administration Record for the month of November 2019 indicated the following medications and treatments were not administered as prescribed by the physician on 11/15/19 and 11/16/19: [MEDICATION NAME], Aspirin, Losartan, [MEDICATION NAME] HCL, [MEDICATION NAME], apixaban, [MEDICATION NAME] and lubiprostone. On 11/15/19, there was no oxygen saturation monitored and documented on the MAR for 11-7 a.m. shift as ordered by the physician. On 11/15/19 and 11/16/19, there was no documentation of Resident 1's blood sugar monitoring as prescribed by the physician. A review of Resident 1's progress nurses notes, dated 11/15/19 and 11/16/19 indicated there was no documentation Resident 1's physician was notified as to why the resident did not receive the prescribed medications and treatments. On 11/16/19, the [MEDICATION NAME] and [MEDICATION NAME] breathing treatments were not administered as prescribed at 12 a.m., 4 a.m., 8 a.m. and 12 noon . There was no documentation for the reason the medications and breathing treatments were not administered. A review of Resident 1's nursing progress notes indicated there was no nursing documentation from 11/15/19 at 9 p.m. until 11/16/19 at 8:23 a.m. A review of a nursing progress note dated 11/16/19 at 8:23 a.m. indicated Resident 1's [MEDICAL CONDITION] machine was delivered without a power adapter (not usable). A review of Resident 1's nursing progress note, dated 11/16/19 at 9:48 a.m., indicated all of Resident 1's admission orders [REDACTED]. Resident 1's medication list was updated, transcribed (put in written form), and faxed to pharmacy. A review of Resident 1's nursing progress note, dated 11/16/19 at 10:33 a.m. indicated at approximately 9:50 a.m., Resident 1 was noted with increased respirations (breathing) and congestion (stuffiness, or a runny nose is generally caused by increased blood volume to the vessels that line the passages inside the nose (feeling of fullness in the sinuses)). The note indicated Resident 1's oxygen saturation had decreased to 80% (normal range 92 to 100%) and a breathing treatment was provided, and the resident was suctioned. The nursing progress note indicated the NP ordered to increase Resident 1's oxygen to 5 liters, give [MEDICATION NAME] 40 mg IVP (intravenous (into the vein) push) and give breathing treatments every 4 hours around the clock (ATC) and a STAT (immediate) chest x-ray. A review of a nurse's progress note dated 11/16/19 at 12 noon indicated Resident 1's family member (FM)1 came to the nursing station stating Resident 1 had troubled or labored breathing (abnormal respiration and an increased effort to breathe). The note indicated Resident 1's oxygen saturation level fluctuated between 88-90%. FM 1 requested the resident be transferred to the GACH. The nursing note indicated the paramedics were called and the oxygen was increased to 10 liters per minute. The paramedics arrived and transferred the resident to the GACH. A review of Resident 1's Paramedic Run Sheet, dated 11/16/19 at 12:05 p.m., indicated Resident 1 was conscious (awake and alert) and coherent (rational). The paramedics documented Resident 1 had been complaining of shortness of breath (SOB) since that morning and was found with a low oxygen saturation that did not get better with increase of oxygen to 10 liters per minute. Resident 1's vital signs were recorded as follows; a low blood pressure (BP- the pressure of the blood in the circulatory system,) of 96/54 (normal range 120/80), an elevated pulse of 108 beats per minute (normal range-80 beats per minute (bpm), respirations of 20 breaths per minute (normal range 16 to 20 breaths per minute) and oxygen saturation at 100%. A review of Resident 1's GACH Emergency Department (ED) documentation, dated 11/16/19 at 12:44 p.m. indicated Resident 1 arrived at the ED with [MEDICAL CONDITION](increased heart rate) and tachypneic (fast, shallow breathing) with impending (about to happen) [MEDICAL CONDITION]. Resident 1's chest x-ray revealed an almost complete whiteout on the left lung field which suggested due to a left lung collapse and/or from a mucus plug (large collection of mucus). Resident 1 required an endotracheal intubation ((ET) a tube placed in the trachea for air exchange) and was admitted into the GACH's intensive care unit ((ICU) a unit for residents who requires a higher level of care (critical care)) for further care and treatment. Resident 1's treatment included [MEDICATION NAME] (breathing treatment), postural drainage (position to encourage drainage by gravity) and chest PT (physiotherapy/clapping of the chest wall to loosen mucus from the lungs). A review of Resident 1's GACH note, dated 11/18/19 indicated the resident was extubated (tube in trachea removed). The note indicated Resident 1 refused to return to the prior SNF but agreed for admission to another SNF 2. On 11/22/19, the resident was transferred to the SNF 2. On 11/27/19 at 11:08 a.m., during an interview, Certified Nurse Assistant (CNA) 1 stated, After breakfast Resident 1 was observed to be short of breath (SOB) and looked tired. Resident 1 was not receiving oxygen at that time . CNA 1 was unable to recall the resident's mental status at that time. CNA 1 stated Resident 1 was nonverbal and only respond by nodding her head. On 1/23/2020 at 1:45 p.m., during an interview, Licensed Vocational Nurse (LVN) 1 stated on 11/15/19 the [MEDICAL CONDITION] machine was delivered without the power cord. The resident slept without the [MEDICAL CONDITION] machine as ordered by the physician. LVN 1 stated Resident 1's condition changed due to SOB. LVN 1 stated he did not give the resident any medications or breathing treatments, as ordered by the physician, but the registered nurse (RN) 1 gave the resident the [MEDICATION NAME]. On 1/23/2020 at 3 p.m., during an interview, RN 1 stated LVN 1 notified her of the resident's COC and she notified the NP . RN 1 stated she was in between two emergency situations and could not recall giving Resident 1 the [MEDICATION NAME] IVP (intravenous push) and/or the breathing treatment. On 1/24/2020 at 10:45 a.m., during a telephone interview, the facility's contracting pharmacist ((Pharmacist 1) a medication expert) stated the orders for Resident 1 was received on 11/15/19 after 10 p.m. Pharmacist 1 stated LVN 1 called the pharmacy on 11/16/19 and stated Resident 1's orders that were faxed on 11/15/19, which was incorrect. Then a nursing staff member called back on the same day at 1:15 p.m. and informed the pharmacist not to send any medications because the resident went to the GACH. On 2/6/2020 at 10:40 a.m., during an interview, RN 2 stated Resident 1 was tired when she arrived at the facility. The resident's oxygen saturation was 95% on room air and the resident did not need oxygen. On 2/6/2020 at 11:21 a.m., during an interview, Resident 1's primary care physician (PCP) 1) stated he was not called about Resident 1's change of condition (COC) due to difficulty in breathing. On 2/6/2020 at 12:31 p.m., during a telephone interview, FM 1 stated when he arrived to visit Resident 1 and there was no staff in Resident 1's room. FM 1 stated Resident 1's face was red, and he could hear the noises coming from the resident's lungs. FM 1 stated Resident 1 had on oxygen face mask but was unable to catch her breath. FM 1 stated he immediately ran out to the nurse's station to get the nurse, as he (FM 1) called 911. On 2/7/2020 at 3:45 p.m., during an interview and review of Resident 1's physician's orders [REDACTED]. RN 3 stated the orders were verified with the resident's physician but could not recall the physician's name. RN 3 stated she missed verifying Resident 1's new medication and treatment orders that was included in the package. RN 3 denied placing oxygen on Resident 1. RN 3 stated she verified Resident 1's admission orders [REDACTED]. On 2/11/2020 at 8:30 a.m. and 3:40 p.m., during the interviews, LVN 2 stated she was Resident 1's medication nurse on 11/16/19. LVN 2 stated there was a delay in receiving Resident 1's medication and that was why she did not administer any medications or breathing treatments to Resident 1. A review of the facility's policy and procedure titled, Change of Condition Notification, revised on 1/1/17 indicated the purpose was to ensure the physicians were informed of changes in the resident's condition in a timely manner. The policy indicated the facility would promptly consult with the resident's attending physician when the resident endures a significant change in the resident's physical, cognitive, functional and behavioral status (example given) e.g., deterioration in health, life threatening conditions or clinical complications. The policy also stipulated in emergency situations, e.g., the resident is experiencing unexpected shortness of breath, the Licensed Nurse (LN) would- Immediately call the attending physician, if unable to reach the physician or the physician on-call during emergency situations, he/she would notify the facility's Medical Director. The policy also indicated, If the resident deteriorates, the symptoms are serious, and the most rapid intervention available by a physician would place the resident in great jeopardy, call 911 for transport to hospital.

Based on record review and interview, the facility failed to ensure a resident received medications and breathing treatment, as prescribed by the physician for one of three sampled residents (Resident 1). Resident 1 did not receive the medications and respiratory treatments as prescribed by the physician, which resulted in a change of condition (COC). This deficient practice of not reporting Resident 1's continuous change of condition which resulted in a delay in diagnosis, care and treatment and the resident's family member (FM 1) calling 911 (emergency services) for Resident 1 to be transferred to a general acute care hospital (GACH). Resident 1 was readmitted to the GACH within 24 hours of admission to the skilled nursing facility (SNF) after experiencing a COC due to not receiving the prescribed medications, oxygen and treatments. In the emergency department (ED) Resident 1 required an emergency intubation ((ET) a tube placed in the trachea for air exchange) and was admitted into the intensive care unit ((ICU) a unit for residents who requires a higher level of care (critical care)) for further care and treatment. Findings: A review of Resident 1's GACH Discharge Summary prior to admission to the SNF, dated 11/15/19 indicated Resident 1 had an acute hypoxic [MEDICAL CONDITION] (fluid build-up in the air sacs of the lungs), septic shock (wide spread infection), obstructive sleep apnea (complete or partial obstruction during sleep) requiring continue positive airway pressure (([MEDICAL CONDITION]) continuous positive airway pressure a treatment for [REDACTED]. A review of Resident 1's GACH medications and treatments indicated the following were administered at the GACH: 1. [MEDICATION NAME] (a medication that relaxes muscles in the airway to increase air flow to the lungs) 3 milliliters (ml-a unit of measure) nebulizer ((neb)-a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) every 4 to 6 hours while awake and when necessary for shortness of breath (SOB) or wheezing (a [MEDICATION NAME] sound made when breathing). 2. [MEDICATION NAME] (a drug that loosens and thins mucus) 10% 2 ml neb every 4 hours while awake. 3. [MEDICAL CONDITION] (positive airway pressure breathing device to treat sleep apnea/ delivers pressurized air to regulate the breathing pattern). A review of Resident 1's skilled nursing facility (SNF) Admission Record indicated Resident 1 was admitted to the facility on [DATE] , with [DIAGNOSES REDACTED]. Resident 1's admission vital signs included a blood pressure (BP) of 130/70 (normal reference range (NRR) is 139/70-120/70), heart rate 84 beats per minute (bpm) (NRR is 60-100 bpm) and respiratory rate of 21 breaths per minute (bpm) (NRR is 12-20 bpm). Resident 1's pulse oximeter (an electronic device that measures the saturation of oxygen carried in the red blood cells) measured at 95% (NRR is 95-100%) on room air with clear breath sounds in both lungs, no cough and regular respirations. Resident 1 was alert and oriented to person and place with verbal coherent communication and the ability to understand others. Resident 1's neurological status (mental state) was within normal limits. The medication list was obtained from the GACH transfer form and the admission orders [REDACTED]. A review of Resident 1's SNF Order Summary Report dated 11/15/19 indicated the following orders: 1. Oxygen 2-3 liter per minute (LPM) via nasal cannula (a plastic tube for oxygen infusion) continuous. 2. [MEDICATION NAME] (([MEDICATION NAME]) medication to remove excess fluids from the body) and Losartan potassium each once a day for hypertension (high blood pressure (HTN)). 3. Lubriprostone 24 micrograms (mcg) one capsule two times a day for [MEDICAL CONDITION] (a [MEDICAL CONDITION] disease of the liver resulting in scarring and liver failure). 4. [MEDICATION NAME] HCL 1000 milligrams (mg) one tablet two times a day for diabetes (high blood sugar level). 5. [MEDICATION NAME] 40 mg tablet at bedtime for HLD (hypersensitivity lung disease). 6. [MEDICATION NAME] 1 tablet every 24 hours as needed for allergy. A review of Resident 1's physician telephone orders, dated 11/16/19 and noted at 5:53 a.m., indicated the following orders: 1. Discontinue [MEDICATION NAME], losartan, Lubiprostone and [MEDICATION NAME]. 2. Accu-check (blood sugar monitoring) before meals and at hour of sleep and cover with regular insulin ((a short acting, form of the hormone) the body uses insulin to process blood sugar). A review of Resident 1's History and Physical (H/P), dated 11/16/19 , within 24 hours of admission indicated the resident had decreased breath sounds and the resident did not have the capacity to understand and make decisions. A review of Resident 1's Medication Administration Record (MAR) of the physician's orders [REDACTED]. 1. [MEDICATION NAME]-[MEDICATION NAME] Solution 3 ml inhale orally via nebulizer every 4 hours for shortness of breath (sob)/ wheezing every 4 hours while awake and/or every 6 hours as needed 2. [MEDICATION NAME] 10% 2 ml neb every 4 hours while awake to loosen secretions 3. Oxygen (O2) 2-3 LPM via nasal cannula continuous three times a day 4. Monitor oxygen saturation (the percentage of oxygen is in the blood) every shift three times a day 5. [MEDICATION NAME] (a synthetic drug used to relieve rheumatic and allergic conditions and to treat [MEDICAL CONDITION]) 20 mg one time a day for [MEDICAL CONDITION] 6. Accu-checks (blood sugar monitoring) before meals and at bedtime cover with regular insulin for diabetes mellitus ((DM) high blood sugar) 7. [MEDICATION NAME] ((an insulin) a hormone that works by lowering levels of glucose in the blood) Solution 100 units/ml 10 at bedtime for DM 8. [MEDICATION NAME] HCL (an oral diabetes medicine that helps control blood sugar levels) 500 mg two times a day for DM 9. [MEDICATION NAME] (a medication that rids excess fluid in the system) 40 mg one tablet a day for high blood pressure (HTN) 10. [MEDICATION NAME] (a medication used to treat high blood pressure) extended release (XR-the drug takes longer to clear from the body) 25 mg one time a day [MEDICAL CONDITION] 11. Losartan Potassium (a medication used to treat high blood pressure) 50 mg one time a day for HTN 12. [MEDICATION NAME] HCL (a medication designed to raise the blood pressure) 2.5 mg every 8 hours for orthostatic (change in position from lying down to standing) low blood pressure 13. Lubiprostone 24 mcg two times a day for [MEDICAL CONDITION] (scarring of the liver) 14. Apixaban 2.5 mg two times a day for [MEDICAL CONDITION] (blood clot prevention) 15. [MEDICATION NAME] 40 mg at bedtime for HLD (abnormally high concentration of fats in the blood) 16. Aspirin 81 mg one time a day for stroke prevention A review of Resident 1's Medication Administration Record for the month of November 2019 indicated the following medications and treatments were not administered as prescribed by the physician on 11/15/19 and 11/16/19: [MEDICATION NAME], Aspirin, Losartan, [MEDICATION NAME] HCL, [MEDICATION NAME], apixaban, [MEDICATION NAME] and lubiprostone. On 11/15/19, there was no oxygen saturation monitored and documented on the MAR for 11-7 a.m. shift. As ordered by the physician . On 11/15/19 and 11/16/19, there was no documentation of Resident 1's blood sugar monitoring as prescribed by the physician. A review of Resident 1's progress nurses notes, dated 11/15/19 and 11/16/19 indicated there was no documentation Resident 1's physician was notified as to why the resident did not receive the prescribed medications and treatments. On 11/16/19, the [MEDICATION NAME] and [MEDICATION NAME] breathing treatments were not administered as prescribed at 12 a.m., 4 a.m., 8 a.m. and 12 noon. There was no documentation for the reason the medications and breathing treatments were not administered. A review of Resident 1's nursing progress notes indicated there was no nursing documentation from 11/15/19 at 9 p.m. until 11/16/19 at 8:23 a.m. A review of a nursing progress note dated 11/16/19 at 8:23 a.m. indicated Resident 1's [MEDICAL CONDITION] machine was delivered without a power adapter (not usable). A review of Resident 1's nursing progress note, dated 11/16/19 at 9:48 a.m., indicated all of Resident 1's admission orders [REDACTED]. Resident 1's medication list was updated, transcribed (put in written form), and faxed to pharmacy . A review of Resident 1's nursing progress note, dated 11/16/19 at 10:33 a.m. indicated at approximately 9:50 a.m., Resident 1 was noted with increased respirations (breathing) and congestion (stuffiness, or a runny nose is generally caused by increased blood volume to the vessels that line the passages inside the nose (feeling of fullness in the sinuses)). The note indicated Resident 1's oxygen saturation had decreased to 80% (normal range 92 to 100%) and a breathing treatment was provided, and the resident was suctioned. The nursing progress note indicated the NP ordered to increase Resident 1's oxygen to 5 liters, give [MEDICATION NAME] 40 mg IVP (intravenous (into the vein) push) and give breathing treatments every 4 hours around the clock (ATC) and a STAT (immediate) chest x-ray. A review of a nurse's progress note dated 11/16/19 at 12 noon indicated Resident 1's family member (FM)1 came to the nursing station stating Resident 1 had troubled or labored breathing (abnormal respiration and an increased effort to breathe). The note indicated Resident 1's oxygen level fluctuated between 88-90%. FM 1 requested the resident be transferred to the GACH. The nursing note indicated the paramedics were called and the oxygen was increased to 10 liters per minute. The paramedics arrived and transferred the resident to the GACH. A review of Resident 1's Paramedic Run Sheet, dated 11/16/19 at 12:05 p.m., indicated Resident 1 was conscious (awake and alert) and coherent (rational). The paramedics documented Resident 1 had been complaining of shortness of breath (SOB) since that morning and was found with a low oxygen saturation that did not get better with increase of oxygen to 10 liters per minute. A review of Resident 1's GACH Emergency Department (ED) documentation, dated 11/16/19 at 12:44 p.m. indicated Resident 1 arrived at the ED with [MEDICAL CONDITION](increased heart rate) and tachypneic (fast, shallow breathing) with impending (about to happen) [MEDICAL CONDITION]. Resident 1's chest x-ray revealed an almost complete whiteout on the left lung field which suggested due to a left lung collapse and/or from a mucus plug (large collection of mucus). Resident 1 required an endotracheal intubation ((ET) a tube placed in the trachea for air exchange) and was admitted into the GACH's intensive care unit ((ICU) a unit for residents who requires a higher level of care (critical care)) for further care and treatment. Resident 1's treatment included [MEDICATION NAME] (breathing treatment), postural drainage (position to encourage drainage by gravity) and chest PT (physiotherapy/clapping of the chest wall to loosen mucus from the lungs). A review of Resident 1's GACH note, dated 11/18/19 indicated the resident was extubated (tube in trachea removed). The note indicated Resident 1 refused to return to the prior SNF but agreed for admission to another SNF 2. On 11/22/19, the resident was transferred to the SNF 2. On 11/27/19 at 11:08 a.m., during an interview, Certified Nurse Assistant (CNA) 1 stated, After breakfast Resident 1 was observed to be short of breath (SOB) and looked tired. Resident 1 was not receiving oxygen at that time. CNA 1 was unable to recall the resident's mental status at that time. CNA 1 stated Resident 1 was nonverbal and only respond ed by nodding her head. On 1/23/2020 at 1:45 p.m., during an interview, Licensed Vocational Nurse (LVN) 1 stated on 11/15/19 the [MEDICAL CONDITION] machine was delivered without the power cord. The resident slept without the [MEDICAL CONDITION] machine as ordered by the physician. LVN 1 stated Resident 1's condition changed due to SOB. LVN 1 stated he did not give the resident any medications or breathing treatments, as ordered by the physician, but the registered nurse (RN) 1 gave the resident the [MEDICATION NAME]. On 1/23/2020 at 3 p.m., during an interview, RN 1 stated LVN 1 notified her of Resident 1's COC and she notified the NP. RN 1 stated she was in between two emergency situations and could not recall giving Resident 1 the [MEDICATION NAME] IVP (intravenous push) and/or the breathing treatment. On 1/24/2020 at 10:45 a.m., during a telephone interview, the facility's contracting pharmacist ((Pharmacist 1) a medication expert) stated the orders for Resident 1 w ere received on 11/15/19 after 10 p.m. Pharmacist 1 stated LVN 1 called the pharmacy on 11/16/19 and stated Resident 1's orders that were faxed on 11/15/19, which were incorrect . Then a nursing staff member called back on the same day at 1:15 p.m. and informed the pharmacist not to send any medications because the resident went to the GACH. On 2/6/2020 at 10:40 a.m., during an interview, RN 2 stated Resident 1 was tired when she arrived at the facility. The resident's oxygen saturation was 95% on room air and the resident did not need oxygen. On 2/6/2020 at 11:21 a.m., during an interview, Resident 1's primary care physician (PCP) 1) stated he was not called about Resident 1's change of condition (COC) due to difficulty in breathing. On 2/6/2020 at 12:31 p.m., during a telephone interview, FM 1 stated when he arrived to visit Resident 1 and there was no staff in Resident 1's room. FM 1 stated Resident 1's face was red, and he could hear the noises coming from the resident's lungs. FM 1 stated Resident 1 had on oxygen face mask but was unable to catch her breath. FM 1 stated he immediately ran out to the nurse's station to get the nurse, as he (FM 1) called 911. On 2/6/2020 at 2:48 p.m., during an interview, the NP stated she did not see Resident 1 in the facility because she does not go to the facility to see residents. The NP stated she was currently out of town and was unable to continue the interview and abruptly hung up the phone. On 2/7/2020 at 3:45 p.m., during an interview and review of Resident 1's physician's orders [REDACTED]. RN 3 stated the orders were verified with the resident's physician but could not recall the physician's name. RN 3 stated she missed verifying Resident 1's new medication and treatment orders that was included in the package. RN 3 denied placing oxygen on Resident 1. RN 3 stated she verified Resident 1's admission orders [REDACTED]. On 2/11/2020 at 6:30 a.m., during an interview, RN 4 stated she provided care to Resident 1 on 11/15/19 during the night shift (11 p.m.-7 a.m.). RN 4 stated she received a report regarding Resident 1's respiratory diagnoses. RN 4 stated there were no medications delivered for Resident 1. RN 4 stated she verified the confusing admission orders [REDACTED]. On 2/11/2020 at 8:30 a.m. and 3:40 p.m., during the interviews, LVN 2 stated she was Resident 1's medication nurse on 11/16/19. LVN 2 stated there was a delay in receiving Resident 1's medication and that was why she did not administer any medications or breathing treatments to Resident 1. A review of the facility's policy and procedure titled, Physician order [REDACTED].

The Department received a SOC 341 (Report of Suspected Dependent Adult/Elder Abuse) on March 23, 2012, alleging a resident (Resident 1) was neglected by a skilled nursing facility (SNF) due to withholding pain medications. On April 6, 2012, at 9:11 a.m., an unannounced complaint investigation was conducted. Based on interviews and record review, the facility failed to follow physician's orders [REDACTED]. Resident 1 was transferred to the SNF three days post-op laminectomy (L4) surgery (surgery performed to primarily alleviate leg pain caused by lumbar spinal stenosis- a narrowing of one or more areas in the spine). The physician ordered muscle relaxants and pain medications that the facility failed to order timely to be administered to Resident 1. These failures resulted in Resident 1 complaining of severe uncontrolled back pain with spasm, and being readmitted to a general acute care hospital (GACH) for uncontrolled back pain. Findings: On April 6, 2012, a review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE], 2012, at 5 p.m., from a GACH with [DIAGNOSES REDACTED].). A review of a SNF Nursing Admission and Assessment form, dated March 9, 2012, indicated Resident 1 was alert and oriented requiring assistance with bed mobility, ambulation, and transferring. The pain assessment indicated the resident's primary pain site was the lower back and the goal was to control the resident's back pain. On April 6, 2012, a review of the GACH physician's transfer medication order, dated March 9, 2012, and timed at 2:36 p.m., indicated the physician ordered, [MEDICATION NAME] 10 milligrams (mg), three times a day for spasm (0900, 1300 and 1700), [MEDICATION NAME] 325 mg, two tablets twice a day as needed for temperature greater than 101F, [MEDICATION NAME] 7.5/325 mg, two tablets every three hours prn for severe pain. In addition, a hand written order by the physician, dated March 9, 2012, without a time included, [MEDICATION NAME] 30 milligrams every four hours as needed for severe pain (prn) [MEDICATION NAME] mg, four times a day for muscle relaxant. The physician's orders [REDACTED]. During an interview, April 6, 2012, at 11:03 a.m., the registered nursing (RN) supervisor stated she had three admissions on March 9, 2012. The RN Supervisor stated on March 9, 2012 at 8 p.m., she entered Resident 1's medication orders into the computer by the point and click system to be printed and faxed later to the pharmacy. According to a written declaration and interview, the RN supervisor stated that RN 2 called and placed the pharmacy order. However, during a telephone interview with RN 2 on May 30, 2012, at 9:37 a.m., RN 2 stated, " No, I did not call in the medication order to the pharmacy for Resident 1, but it was faxed to the pharmacy around 10:30 p.m. " The RN Supervisor stated on March 9, 2012, at 9 p.m., she gave the resident two [MEDICATION NAME] 7.5/325 mg tablets, but stated Resident 1 was asking for [MEDICATION NAME] spasm. The RN Supervisor stated those medications were not in the facility's emergency kit (E-Kit) and the pharmacy was told the medication was needed, but not as a STAT (immediate) order, just a PRN (whenever necessary) order. The RN Supervisor stated she observed Resident 1 on March 9, 2012 at 11 p.m. in bed crying, wanting [MEDICATION NAME] and Soma. She stated Resident 1 was transferred back to the GACH on March 9, 2012 after the resident called 911 at 11:30 p.m., due to uncontrolled back pain. During a telephone interview, on April 6, 2012, at 11:38 a.m., Resident 1 stated she had back surgery on March 6, 2012, in which bone marrow (spongy fatty tissue inside large bones) and four screws were placed into her spine. Resident 1 stated while at the GACH at 4 p.m., on March 9, 2012, prior to transferring to the (SNF) she received two tablets of [MEDICATION NAME] 7.5/325 mg ([MEDICATION NAME]/[MEDICATION NAME]). The resident stated once transferred to the SNF she did not receive [MEDICATION NAME] 7.5/325 mg until 9 p.m., and the RN Supervisor came back and told her there were no [MEDICATION NAME] give her. The resident stated, the RN Supervisor informed her she would see if any other residents were receiving [MEDICATION NAME] so she could give it to her. Resident 1 stated, "That's when I realized this is so wrong and I called 911 and RN 3 came back and told her no other resident was receiving [MEDICATION NAME] to give to her." The resident stated she told both the RN Supervisor and RN 2, she had already called 911. On April 6, 2012, at 1:42 p.m., during a subsequent interview, the RN Supervisor stated the pharmacy could have brought the medication, because it was open for twenty-four hours. We thought we could have managed, but Resident 1 was in so much pain and could not wait for the medications. The RN Supervisor stated, " I would have been frustrated too." During a telephone interview, on April 6, 2012, at 2:56 p.m., Pharmacist 1, from the facility's distributing pharmacy, stated the resident was admitted to the SNF on March 9, 2012, but the SNF did not fax the resident's medication order over until 10:33 p.m. (over five hours after the resident's admission). Pharmacist 1 stated new admission medications are filled within four hours. On May 15, 2012, at 8:24 a.m., during a telephone interview, Pharmacist 2 (pharmacy manager) stated there are two ways for the facility to order medications, by fax or called in by nurses or physician. Pharmacist 2 stated, "We didn't receive any verbal call in for Resident 1 on March 9, 2012. "Pharmacist 2 faxed a copy of Resident 1's medication order form sent to the pharmacy from the SNF on March 9, 2012. A review of the faxed medication order indicated the SNF faxed it to the pharmacy on March 9, 2012 at 10:33 p.m., which was over five hours after Resident 1 was admitted . On May 15, 2012, a review of the GACH's emergency room (ER) records indicated Resident 1 arrived in the ER at 12 a.m., on March 10, 2012, with a chief complaint of back pain. Resident 1 was brought in by paramedics from a skilled nursing facility with severe back pain. According to the ER note, Resident 1 complained that the pain radiated down her left leg with numbness to the left leg. The resident's blood pressure upon arrival was elevated at 139/103, (the resident had no prior history of high blood pressure) normal blood pressure is 120/80 blood pressure. According to an article titled, "Acute Pain and Blood Pressure" acute pain leads to generalized arousal and increased sympathetic nerve activity. This produces a dramatic increase in muscle sympathetic nerve activity (MSNA), which is paralleled by a marked increase of blood pressure, www.medscape.com.viewarticle/ 5_2 <http://www.medscape.com.viewarticle/ 5_2>. Resident 1's pulse rate was also elevated to 143 (pulse rate is the rate at which the heart beats/normal rate is 100 bpm) when the body is under stress, it responds by increasing the heartbeat to meet energy demands. While in the ER, the resident received [MEDICATION NAME] 2 mg intramuscularly (narcotic pain reliever for moderate to severe pain) and [MEDICATION NAME] 25 mg intramuscularly (treat pain in combination with other medicines) were given to help take the edge off the resident's pain. However, during the night the resident required [MEDICATION NAME] 30 mg by mouth to further control the pain. During an interview, on May 18, 2012 at 8:28 a.m., the director of nursing (DON) at the SNF stated they had three admissions on March 9, 2012 and when there was more than one admission all the medication orders are called in together to the physician to verify and then to the pharmacy. The DON stated then they enter the medication orders into a point and click computer system to be printed out at a later time and faxed to the pharmacy. The DON stated the turn-around time is usually four hours from the time the call was placed to the pharmacy until the medication is received. During an interview, on May 18, 2012 at 11:28 a.m., the medication nurse, (licensed vocational nurse-(LVN 1)) stated between 10:45 p.m. and 11 p.m., on March 9, 2012 she heard Resident 1 in the room crying and went to see why the resident was crying. LVN 1 stated the resident stated, "I don't want to be here anymore, I want to go back to the hospital. I am in so much pain." On May 30, 2012, at 11:20 a.m., during a telephone interview, Resident 1's family member stated the resident called and informed him the nurses just left her and had not checked on her. The family member also stated Resident 1 informed him the facility did not fill the physician's prescription for her pain medication. The family member stated he had called the facility three times, speaking to three different nurses. He stated he felt so helpless, because Resident 1 was crying stating the pain was so severe. He stated the nurses informed him the pharmacy was closed and that was why the medication was not in the facility. However, according to a subsequent interview with Pharmacist 1, on May 30, 2012, at 11:42 a.m., she stated the pharmacy hours of operation was twenty-four hours, Monday through Friday, and Saturday and Sundays with a pharmacist on call. She stated the day of the incident, March 9, 2012, which was a Friday, the pharmacy was open for business until 2 am Saturday morning. A review of the facility's policy, titled, "Medication Ordering and Receiving from Pharmacy" dated August 1, 2010, indicated, new medications, except for emergency or " stat " medications, are ordered as follows: a) If needed before the next regular delivery, phone the medication order to the pharmacy immediately upon receipt. Inform pharmacy of the need for prompt delivery and request delivery within two hours. b) Timely delivery of new orders is requires so that medication administration is not delayed. The emergency kit is used when the resident needs a medication prior to pharmacy delivery. A review of facility's undated policy, titled, " Department: Patient Care, Subject: Pain management, Policy Number: P " included unrelieved pain has negative physical and psychological consequences including the potential for threatening functional ability and pain medications prescribed for a resident must be assessed on admission or at the time first prescribed and on an ongoing basis.