Every finding on record at Maywood Skilled Nursing & Wellness Centre

Based on interview and record review, the facility failed to ensure safe transfer of one of three sampled residents (Resident 1) when Certified Nursing Assistant (CNA) 1 did not use a Hoyer lift (mechanical device used to safely lift and transfer non-weight bearing residents) to transfer Resident 1 from the shower chair to the bed. This deficient practice resulted in the unsafe transfer of Resident 1 and a displaced left femur fracture (a complete break in left thigh bone resulting in bone shift out of normal alignment). Resident 1 was transferred to the general acute care hospital (GACH) for evaluation and treatment and underwent an open reduction and internal fixation procedure (surgery performed to repair severe, displaced bone fractures).Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), schizophrenia (a mental illness that is characterized by disturbances in thought), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's History and Physical (H&P) dated 1/10/2026, the H&P indicated Resident 1 could make needs known but could not make medical decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 6/2/2026, the MDS indicated Resident 1 had moderate cognitive (trouble with memory, thinking, or language) impairment. The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for toileting and bathing and personal hygiene. The MDS indicated Resident 1 was dependent on staff for transfers to and from a bed to a chair. During a review of Resident 1's care plan titled Activity of Daily Living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) Activity, dated 1/9/2026, the care plan did not indicate Resident 1 required the use of a Hoyer lift for transfers. During a review of Resident 1's Lift and Transfer Screen (assessment used to evaluate a resident's weight bearing (not allowing the affected limb to support any body weight or touch the floor) ability and the level of assistance required to safely move and transfer them) dated 6/2/2026 at 11:51 p.m., the lift and transfer screen indicated Resident 1 required a mechanical lift or at least two persons assist with assistive devices for transfers. During a review of the facility's Shift Report (outlines residents on each unit with special instructions, restrictions, considerations and requiring the use of a Hoyer lift for transfers) dated 6/20/2026 for the 7 a.m. to 3 p.m. shift, the shift report indicated Resident 1 required a Hoyer lift for transfers. During a review of Resident 1's Situation Background Assessment Recommendation (SBAR- communication form used to provide essential resident information during critical situations) dated 6/20/2026 at 11:30 a.m., the SBAR indicated on 6/20/2026, Resident 1 accidentally twisted her left leg during transfer from the shower chair to bed due to agitation (a state of being stirred up, disturbed, or restless). The SBAR indicated Resident 1 had mild swelling to the left leg and was unable to move her leg. The SBAR indicated physician orders for a stat (immediate) X-ray of the left hip and ibuprofen (medication used to relieve pain and decrease swelling) 600 milligrams (mg-metric unit of measurement, used for medication dosage and/or amount) every eight hours PRN (given as needed or requested) for severe pain. During a review of Certified Nursing Assistant (CNA) 1's Incident/Accident Interview Record dated 6/20/2026 at 11:30 a.m., the record indicated CNA 1 stated on 6/20/2026, she alone transferred Resident 1 from the bed to the shower chair and proceeded to give Resident 1 a shower. The record indicated that while CNA 1 transferred Resident 1 from the shower chair back to bed, Resident 1 became agitated (state of feeling highly stressed, upset, or irritated) and twisted her left leg. The record indicated CNA 1 stated she did not use the Hoyer lift during Resident 1's transfer because she is not heavy that's why I transferred her by myself. During a review of Resident 1's Radiology Results Report (details the findings of a medical imaging exam, such as an X-ray) dated 6/21/2026 at 12:49 a.m., the Radiology Results Report indicated an acute left femoral fracture (a recent, sudden break in the left thighbone). During a review of Resident 1's Physician's Order dated 6/21/2026 at 2:05 a.m., the physician order indicated to transfer Resident 1 to the general acute care hospital (GACH) for further evaluation and treatment. During a review of Resident 1's Nursing Progress Note dated 6/21/2026 at 2:08 a.m., the progress note indicated the physician was notified of Resident 1's X-ray results and a new order was received to transfer to the general acute care hospital (GACH) for further evaluation and treatment. During a review of Resident 1's Nursing Progress Note dated 6/21/2026 at 12:11 p.m., the progress note indicated Resident 1 was transferred to the GACH for further evaluation and management of a left femoral fracture. During a review of Resident 1's GACH Emergency Department (ED) Notes dated 6/21/2026 at 1:43 p.m., the GACH ED Notes indicated Resident 1 was transferred to the ED after a witnessed fall and an X-ray result of displaced left femur fracture. During a review of Resident 1's GACH Operative Report dated 6/30/2026 at 6:23 p.m., the GACH Operative Report indicated Resident 1 underwent a left femur open reduction and internal fixation (ORIF - surgery performed to repair severe, displaced bone fractures). The report indicated a postoperative plan of non-weight bearing to the left lower extremity (leg) and likely need for a subacute nursing facility (level of care for resident who does not require hospital care but requires more intensive licensed skilled nursing care than provided in a skilled nursing facility). During a concurrent interview and record review on 7/1/2026 at 11:58 a.m. with Licensed Vocational Nurse (LVN) 1, the facility's Shift Report dated 6/20/2026 was reviewed. The Shift Report indicated Resident 1 required the use of a Hoyer lift for transfers. LVN 1 stated in the beginning of every shift, the charge nurse reviewed the Shift Report with the CNAs. LVN 1 stated on 6/20/2026, he went over the Shift Report with CNA 1 that indicated Resident 1 required a Hoyer lift for transfer. LVN 1 stated around 11 a.m., the Treatment Nurse (TXN) notified him that Resident 1 had swelling to her left thigh. LVN 1 stated a Hoyer lift should have been used to transfer Resident 1 from the shower chair back to bed. LVN 1 stated not using a Hoyer lift placed the resident at risk for injury. During a concurrent interview and record review on 7/1/2026 at 10:35 a.m. with Physical Therapist (PT) 1, Resident 1's Physical Therapy (PT) Recertification, Progress Report and Updated Therapy Plan dated 5/23/2026 at 6:16 p.m., and the Shift Report dated 6/20/2026 were reviewed. The PT Recert, Progress Report and Updated Therapy plan indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) for transfers from bed to chair. The Shift Report dated 6/20/2026 indicated Resident 1 required a Hoyer lift for transfers. PT 1 stated for safety reasons the Rehab Department would recommend the use of a Hoyer lift for residents that required substantial assistance for transfers. PT 1 stated Resident 1's assistance level fluctuated depending on if she was cooperative or agitated. PT 1 stated Resident 1 had episodes of agitation and noncompliance with instructions for transfers. PT 1 stated CNA 1 should have used a Hoyer lift when transferring Resident 1 from the shower chair to bed. PT 1 stated failure to use a Hoyer lift during transfer placed Resident 1 at risk for unsafe transfers and injury. During an interview on 7/1/2026 at 11:32 a.m. with CNA 2, CNA 2 stated for the safety of the resident she always used a Hoyer lift for Resident 1's transfers. CNA 2 stated at the beginning of every shift, the charge nurse reviewed the shift report, and the CNAs were expected to follow the recommendations for residents requiring Hoyer lift transfers. During an interview on 7/1/2026 at 3:50 p.m. with Registered Nurse (RN) 2, RN 2 stated on 6/20/2026, she was notified by the TXN that Resident 1 had a new onset of swelling to her left thigh. RN 2 stated when she interviewed CNA 1, CNA 1 stated she did not use a Hoyer lift and transferred Resident 1 from the shower chair to bed on her own because Resident 1 was not heavy. During an interview on 7/1/2026 at 3:45 p.m. with the Administrator (ADM), the ADM stated staff were expected to follow policies and transfer recommendations to ensure safety of residents. During a review of the facility's policy and procedure (P&P), titled, Transfer of Residents dated 5/4/2023, the P&P indicated, A licensed nurse completes a lift/transfer assessment to determine the proper procedure for each resident. The P&P indicated, Residents will be lifted or transferred according to the assessment and needs of the residents. During a review of the facility's P&P titled, Total Mechanical Lift dated 5/4/2023, the P&P indicated, Mechanical lifts are devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by nursing staff alone. The P&P indicated, A mechanical lift is used appropriately to facilitate transfer of residents.

Based on interview and record review, the facility failed to ensure the fall risk care plan included interventions for two-persons assist (method where two staff members move a resident who cannot bear weight or stand independently) and the use of a Hoyer lift (mechanical device used to safely lift and transfer non-weight bearing residents) with transfers for one of three sampled residents (Resident 1) . This deficient practice had the potential to place Resident 1's safety at risk.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), schizophrenia (a mental illness that is characterized by disturbances in thought), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's History and Physical (H&P) dated 1/10/2026, the H&P indicated resident 1 could make needs known but could not make medical decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 6/2/2026, the MDS indicated Resident 1 had moderate cognitive (ability to think and understand) impairment. The MDS indicated Resident 1 was dependent on staff for toileting, bathing, and personal hygiene. The MDS indicated Resident 1 was dependent on staff for transfers to and from a bed to a chair. During an interview on 7/2/2026 at 10:34 a.m. with Physical Therapist (PT) 1, the facility's Shift Report (outlines residents on each unit with special instructions, restrictions, considerations and requiring the use of a Hoyer lift for transfers) dated 6/20/2026 was reviewed. The Shift Report indicated Resident 1 required a Hoyer lift for transfers. PT 1 stated physical therapists and nursing collaborated to create the Shift Report, and all residents that should be transferred using a Hoyer lift were indicated in the document. PT 1 stated Resident 1's care plan should have indicated the need for the use of a Hoyer lift for transfers to ensure safety. PT 1 stated not including the need for a Hoyer lift for transfers in Resident 1's care plan placed the resident at risk for low quality care. During a concurrent interview and record review on 7/1/2026 at 2:30 p.m. with Registered Nurse (RN) 1, Resident 1's Lift and Transfer Screen (assessment used to evaluate a resident's weight bearing ability and the level of assistance required to safety move and transfer them) dated 6/2/2026 and care plan titled At risk for falls/potential for injury or further falls dated 1/9/2026 were reviewed. Resident 1's Lift and Transfer Screen indicated Resident 1 required a mechanical lift or at least two person assist with assistive devices for transfers. Resident 1's fall risk care plan did not indicate an intervention that addressed Resident 1's need for a mechanical lift or two person assist for transfers. RN 1 stated Resident 1's care plan should have included interventions that addressed Resident 1's need for a mechanical lift or two person assist for transfers. RN 1 stated care plans should be comprehensive and address the specific needs of residents for safe transfers. During a review of the facility's policy and procedure (P&P), titled, Person-Centered Care Planning dated 5/22/2025, the P&P indicated resident care plans should address resident-specific health and safety concerns to prevent decline and injury, and identify needs for supervision and assistance with activities of daily living.

Based on observation, interview, and record review, the facility failed to ensure the Office of the State Long-Term Care Ombudsman program (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) contact information was posted in a visible area to residents. This deficient practice had the potential to violate residents rights to file a complaint. Findings: During a review of Resident 52's admission Record, the admission Record indicated Resident 52 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 52's diagnoses included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), hypertension (HTN-high blood pressure) and dysphagia (difficulty swallowing). During a review of Resident 52's History and Physical (H&P) dated 9/9/2025, the H&P indicated Resident 52 had the capacity to understand and make decisions. During a review of Resident 52's Minimum Data Set (MDS- a resident assessment tool), dated 12/10/2025, the MDS indicated Resident 52 was cognitively intact (ability to think and understand). The MDS indicated Resident 52 required staff supervision for eating and toileting and partial staff assistance with bathing and personal hygiene. During an interview on 3/25/2026 at 2:14 p.m. with Resident 52, Resident 52 stated he did not know where to find the Ombudsman's contact information in the facility. During a concurrent observation and interview on 3/24/2026 at 4:00 p.m. with the Infection Prevention Nurse (IPN), observed the walls of the front lobby and the walls throughout the entire facility. There was no Ombudsman contact information posted. The IPN stated Ombudsman contact information was usually posted in the front lobby of the facility. The IPN stated the Ombudsman contact information was not posted. The IPN stated the Ombudsman contact information should be posted in a visible place for residents because it was their right to be able to report concerns or make complaints to the Ombudsman. During an interview on 3/26/2026 at 9:21 a.m. with the Director of Nursing (DON), the DON stated Ombudsman information was usually posted in the front lobby of the facility but was taken down when the walls were recently repainted. The DON stated it was important for Ombudsman contact information to be visible to residents because it honors the residents rights to report concerns or make complaints to the Ombudsman. During a review of the facility's policy and procedure (P&P) titled, Grievances and Complaints dated 10/2/2025, the P&P indicated, If the resident is not satisfied with the result of the investigation, or the recommended actions, he or she may file a written complaint with the local Long Term Care Ombudsman's office or with the California Department of Public Health. Addresses and telephone numbers of these agencies are posted on the facility consumer board.

Based on observation, interview, and record review, the facility failed to ensure three of 11 sampled residents (Resident 106, Resident 25, and Resident 4) received treatment and care in accordance with professional standards of care when:1. Licensed Vocational Nurse (LVN) 2 did not clarify Resident 106's order for cholecalciferol (also known as Vitamin D3, a vitamin essential for building and maintaining strong bones and immune function) and accurately document the omission on the Medication Administration Report (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident).2. Resident 25's physician order for a urinalysis (UA- lab test to check the urine for signs of disease) and culture and sensitivity (C&S- a lab test to determine the specific bacteria and what medication works best to treat it) were not carried out due to the incorrect input of the physician order and ineffective follow up, documentation, and communication between the licensed nurses.3. Resident 4 was not monitored for sedation, drowsiness, and possible side effects while receiving Haldol (an antipsychotic used to treat mental health conditions) 4 milligrams (mg, a unit of measurement) twice a day.These deficient practices resulted in Resident 106 missing her daily dose of cholecalciferol and potential for additional missed doses. These deficient practices also had the potential to result in a delay in treatment and diagnosis of a possible urinary tract infection (UTI- an infection in the bladder/urinary tract) for Resident 25. These deficient practices also had the potential to result in undetected drowsiness, sedation, and side effects which could result in delay in Resident 4's treatment.Cross Reference F759 and F656.Findings:1. During a review of Resident 106's admission Record, the admission Record indicated Resident 106 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 106's diagnoses included protein-calorie malnutrition (when an individual does not eat enough protein and calories to meet nutritional needs), generalized muscle weakness, and generalized osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage).During a review of Resident 106's Minimum Data Set (MDS- a resident assessment tool), dated 12/12/2025, the MDS indicated Resident 106's cognition (process of thinking) was intact. The MDS indicated Resident 106 required supervision or touching assistance with eating, oral hygiene, bathing, dressing, and personal hygiene. During a review of Resident 106's History and Physical (H&P), dated 9/9/2025, the H&P indicated Resident 106 had the capacity to understand and make decisions.During a review of Resident 106's physician order, dated 9/28/2023, the physician order indicated to administer cholecalciferol (also known as Vitamin D3, a vitamin essential for building and maintaining strong bones and immune function) 1000 units, by mouth, once a day for supplement.During an observation on 3/24/2026 at 8:04 a.m., in Resident 106's room, observed Licensed Vocational Nurse (LVN) 2 prepare Resident 106's medications. Resident 106 received five medications by mouth and one medication by injection. LVN 2 did not prepare and administer cholecalciferol to Resident 106. LVN 2 returned to the medication cart and documented the medications administered to Resident 106.During a concurrent interview and record review on 3/24/2026 at 1:41 p.m., with LVN 2, Resident 106's Medication Administration Report (MAR), dated 3/1/2026 through 3/31/2026, was reviewed. The MAR indicated, on 3/24/2026, LVN 2 administered cholecalciferol to Resident 106. LVN 2 stated she did not administer cholecalciferol to Resident 106 and she documented incorrectly. During an interview on 3/24/2026 at 1:45 p.m., with LVN 2, LVN 2 stated during the observed medication administration she was confused by the cholecalciferol order and the house supply medications (over-the-counter medications). LVN 2 stated none of the medication bottles in her medication cart indicated cholecalciferol and did not want to risk giving the wrong medication. LVN 2 stated by the time she clarified the medication with another licensed nurse, it was past the acceptable medication administration time frame. LVN 2 stated she should have clarified with another licensed nurse during the medication administration timeframe to ensure Resident 106 received her daily cholecalciferol dose. During an interview on 3/25/2026 at 1:35 p.m., with the Director of Nursing (DON), the DON stated medications should be administered to the resident unless the resident refused or the medication parameters (instructions that dictate when a medication should be given, withheld, or adjusted) were not met. The DON stated LVN 2 was responsible for consulting another licensed nurse, or with the DON, as soon as possible to clarify which bottle in the medication cart contained cholecalciferol. The DON stated LVN 2 should not have documented anything in the MAR for cholecalciferol during the medication administration so she could remember to clarify the medication. The DON stated because LVN 2 did not clarify Resident 106's cholecalciferol timely, LVN 2 should have consulted with Resident 106's physician for an order to administer the medication late or hold the medication until the following day. The DON stated due to LVN 2's actions, Resident 106 did not receive her daily dose of cholecalciferol, on 3/24/2026, which was important for her bone health and immune function.During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated 8/19/2025, the P&P indicated, All medications shall be administered by licensed nursing staff according to physician orders, current best practices, and federal and state regulations. The P&P indicated, When a medication is held for any reason, it must be documented along with reason and the prescribing provider will be notified. During a review of the facility's LVN Job Description, undated, the Job description indicated the following LVN's duties and responsibilities: a. Records care information accurately, timely, and concisely, Completes all required documentation including resident observations, interventions, and patient response(s) in the medical record in accordance with policy. b. Prepares/administers medications as ordered by the physician and within the legal scope of practice. 2. During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 25's diagnoses included diabetes (poor blood sugar control), Alzheimer's (a disease characterized by a progressive decline in mental abilities), muscle weakness, and neuromuscular dysfunction of bladder (a condition where nerve damage from diseases or injuries disrupts the brain-bladder communication). During a review of Resident 25's MDS, dated [DATE], the MDS indicated Resident 25's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 25 required moderate assistance (helper does less than half the effort) for oral hygiene, toileting, and dressing. During a review of Resident 25's Change of Condition Note, dated 3/22/2026, the note indicated on 3/22/2026, Resident 25 was getting up unassisted, yelling, and displaying combative and aggressive behaviors. The note indicated the physician ordered a urinalysis (lUA- lab test to check the urine for signs of disease) with culture and sensitivity (C&S- a lab test to determine the specific bacteria and what medication works best to treat it). During a concurrent interview and record review on 3/24/2026 at 3:40 p.m. with Registered Nurse (RN) 2, Resident 25's Change of Condition Note, dated 3/22/2026, all of Resident 25's Physician Orders, dated 3/2026, and Nursing Progress Notes, dated 3/2026, were reviewed. The Change of Condition note indicated an order for a urinalysis and C&S. The physician orders did not indicate an order for a UA and C&S. The Nursing Progress Notes did not indicate the physician order was endorsed, attempted or followed up. RN 2 stated she received the physician order but did not document endorsement or follow up to ensure the specimen was obtained. RN 2 stated that she should have ensured adequate documentation to endorse the order and follow up. RN 2 stated that this had the potential to delay treatment and diagnosis for Resident 25. During a concurrent interview and record review on 3/24/2026 at 3:50 p.m. with LVN 3, Resident 25's completed physician orders, dated 3/22/2026, and the facility's Lab Requisition Book (facility-maintained log used to document and track all laboratory tests ordered for residents), and Electronic Lab Requisitions, dated 3/2026, were reviewed. The completed physician orders indicated the UA with C&S was marked as complete. The lab requisitions did not indicate labs were completed for Resident 25's. LVN 3 stated the facility's process was to enter physician orders into the electronic medical record system right away. LVN 3 stated she was Resident 25's assigned nurse (on 3/24/2026) and was not made aware of the order because it was not endorsed and was not visible in the active physician orders. During an interview on 3/24/2026 at 4:00 p.m. with LVN 4, LVN 4 stated she was also one of Resident 25's assigned nurse and was not made aware Resident 25 had a pending order for a UA with C&S because it was not endorsed or documented in a manner that made it visible for follow-up. During an interview on 3/24/2026 at 4:04 p.m. with the DON, the DON stated Resident 25's physician order was not properly inputted and should have had an end date of approximately five days after it was ordered to ensure all licensed nursing staff were aware. The DON stated that there should have been documentation of proper endorsement, any attempts to obtain the specimen, and adequate follow-up to ensure the order was completed. The DON stated there was potential to delay timely diagnosis and treatment. During a review of the facility's P&P titled, Physician Orders, revised 11/16/2022, the P&P indicated the facility was to ensure the following: 1. Licensed nurses that received telephone/verbal orders would transcribe the order in the resident medical record at the time the order is taken. 2. Lab orders would include the name of the desired test, the frequency, reason for the test associated diagnosis 3. Documentation pertaining to physician orders would be maintained the Resident's medical record During a review of the facility's P&P titled, Laboratory Services, revised 1/1/2012, the P&P indicated the facility was to ensure laboratory services were provided in an accurate and timely manner to meet the needs of residents per Attending Physician orders. The P&P indicated the following: A. Laboratory services would be provided when ordered by the Attending Physician. B. Upon receiving the order, the Licensed Nurse would do the following: i. Write out an order to the laboratory that includes the following: a. The date the order was obtained. b. The resident's room number. c. The resident's name with the residents assigned medical record number. d. The ordering physician's full name. e. The name of the test to be done. ii. Notify the laboratory of the laboratory orders. During a review of the facility's RN Supervisor Job Description (undated), the job description indicated the RN Supervisor was to assure all nurse's notes were charted in an informative and descriptive manner that reflected the care provided as well as the resident's response to the care and make resident rounds to ensure appropriate care was rendered, identifying and making corrections as necessary. 3. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4's diagnoses included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), muscle weakness, dysphagia (trouble swallowing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 4's hearing was adequate. The MDS indicated Resident 4 was dependent on staff for toileting, bathing, and dressing. During a review of Resident 4's H&P, dated 5/23/2025, the H&P indicated Resident 4 did not have the capacity to understand and make decisions. During a review of Resident 4's Physician Order, dated 11/5/2025, the order indicated to administer Haloperidol (an antipsychotic [a drug customarily used for the treatment of symptoms of psychoses and other severe mental and emotional disorders]) oral tablet four (4) milligrams (mg, a unit of measurement) by mouth two times a day. During a review of Resident 4's care plan titled, Psychotropic Medication (prescription drugs that affect mood, thoughts, behavior, or perception to treat mental health conditions), dated 11/5/2025, the care plan indicated to observe for adverse reactions like sedation (a medically induced state of reduced consciousness and responsiveness) and dizziness. During a review of Resident 4's Psychotropic Risk and Benefit Form (undated), the form indicated a risk of the use of haloperidol was sedation. During a concurrent observation and interview on 3/23/2023 at 10:00 a.m., with Certified Nursing Assistant (CNA) 3, in Resident 4's room, Resident 4 was observed lying asleep in bed. CNA 3 called Resident 4's name three times with increasing volume. Resident 4 slowly opened his eyes after the fourth attempt. During a concurrent observation and interview on 3/24/2026 at 11:05 a.m. with LVN 6, in Resident 4's room, Resident 4 was observed lying in bed with both of his eyes closed. Resident 4 did not respond to verbal stimuli. LVN 6 called Resident 4's name four times with increasing volume and applied tactile (touch) stimulation by tapping the resident's shoulders, with no response. Resident 4 opened his eyes after a sternal rub (painful, central stimulation technique used in emergencies to assess a patient's level of consciousness). LVN 6 stated Resident 4 liked to be in bed and asleep. During a concurrent interview and record review with the DON on 3/24/2026 at 2:16 p.m., Resident 4's MAR, dated 3/2025, was reviewed. The MAR did not indicate monitoring was in place for sedation. The DON stated it was important to monitor for sedation or drowsiness due to the risk for falls or excessive sedation. The DON stated it was important to monitor for sedation so that the licensed staff could notify the physician so adjustments could be to made to the medication. The DON stated Resident 4 was placed at risk for sedation. During a review of the facility's P&P titled, Behavior/Psychoactive Medication Management, revised 1/30/2026, the P&P indicated the facility was to ensure the resident would be observed and/or monitored for side effects, and adverse consequences, including sedation. All complications and side effects should be reported to the Healthcare practitioner.

Based on interview and record review, the facility failed to ensure direct care staffing information [actual, hands-on hours worked by qualified staff such as registered nurses (RN), licensed vocational nurses (LVN) and certified nursing assistants (CNA) providing direct nursing services to residents] was submitted to the Centers for Medicaid Services (CMS- federal agency responsible for regulating healthcare quality).This deficient practice had the potential to place the facility at risk of unidentified staffing issues.Findings:During a review of the Payroll Based Journal (PBJ- dataset that provides information submitted by nursing homes quarterly) Staffing Data Report dated 3/19/2026, the PBJ Staffing Data Report indicated the facility failed to submit data for quarter one (10/1/2025-12/31/2025). During a concurrent interview and record review on 3/25/2026 at 1:50 p.m. with the Administrator (ADM), the CMS Submission Report dated 2/13/2026 was reviewed. The CMS Submission Report indicated direct care staffing information was submitted for quarter two (1/1/2026-3/31/2026) on 2/13/2026. The ADM stated direct care staffing information was submitted quarterly by a third-party company. The ADM stated the facility submitted required data to their contracted third-party company and direct care staffing information should have been submitted for quarter one. The ADM stated failing to submit direct care staffing information placed the facility at risk of not identifying large scale staffing issues. During an interview on 3/26/2026 at 10:00 a.m. with the Clinical Project Director (CPD), the CPD stated the database used to submit direct care staffing information to CMS changed the selection for submission for quarter one to quarter two. The CPD stated quarter one's data was submitted, but the error in quarter selection went unnoticed. The CPD stated this error caused the facility to be triggered for failing to submit data for quarter one. During an interview on 3/26/2026 at 9:21 a.m. with the Director of Nursing (DON), the DON stated submitting direct care staffing hours was important because it ensured the facility met the required hours and helped identify staffing issues. The DON stated direct care staffing hours helped indicate the level of care being provided to residents, with higher staffing hours being optimal for resident care. During a review of the facility's policy and procedure (P&P) titled, Electronic Staffing Data Submission Payroll-Based Journal dated June 2025, the P&P indicated Direct care staffing and census data will be collected quarterly, and it is required to be timely and accurate.

Based on observation, interview, and record review, the facility failed to ensure the call light was readily accessible and within reach for one of six sampled residents (Resident 112). The call light was observed positioned behind the resident's bed, preventing immediate access. This deficient practice had the potential to significantly compromise Resident 112's safety by delaying Resident 112's ability to request assistance, thereby increasing the risk for unmet needs, injury, and adverse outcomes.Findings: During a review of Resident 112's admission Record, the admission Record indicated Resident 112 was admitted to the facility on [DATE]. Resident 112's diagnoses included falls, muscle weakness, dysphagia (difficulty swallowing), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), chronic obstructive pulmonary disease (COPD- a progressive lung disease that restricts airflow causing significant breathing difficulties) and contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the right and left knee. During a review of Resident 112's History and Physical (H&P), dated 3/14/2026, the H&P indicated Resident 112 could make needs known but couldnot make medical decisions. During a review of Resident 112's Minimum Data Set (MDS, a resident assessment tool), dated 12/9/2025, the MDS indicated Resident 112 cognitive skills for daily decision making (the ability to think and process information) was mildly impaired. The MDS indicated Resident 112 required moderate (helper does less than half the effort) assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During an observation on 3/23/2026 at 10:04 a.m., at Resident 112's bedside, Resident 112 was observed lying in bed. The call light was hanging behind and under Resident 112's bed. During a concurrent interview and record review on 3/24/2026 at 1:40 p.m. with Licensed Vocational Nurse (LVN) 1, a photo of Resident 112's call light, dated 3/23/2026 and timed at 10:04 a.m., was reviewed. The photo revealed the call light was hanging behind the bed and not within reach. LVN 1 stated Resident 112 was able to make her needs known. LVN 1 stated that regardless of residents being able to make their needs known, the call light should always be within reach of the residents. LVN 1 stated call lights were a way for residents to call out for assistance and prevent injuries. LVN 1 stated staff were expected to ensure call lights were placed within reach during and after all care, including after repositioning, toileting, and transfers. LVN 1 stated that failing to ensure the call light was accessible could delay a resident's ability to request assistance, increasing the risk for falls, incontinence (inability to control bladder and bowel functions) episodes, or other unmet needs. LVN 1 stated that it was the responsibility of all nursing staff to verify call light accessibility as part of routine safety checks and that this expectation applied to all residents at all times. LVN 1 stated that the call light for Resident 112 should have been within reach and that not having it accessible did not meet the facility's standard of care and safety practices.During a review of the facility's policy and procedures (P&P) titled Communication- Call System, dated 8/24/2024, the P&P indicated The call alert device will be placed within the residents reach.

Based on observation, interview, and record review, the facility failed to notify one of one sampled resident's (Resident 91) physician of the resident's preference of taking Depakote Sprinkle (an anticonvulsant medication, used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] with small beads within a capsule that could be sprinkled onto soft food) capsules whole. This deficient practice had the potential to result in Resident 91 choking.Cross Reference F657 and F759.Findings:During a review of Resident 91's admission Record, the admission Record indicated Resident 91 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 91's diagnoses included epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 91's Minimum Data Set (MDS, a resident assessment tool), dated 2/16/2026, the MDS indicated Resident 91's cognition (process of thinking) was intact. The MDS indicated Resident 91 required supervision or touching assistance with oral hygiene, toileting, bathing, upper/lower body dressing, and personal hygiene. The MDS indicated Resident 91 received anticonvulsant medication (medication to treat seizures).During a review of Resident 91's History and Physical (H&P), dated 11/11/2025, the H&P indicated Resident 91 had the capacity to understand and make decisions. During a review of Resident 91's care plan titled, At Risk/Potential for Aspiration/Choking, initiated 11/10/2025, the care plan indicated to crush medications and mix with apple sauce if indicated.During an observation on 3/24/2026 at 9 a.m., outside of Resident 91's room, observed Licensed Vocational Nurse (LVN) 5 preparing Resident 91's routine medications. LVN 5 removed four capsules from Resident 91's Depakote Sprinkle bubble pack (also known as a blister pack, a plastic tray with individual compartments of medication doses sealed with foil). LVN 5 divided the four capsules into two medication cups, with two capsules in each medication cup. LVN 5 prepared five medications and kept all capsules and tablets whole. LVN 5 entered Resident 91's room with six labeled medication cups and a cup of water. During an observation on 3/24/2026 at 9:09 a.m., in Resident 91's room, observed LVN 5 explain each medication to Resident 91. LVN 5 administered all of Resident 91's medications.During a concurrent interview and record review on 3/24/2026 at 1:49 p.m., with LVN 5, Resident 91's Physician Order for Depakote Sprinkle, dated 11/9/2025, was reviewed. The order indicated to administer Depakote Sprinkle 500 milligrams (mg, unit of measurement) by mouth twice a day for epilepsy, mix with apple sauce. LVN 5 stated Resident 91's Depakote Sprinkle was supposed to be administered with apple sauce. LVN 5 stated the capsule had to be opened and the beads poured over apple sauce prior to administration. LVN 5 stated she did not follow the physician's order. LVN 5 stated, I know the resident and already know he does not like to take it like that. LVN 5 stated the purpose of mixing with apple sauce was to reduce the risk of choking. LVN 5 stated although taking the capsules whole were Resident 91's usual preference, she should still ask Resident 91 prior to administering the Depakote Sprinkle. LVN 5 stated she did not notify Resident 91's physician of Resident 91's preference to take the Depakote Sprinkle whole. LVN 5 stated notifying Resident 91's physician was necessary to ensure allowing Resident 91 to take the Depakote Sprinkle whole was safe.During an interview on 3/25/2026 at 1:45 p.m., with the Director of Nursing (DON), the DON stated the licensed nurses were responsible for following all medication administration instructions. The DON stated Depakote Sprinkle had the instruction to mix with apple sauce to reduce the risk of choking. The DON stated Resident 91's physician should have been notified of Resident 91's preference. The DON stated the physician ordered for the Depakote Sprinkle to be mixed with apple sauce and the physician would be able to determine whether taking the Depakote Sprinkle capsule whole was safe to do. During a review of the facility's policy and procedure (P&P) titled, Change in Condition, dated 8/25/2022, the P&P indicated the physician must be notified of any change in condition.

Based on observation, interview, and record review, the facility failed to ensure residents' clothing and personal belongings were protected from view and potential loss when closet doors were left uncovered without doors or adequate protective measures for three out of six sampled residents (Resident 11, Resident 25, and Resident 116). This deficient practice had the potential to create a risk for theft and compromise the residents' sense of security and homelike environment.Findings: 1. During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 11's diagnoses included pneumonia (an infection/inflammation in the lungs), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), Alzheimer's (a disease characterized by a progressive decline in mental abilities), and muscle weakness. During a review of Resident 11's Minimum Data Set ([MDS], a resident assessment tool), dated 3/4/2026, the MDS indicated Resident 11's cognitive skills (ability to think and reason) for daily decision making were severely impaired. The MDS indicated Resident 11 was dependent on staff for oral hygiene, bathing, toileting, and dressing. 2. During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 25's diagnoses included diabetes (poor blood sugar control), Alzheimer's, muscle weakness, and neuromuscular dysfunction of the bladder (a condition where nerve damage from diseases or injuries disrupts the brain-bladder communication). During a review of Resident 25's MDS, dated [DATE], the MDS indicated Resident 25's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 25 required moderate assistance (helper does less than half the effort) for oral hygiene, toileting, and dressing. 3. During a review of Resident 116's admission Record, the admission Record indicated Resident 116 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 116's diagnoses included COPD, muscle weakness, and dysphagia (trouble swallowing). During a review of Resident 116's MDS, dated [DATE], the MDS indicated Resident 116's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 116 was dependent on staff for oral hygiene, toileting, bathing and dressing. During observations made on 3/23/2026 at 12:17 p.m., and on 3/24/2026 at 12:19 p.m., in Room A, all three closet doors were missing. Residents 11, 25, and 116's clothing and personal belongings were exposed. During an interview on 3/24/2026 at 12:19 p.m. with Resident 116, Resident 116 stated, The closets are not supposed to be like that and I do not want people seeing my stuff. During an interview on 3/24/2026 at 2:25 p.m. with the Director of Nursing (DON), the DON stated the absence of closet doors made the residents' personal belongings exposed and at risk for potential theft. The DON stated the facility was aware of the issue. During a review of the facility's policy and procedure (P&P) titled, Resident Rooms and Environment, revised 1/1/2012, the P&P indicated the facility was to ensure the facility provides residents with a safe, clean, comfortable, and homelike environment. The P&P indicated the facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. The P&P indicated the facility encouraged residents to use their personal belongings to the extent possible. The P&P indicated facility staff would aim to create a personalized, homelike atmosphere, paying close attention to personalized furniture and room arrangements.

Based on interview and record review, the facility failed to ensure the correct Preadmission Screening and Resident Review (PASRR- a federally mandated screening process designed to ensure individuals with serious mental illnesses or intellectual/development disabilities receive the necessary support) Level 1 Screening was received from the general acute care hospital (GACH) for one of three sampled residents' (Resident 12).This deficient practice resulted in the failure of a more in-depth Level 2 Mental Health Evaluation not being conducted and had the potential for Resident 12 to not receive the necessary and appropriate psychiatric level treatment and evaluation in the facility.Findings:During a review of Resident 12's admission Record, the admission Record indicated Resident 12 was admitted to the facility on [DATE]. Resident 12's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 12's Minimum Data Set (MDS, a resident assessment tool), dated 9/12/2025, the MDS indicated Resident 12's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 12 required moderate assistance (helper does less than half the effort) with toileting, bathing, lower body dressing, and personal hygiene. The MDS indicated Resident 12 had a diagnosis of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). The MDS indicated Resident 12 received antipsychotics (medication used to treat mental health conditions) and antidepressants (medication to treat depression). During a review of Resident 12's History and Physical (H&P), dated 3/1/2026, the H&P indicated Resident 12 could make needs known but could not make medical decisions. During a review of the General Acute Care Hospital (GACH) H&P, dated 9/3/2025, the GACH H&P indicated Resident 12 had diagnoses of bipolar disorder and schizophrenia.During a review of the GACH Discharge Reconciliation, dated 9/4/2025, the GACH Discharge Reconciliation indicated to continue aripiprazole (an antipsychotic medication) 5 milligrams (mg, a unit of measurement), fluoxetine 10mg (an antidepressant medication), and mirtazapine (an antidepressant)15mg upon discharge from the GACH.During a review of Resident 12's Physician Orders, dated 9/5/2025, the Physician Orders indicated to administer:1. Aripiprazole 10 mg, give one tablet by mouth, in the morning for schizophrenia manifested by aggressive behavior as evidence by striking out during care.2. Fluoxetine 10mg, give four tablets by mouth, at bedtime for depression as manifested by refusing to participate with previously enjoyed activity.During a review of Resident 12's Physician Orders, dated 9/8/2025, the Physician Orders indicated to administer mirtazapine 15mg, give one tablet by mouth, at bedtime for depression as manifested by poor oral intake.During a review of Resident 12's Psychiatric Evaluation, dated 9/16/2025, the Psychiatric Evaluation indicated Resident 12 had diagnoses of schizophrenia, bipolar disorder, and depression and received psychotropic medication (medications that affect the mind, emotions, and behavior).During an interview on 3/24/2026 at 2:33 p.m., with MDS Nurse (MDSN) 2, MDSN 2 stated the PASRR level 1 was completed at the GACH before the resident was discharged to the facility. MDSN 2 stated the PASRR level 1 was reviewed upon the resident's admission to the facility to check if a more in-depth level 2 assessment was required. MDSN 2 stated the PASRR level 1 should be reviewed to ensure accuracy and if there were any errors, the facility could submit a new PASRR level 1. During a concurrent interview and record review on 3/24/2026 at 2:40 p.m., with MDSN 2, Resident 12's PASRR Level 1 Screening, dated 9/5/2025, was reviewed. The PASRR Level 1 Screening indicated Resident 12 was not diagnosed with a serious mental illness nor taking psychotropic medication. The PASRR Level 1 Screening indicated Resident 12 was negative for severe mental illness and a Level 2 Assessment was not required. MDSN 2 stated Resident 12's PASRR Level 1 was not accurate because Resident 12 had schizophrenia and bipolar disorder and received psychotropic medications to manage the manifested behaviors. MDSN 2 stated the error should have been identified and a new PASRR Level 1 submitted to ensure a Level 2 assessment was completed. During an interview on 3/25/2026 at 1:19 p.m., with the Director of Nursing (DON), the DON stated the PASRR Level 1 was conducted to identify those residents with mental conditions and to refer for a PASRR Level 2 assessment. The DON stated the purpose of the PASRR Level 2 assessment was to determine whether Resident 12 required additional psychiatric help, behavioral management, or whether Resident 12's behaviors could be managed in the facility. The DON stated Resident 12's PASRR Level 1 came from the GACH and should have been reviewed by the nursing and admissions departments to ensure the PASRR Level 1 was completed accurately. The DON stated Resident 12's inaccurate PASRR Level 1 should have been identified upon his admission and a new PASRR Level 1 should have been submitted to ensure a PASRR Level 2 assessment was done. The DON stated without a PASRR Level 2 assessment conducted, Resident 12 was at risk for mismanagement of his psychiatric diagnoses and behaviors and may not receive all the additional behavioral resources. During a review of the facility's Policy and Procedure (P&P) titled, admission Screening Resident Review (PASRR), dated 6/12/2024, the P&P indicated, The facility staff will ensure that a PASRR Level 1 is completed for each resident prior to admission. The facility staff will complete a new PASRR upon readmission from the acute hospital if there has been a significant change in the resident's condition.

Based on observation, interview, and record review, the facility failed to ensure a care plan was developed and implemented in a timely manner for three of six sampled residents (Resident 22, Resident 28, and Resident 4), who required the use of dentures and who was administered Haloperidol (an antipsychotic [a drug used for the treatment of symptoms of psychosis and other severe mental and emotional disorders]). This deficient practice had the potential to place Residents 22 and 28 at risk for impaired nutrition, oral discomfort, and difficulty with eating. This deficient practice also had the potential to place Resident 4 at risk for compromised mobility, social isolation, and pressure ulcer development (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). Findings: 1. During a review of Resident 22's admission Record, the admission Record indicated Resident 22 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 22's diagnoses included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities).During a review of Resident 22's Minimum Data Set (MDS- a resident assessment tool), dated 2/10/2026, the MDS indicated Resident 22's cognitive skills for daily decision making (process of thinking) was moderately impaired. The MDS indicated Resident 22 was dependent on staff's assistance with eating, oral hygiene, toileting, bathing, dressing, and personal hygiene. The MDS indicated Resident 22 was edentulous (not having any natural teeth or tooth fragments).During a review of Resident 22's History and Physical (H&P), dated 5/24/2025, the H&P indicated Resident 22 could make her needs known but could not make medical decisions.During a review of Resident 22's Dental Notes, dated 1/3/2025, the Dental Notes indicated on 1/3/2025, Resident 22's dentures (removable, artificial teeth and gums designed to replace lost natural teeth) were delivered to the facility.During a review of Resident 22's Dental Notes, dated 1/5/2026, the Dental Notes indicated on 1/5/2025, Resident 22 had full upper and lower dentures.During a concurrent observation and interview on 3/23/2026 at 9:51 a.m., with Resident 22, in Resident 22's room, Resident 22 was observed lying in bed. Resident 22 did not have any natural teeth. Resident 22 stated she lost her natural teeth and had dentures but did not know where they were. Resident 22 stated, They took them.During an interview on 3/24/2026 at 12:26 p.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 stated Resident 22 did not have any natural teeth and received dentures from the dentist. LVN 5 stated Resident 22 refused to wear her dentures. During an interview on 3/24/2026 at 12:35 p.m., with Resident 22, Resident 22 stated she did not want to wear her dentures and was okay with not wearing them.During a concurrent interview and record review, on 3/25/2026 at 9:56 a.m., with MDS Nurse (MDSN) 1, Resident 22's care plan titled, Resident is Edentulous (without natural teeth), dated 3/23/2026, was reviewed. MDSN 1 stated he developed the care plan on 3/23/2026 after Resident 22's annual MDS was completed. MDSN 1 stated Resident 22 was edentulous for an unknown amount of time and the care plan addressing Resident 22's dental status should have been developed sooner. MDSN 1 stated a care plan addressing Resident 22's refusal to wear her dentures should also be developed. MDSN 1 stated care plans addressing Resident 22's lack of natural teeth and refusal to wear her dentures were important so the licensed nurses and dietary department could assess the appropriateness of Resident 22's diet and Resident 22's ability to chew and swallow. During an interview on 3/25/2026 at 1:26 p.m., with the Director of Nursing (DON), the DON stated care plans were developed to identify the necessary individualized care for each resident. The DON stated actual and potential problems, and refusals of care should be care planned. The DON stated care plans were necessary to outline the interventions to properly care for Resident 22. The DON stated the interventions would focus on monitoring Resident 22 for weight loss, tolerance to her diet, and the location of Resident 22's dentures. The DON stated due to the untimely development of Resident 22's care plans, Resident 22 was at risk of not receiving the necessary dental care and treatment.2. During a review of Resident 28's admission Record, the admission Record indicated Resident 28 was admitted to the facility on [DATE]. Resident 28 diagnosis included, COPD, amenia (a condition marked by deficiency of healthy red blood cells to transport oxygen in the blood), muscle weakness, gastro esophageal [a muscular tube that connects the throat to the stomach] reflux disease (GERD- a condition in which stomach acid flows back into esophagus causing heartburn), and diabetes. During a review of Resident 28's H&P, dated 10/19/2025, the H&P indicated Resident 28 could make needs known but could not make medical decisions. During a review of Resident 28's MDS, dated [DATE], the MDS indicated Resident 28 cognitive skills for daily decision making was mildly impaired. The MDS indicated Resident 28 required supervision from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 28's Dental Evaluation Report from the facility's contracted mobile dental services dated 12/30/2025 was reviewed. The dental evaluation report indicted on 12/30/2025, the facility received Resident 28's full upper and lower dentures. During an observation and interview on 3/23/26 at 11:21 a.m., with Resident 28. Resident 28 stated that she used upper and lower dentures. Resident 28 stated, I have no real teeth. I need my dentures to eat. During a concurrent interview and record review on 3/24/26 at 10:54 a.m., with the Social Services Director (SSD), the dental evaluation report from the contracted mobile dental services dated 12/30/2025, was reviewed. The dental evaluation report indicated Resident 28 received full upper and lower dentures on 12/30/2025. The SSD stated that it was the responsibility of the Social Services Department to inform the nursing staff when Resident 28 receives the new dentures. The SSD stated that once nursing staff are notified, it is the nursing staff responsibility to initiate care plans for dentures. The SSD stated that developing care plans was not the responsibility of the social service department. The SSD stated that this process was not followed for Resident 28, resulting in the omission of dentures from both the special needs list and the resident's belongings record During a concurrent interview and record review on 3/24/26 at 4:19 a.m., with the Director of Nursing (DON), the Dental Evaluation Report from the contracted mobile dental services dated 12/30/2025, was reviewed. The dental evaluation report indicated the social services department received Resident 28's dentures. The DON stated that upon receipt, the social services department should have informed nursing so nursing could develop a care plan. The DON stated that there was a breakdown in communication and nursing staff was never informed of Resident 28's dentures. The DON stated that residents with upper and lower dentures required an individualized care plan to address their specific oral health needs. The DON stated a care plan was necessary to ensure proper denture care, including cleaning, storage, monitoring for proper fit, and assessment for any signs of discomfort, irritation, or oral breakdown. The DON stated that without a comprehensive care plan, there was an increased risk for poor oral hygiene, infection, impaired nutrition, and decreased quality of life. The DON stated that it was the facility's responsibility to develop and implement a care plan to ensure the resident's dentures were maintained appropriately and that staff were aware of and followed the resident's specific care needs. 3. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4's diagnoses included COPD, muscle weakness, dysphagia (trouble swallowing) and dementia. During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 4's hearing was adequate. The MDS indicated Resident 4 was dependent on staff for toileting, bathing, and dressing. During a review of Resident 4's H&P, dated 5/23/2025, the H&P indicated Resident 4 did not have the capacity to understand and make decisions. During a review of Resident 4's Physician Order, dated 11/5/2025, the order indicated to administer Haloperidol (an antipsychotic [a drug used for the treatment of symptoms of psychosis and other severe mental and emotional disorders]) oral tablet four (4) milligrams (mg, a unit of measurement) by mouth two times a day. During an observation on 3/23/2023 at 10:00 a.m., with Certified Nursing Assistant (CNA) 3, in Resident 4's room, Resident 4 was observed in bed asleep. CNA 3 called Resident 4's name three times with increasing volume. Resident 4 slowly opened his eyes after the fourth attempt. During a concurrent observation and interview on 3/24/2026 at 11:05 a.m. with LVN 6, in Resident 4's room, Resident 4 was observed lying in bed with both of his eyes closed. Resident 4 did not respond to verbal stimuli. LVN 6 called Resident 4's name four times with increasing volume and applied tactile (touch) stimulation by tapping the resident's shoulders, with no response. Resident 4 opened his eyes after LVN 6 performed a sternal rub (is a painful stimulus technique used by medical professionals to check for responsiveness in unconscious or unresponsive patients). LVN 6 stated Resident 4 liked to be in bed and asleep. During a concurrent interview and record review on 3/26/2026 at 9:20 a.m. with LVN 6, Resident 4's care plan titled Resident 4 Prefers to Stay in Bed During Daytime, initiated 3/24/2026 was reviewed. LVN 6 stated Resident 4 exhibited behaviors of napping for extensive periods throughout the day and keeping his eyes closed for approximately one to two months prior to the initiation of the care plan. LVN 6 stated the care plan should have been initiated sooner to ensure appropriate interventions were implemented. LVN 6 stated the lack of timely implemented care plan interventions placed Resident 4 at risk for the development of pressure ulcers and self-isolation. During a review of the facility's policy and procedure (P&P) titled, Refusal of Treatment, revised 1/1/2012, the P&P indicated, When the resident's refusal brings about a significant change in the resident's condition, a reassessment is made, and new information is incorporated into the resident's Care Plan. During a review of the facility's P&P titled Oral Healthcare & Dental Services, dated 7/14/2017, the P&P indicated Develop a plan of care to ensure that the resident can eat and drink adequately. Implementation of a daily dental and oral hygiene plan of care including daily denture hygiene. During a review of the facility's P&P titled, Person-Centered Care Planning, dated 5/22/2025, the P&P indicated, The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Within 7 days from the completion of the comprehensive Minimum Data Set (MDS) assessment, the comprehensive care plan will be developed.

Based on observation, interview, and record review, the facility failed to revise one of one sampled resident's (Resident 91) care plan to reflect Resident 91's preference of taking Depakote Sprinkle (an anticonvulsant medication, used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] with small beads within a capsule that could be sprinkled onto soft food) capsules whole.This deficient practice had the potential to result in Resident 91 choking.Cross Reference F580 and F759.Findings:During a review of Resident 91's admission Record, the admission Record indicated Resident 91 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 91's diagnoses included epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 91's Minimum Data Set (MDS, a resident assessment tool), dated 2/16/2026, the MDS indicated Resident 91's cognition (process of thinking) was intact. The MDS indicated Resident 91 required supervision or touching assistance with oral hygiene, toileting, bathing, upper/lower body dressing, and personal hygiene. The MDS indicated Resident 91 received anticonvulsant medication (medication to treat seizures).During a review of Resident 91's History and Physical (H&P), dated 11/11/2025, the H&P indicated Resident 91 had the capacity to understand and make decisions. During a review of Resident 91's Physician Order, dated 11/9/2025, the Physician Order indicated to administer Depakote Sprinkle (an anticonvulsant medication, used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] with small beads within a capsule that could be sprinkled onto soft food) 500 milligrams (mg, unit of measurement) by mouth twice a day for epilepsy. Mix with apple sauce.During a review of Resident 91's Care Plan titled, At Risk/Potential for Aspiration/Choking, initiated 11/10/2025, the Care Plan indicated to crush medications and mix with apple sauce if indicated.During a review of Resident 91's Care Plan titled, High Risk for Trauma/Injuries Related to Seizure Disorder, initiated 11/10/2025, the Care Plan indicated to administer Depakote Sprinkle 500 mg by mouth twice a day.During an observation on 3/24/2026 at 9 a.m., outside of Resident 91's room, observed Licensed Vocational Nurse (LVN) 5 began preparing Resident 91's medications. LVN 5 removed four capsules from Resident 91's Depakote Sprinkle bubble pack (also known as a blister pack, a plastic tray with individual compartments of medication doses sealed with foil). LVN 5 divided the four capsules into two medication cups, with two capsules in each medication cup. LVN 5 prepared five medications and kept all capsules and tablets whole. LVN 5 entered Resident 91's room with six labeled medication cups and a cup of water. During an observation on 3/24/2026 at 9:09 a.m., in Resident 91's room, observed LVN 5 explain each medication to Resident 91. LVN 5 administered all of Resident 91's medications.During a concurrent interview and record review on 3/24/2026 at 1:49 p.m., with LVN 5, Resident 91's Physician Order for Depakote Sprinkle, dated 11/9/2025, was reviewed. The order indicated to administer Depakote Sprinkle with apple sauce. LVN 5 stated the capsule had to be opened and the beads poured over the apple sauce prior to administration. LVN 5 stated she did not follow the physician's order. LVN 5 stated, I know the resident and already know he does not like to take it like that. LVN 5 stated the purpose of mixing the medication with apple sauce was to reduce the risk of choking. During an interview on 3/25/2026 at 1:45 p.m., with the Director of Nursing (DON), the DON stated Resident 91 had the right to take his medications however he preferred as long as it was safe. The DON stated Resident 91's care plans should have been updated. The DON stated Resident 91's care plans should have been revised to indicate the resident's preference to take the Depakote Sprinkle capsules whole as long as there were no safety concerns. During a review of the facility's policy and procedure (P&P) titled, Person-Centered Care Planning, dated 5/22/2025, the P&P indicated, The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observations, interview and record review, the facility failed to ensure one of three sampled residents (Resident 94) who was visually impaired was orientated to his meal tray during lunch time. This failure had the potential to put the resident at risk for serious physical harm (choking, aspiration, malnutrition, and/or burns) and negatively impacts their psychological well being, dignity, and independence Findings: During a review of Resident 94's admission Record (AR) dated 3/25/2026, the AR indicated Resident 94 was a [AGE] year-old male, admitted on [DATE], with the diagnosis that included but not limit to: legal blindness (when a person's eyesight is very poor), chronic obstructive pulmonary disease (a long lasting lung disease that makes it hard to breathe), muscle weakness and hypertension (high blood pressure.) During a review of Resident 94's Minimum Data Set (MDS, a resident assessment tool) dated 2/4/2026, MDS indicated Resident 94 had severely impaired vision and needs supervision or touching assistance while eating. During a review of Resident 94's care plan dated 2/24/2026, the care plan indicated Resident 94 is legally blind, needs assistance with activities of daily living, including eating to maintain a hazard free and safe environment. During a concurrent observation and interview on 3/23/2026 at 12:24 p.m. in Resident 94's room. Resident 94 was sitting on the bed with his lunch tray in front of him, eating by himself, Resident 94 stated he could not find his spoon on the meal tray. Resident 94 also stated the staff did not orient him to his meal tray.During an observation on 3/24/2026 at 12:20 p.m. in Resident 94's room. Resident 94 was eating by himself with no utensil in his hand, Resident could not find his spoon on his meal tray. During an interview on 3/24/2026 at 12:30 p.m. with Certified Nurse Assistant (CNA) 2, CNA 2 stated she placed the meal tray on Resident 94's table. CNA 2 also stated Resident 94 is legally blind, she did not provide Resident 94 with a detailed orientation of the meal tray, and she should do it for the resident's convenience and safety. During an interview on 3/24/2026 at 2:15 p.m. with Director of Nursing (DON), DON stated that Resident 94 is legally blind and should receive coaching when a meal tray is provided so the resident knows where each item is located. The DON explained that without proper coaching or orientation, Resident 94 is at risk of hazards, such as accidentally spilling hot coffee or soup, which could cause burns. During a review of the facility's policy and procedure (P&P) titled, Resident safety, dated 4/15/2021, the P&P indicated staffs should identified the safety risk and provide more frequent safety check according to residents' person-centered care plan.

Based on observation, interview, and record review, the facility failed to ensure their error rate was less than five percent (%) during the medication administration observation for two of five randomly selected residents (Residents 106 and 91).The outcome was four medication errors out of 27 opportunities for errors, which resulted in a medication administration error rate of 14.81%, based on the following:1. Resident 106 was given a multivitamin (dietary supplement containing a combination of essential vitamins) instead of multivitamin-minerals (multivitamin with minerals).2. Resident 106's cholecalciferol (also known as Vitamin D3, a vitamin essential for building and maintaining strong bones and immune function) was unnecessarily omitted and incorrectly documented.3. Resident 106's Colace (stool softener) refusal was inaccurately documented on the Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident).4. Resident 91's Depakote Sprinkle (an anticonvulsant medication, used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] with small beads within a capsule that could be sprinkled onto soft food) was not administered in accordance with the physician's order. These deficient practices had the potential for Resident 106 to develop nutritional deficiencies that affect her bone health and immune function and potential for Resident 106 to develop constipation or loose stools with inaccurate explanation. These deficient practices also had the potential for Resident 91 to have difficulty swallowing the Depakote Sprinkle capsules. Cross Reference F580, F657, and F684.Findings:1. During a review of Resident 106's admission Record, the admission Record indicated Resident 106 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 106's diagnoses included protein-calorie malnutrition (when an individual does not eat enough protein and calories to meet nutritional needs), generalized muscle weakness, and generalized osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage).During a review of Resident 106's Minimum Data Set (MDS- a resident assessment tool), dated 12/12/2025, the MDS indicated Resident 106's cognition (process of thinking) was intact. The MDS indicated Resident 106 required supervision or touching assistance with eating, oral hygiene, bathing, dressing, and personal hygiene. During a review of Resident 106's History and Physical (H&P), dated 9/9/2025, the H&P indicated Resident 106 had the capacity to understand and make decisions.During a review of Resident 106's physician order, dated 9/28/2023, the physician order indicated to administer: 1. Cholecalciferol (also known as Vitamin D3, a vitamin essential for building and maintaining strong bones and immune function) 1000 units, by mouth, once a day for supplement.2. Colace (stool softener) 100 milligrams (mg, a unit of measurement), by mouth, one time a day for bowel management. Hold for loose stools.3. Multivitamin-Minerals (dietary supplement containing a combination of essential vitamins and minerals), one tablet by mouth, once a day for supplement.During an observation on 3/24/2026 at 8:04 a.m., outside of Resident 106's room, observed Licensed Vocational Nurse (LVN) 2 began preparing Resident 106's medications. LVN 2 removed one tablet from a pill bottle labeled Multivitamin. LVN 2 prepared seven medications that totaled 10 tablets and one injection. LVN 2 did not prepare the cholecalciferol capsule. LVN 2 crushed the tablets separately and poured the contents from the sleeve (thick plastic pouch designed to hold medication safely while it is crushed into a fine powder) into individual medication cups. LVN 2 entered Resident 106's room with six labeled medication cups, one injection, a cup of juice, and a cup of apple sauce. During an observation on 3/24/2026 at 8:15 a.m., in Resident 106's room, observed LVN 2 explain each medication to Resident 106 prior to mixing with apple sauce. Resident 106 refused to take the Colace. LVN 2 explained the risks and benefits. LVN 2 administered the rest of Resident 106's medications. During a concurrent interview and record review on 3/24/2026 at 1:37 p.m., with LVN 2, Resident 106's Physician Order for Multivitamin-Minerals, dated 9/28/2023, was reviewed. The order indicated to administer one tablet by mouth, once a day for supplement. LVN 2 stated the Multivitamin-Minerals contained additional minerals to supplement Resident 106's body. LVN 2 stated the Multivitamin-Minerals was not the same as the regular Multivitamin supplement.During a concurrent observation and interview on 3/24/2026 at 1:39 p.m., with LVN 2, at LVN 2's medication cart, observed LVN 2 compare the Multivitamin-Minerals bottle and Multivitamin. LVN 2 stated she administered the Multivitamin to Resident 106 instead of the ordered Multivitamin-Minerals. LVN 2 stated she gave the incorrect medication to Resident 106. LVN 2 stated it was important to give the correct multivitamin because Resident 106 could have a mineral deficiency and the Multivitamin-Minerals would help supplement those missing minerals. During an interview on 3/25/2026 at 1:30 p.m., with the Director of Nursing (DON), the DON stated LVN 2 was responsible for administering the correct multivitamin to Resident 106. The DON stated when preparing medication, LVN 2 was responsible for checking the Five Medication Rights such as right medication, right dose, right route, right resident, and right time. The DON stated Multivitamin and Multivitamin-Minerals were not the same medication. The DON stated Resident 106 did not receive the additional minerals when she received the Multivitamin. The DON stated the additional minerals were essential to increase the immune system and other health benefits. 2. During a concurrent interview and record review on 3/24/2026 at 1:41 p.m., with LVN 2, Resident 106's Medication Administration Record (MAR), dated 3/1/2026 through 3/31/2026, was reviewed. The MAR indicated The MAR indicated, on 3/24/2026, LVN 2 administered cholecalciferol to Resident 106. LVN 2 stated she did not administer cholecalciferol to Resident 106 and she documented it incorrectly. LVN 2 stated during the observed medication administration she was confused by the cholecalciferol order and the house supply medications (over-the-counter medications). LVN 2 stated none of the medication bottles in her medication cart indicated cholecalciferol and did not want to risk giving the wrong medication. LVN 2 stated by the time she clarified the medication with another licensed nurse, it was past the acceptable medication administration time frame. LVN 2 stated she should have clarified with another licensed nurse during the medication administration timeframe to ensure Resident 106 received her daily cholecalciferol dose. During an interview on 3/25/2026 at 1:35 p.m., with the Director of Nursing (DON), the DON stated medications should be administered to the resident unless the resident refused or the medication parameters (instructions that dictate when a medication should be given, withheld, or adjusted) were not met. The DON stated LVN 2 was responsible for consulting another licensed nurse, or himself, as soon as possible to clarify which bottle in the medication cart contained cholecalciferol. The DON stated LVN 2 should not have documented anything in the MAR for cholecalciferol during the medication administration so she could remember to clarify the medication. The DON stated because LVN 2 did not timely clarify Resident 106's cholecalciferol, LVN 2 should have consulted with Resident 106's physician for an order to administer the medication late or hold the medication until the following day. The DON stated due to LVN 2's actions, Resident 106 did not receive her daily dose of cholecalciferol, on 3/24/2026, which was important for her bone health and immune function.3. During a concurrent interview and record review on 3/25/2026 at 2:50 p.m., with LVN 2, Resident 106's MAR, dated 3/1/2026 through 3/31/2026, was reviewed. The MAR indicated The MAR indicated, on 3/24/2026, LVN 2 administered Colace to Resident 106. LVN 2 stated she incorrectly documented Resident 106's refusal. LVN 2 stated she did not intend to document the Colace as given. During an interview on 3/25/2026 at 2:55 p.m., with the DON, the DON stated Resident 106's refusal to take Colace should have been accurately documented on the MAR. The DON stated accurate documentation was necessary to track Resident 106's bowel movements. The DON stated if Resident 106 ceased to have bowel movements or began to have loose stools, knowing that Resident 106 did not take Colace would help determine Resident 106's plan of care. 4. During a review of Resident 91's admission Record, the admission Record indicated Resident 91 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 91's diagnoses included epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 91's MDS, dated [DATE], the MDS indicated Resident 91's cognition was intact. The MDS indicated Resident 91 required supervision or touching assistance with oral hygiene, toileting, bathing, upper/lower body dressing, and personal hygiene. The MDS indicated Resident 91 received anticonvulsant medication (medication to treat seizures).During a review of Resident 91's H&P, dated 11/11/2025, the H&P indicated Resident 91 had the capacity to understand and make decisions. During a review of Resident 91's Care Plan titled, At Risk/Potential for Aspiration/Choking, initiated 11/10/2025, the Care Plan indicated to crush medications and mix with apple sauce if indicated.During an observation on 3/24/2026 at 9 a.m., outside of Resident 91's room, observed LVN 5 began preparing Resident 91's medications. LVN 5 removed four capsules from Resident 91's Depakote Sprinkle bubble pack (also known as a blister pack, a plastic tray with individual compartments of medication doses sealed with foil). LVN 5 divided the four capsules into two medication cups, with two capsules in each medication cup. LVN 5 prepared five medications and kept all capsules and tablets whole. LVN entered Resident 91's room with six labeled medication cups and a cup of water. During an observation on 3/24/2026 at 9:09 a.m., in Resident 91's room, observed LVN 5 explain each medication to Resident 91. LVN 5 administered all of Resident 91's medications.During a concurrent interview and record review on 3/24/2026 at 1:49 p.m., with LVN 5, Resident 91's Physician Order for Depakote Sprinkle, dated 11/9/2025, was reviewed. The order indicated to administer Depakote Sprinkle (an anticonvulsant medication with small beads within a capsule that could be sprinkled onto soft food) 500mg, by mouth twice a day for epilepsy, mix with apple sauce. LVN 5 stated Resident 91's Depakote Sprinkle was supposed to be administered with apple sauce. LVN 5 stated the capsule had to be opened and the beads poured over apple sauce prior to administration. LVN 5 stated she did not follow the physician's order. LVN 5 stated, I know the resident and already know he does not like to take it like that. LVN 5 stated the purpose of mixing with apple sauce was to reduce the risk of choking. LVN 5 stated although taking the capsules whole were Resident 91's usual preference, she should still ask Resident 91 prior to administering the Depakote Sprinkle. During an interview on 3/25/2026 at 1:45 p.m., with the DON, the DON stated the licensed nurses were responsible for following all medication administration instructions. The DON stated Depakote Sprinkle had the instruction to mix with apple sauce to reduce the risk of choking. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated 8/19/2025, the P&P indicated, All medications shall be administered by licensed nursing staff according to physician orders, current best practices, and federal and state regulations.

Based on observation, interview, and record review, the facility failed to ensure proper cleaning and sanitization of resident-use dining equipment, and properly label and store one of one resident's (Resident 54) food item brought in from the outside. These deficient practices had the potential to result in the use of improperly cleaned dishware and placed residents at risk for exposure to bacteria and contaminants, increasing the risk of foodborne illness, infection, and compromised health and safety.Findings: 1. During a concurrent observation and interview on 3/23/2026 at 8:40 a.m. with [NAME] 1, in the kitchen, observed the storage rack designated for clean water pitchers. Six water pitchers labeled as clean were observed with a sticky residue with previously dated labels (dated 3/21/2026 and 3/22/2026) on the lids. [NAME] 1 stated the residue of the old labels indicated the pitchers had not been thoroughly cleaned prior to being placed in the clean storage area. [NAME] 1 stated that all labels should be removed prior to washing and that the pitchers should have been properly washed, rinsed, and sanitized before being stored. [NAME] 1 stated that the pitchers were not properly cleaned and should not have been placed in the clean storage area. During an interview on 3/23/2026 at 8:50 a.m. with Dishwasher 1, Dishwasher 1 stated that all dining equipment must be inspected after removal from the dishwasher to ensure cleanliness. Dishwasher 1 stated that any items observed to have residual food or debris must be rewashed and sanitized prior to placement in the clean storage area. Dishwasher 1 stated that the labels should have been removed prior to placing the water pitchers in the dishwashing machine. During a concurrent observation and interview on 3/23/2026 at 9:30 a.m. with the Dietary Supervisor (DS), multiple breakfast bowls were observed with dried food residue remaining on the surfaces. The DS stated that all resident-use dishware, including bowls and water pitchers, must be thoroughly washed, rinsed, and sanitized in accordance with facility policy and infection control standards prior to reuse. The DS stated that all kitchen staff should report the dirty dishware to the supervisor or dishwasher so that proper washing can occur. The DS stated that failure to follow proper dishwashing and sanitization procedures was unacceptable and placed residents at risk for potential health complications, including foodborne illness. The DS stated that the observed condition did not meet facility expectations for safe food handling and sanitation practices. During a review of the facility's policy and procedures (P&P) titled Dietary Assistant/Dishwasher the P&P indicated maintain a safe and sanitary work environment. 2. During a review of Resident 54's admission Record, the admission Record indicated Resident 54 was admitted to the facility on [DATE]. Resident 54's diagnoses included type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 54's Minimum Data Set (MDS- a resident assessment tool), dated 12/10/2025, the MDS indicated Resident 54's cognition (process of thinking) was intact. The MDS indicated Resident 54 required supervision or touching assistance with eating and oral hygiene.During a review of Resident 54's History and Physical (H&P), dated 12/2/2025, the H&P indicated Resident 54 had the capacity to understand and make decisions.During a review of Resident 54's physician order, dated 11/30/2025, the physician order indicated a No Added Salt (NAS) and Consistent Carbohydrate (CCHO) diet (diet to manage blood sugar and blood pressure by limiting sugar intake and sodium), regular texture.During an observation on 3/23/2026 at 10:19 a.m., 3/23/2026 at 3:54 a.m., and 3/23/2026 at 3:54 p.m., in Resident 54's room, observed an opened bag of green grapes stored on top of Resident 54's nightstand. The bag of green grapes was not labeled with the brought in date. During a concurrent observation and interview on 3/24/2026 at 12:23 p.m., in Resident 54's room, observed a cup full of green grapes on top of Resident 54's bedside table. The cup was not labeled/dated. Resident 54 stated the grapes were brought to her by a family member. Resident 54 stated the bag of grapes were at her bedside for about two days and was put into the cup to save space. During an interview on 3/24/2026 at 2:03 p.m., with the DS, the DS stated when food was brought into the facility by a visitor, the visitor or resident had to inform the nurse. The DS stated the nurse would look at the food and determine whether the food item was safe to eat and/or store. The DS stated all food brought in from visitors had to be labeled with the resident's name and the date it was brought into the facility. The DS stated labeling with the date was necessary to keep track of the food's freshness and to know when the food had to be thrown away. The DS stated grapes could be stored at the bedside or the refrigerator, however, the refrigerator was the best practice to keep the grapes fresh and prolong their shelf life. The DS stated the grapes should have been stored in the refrigerator. The DS stated unsafe food storage placed the grapes at risk of bacterial contamination and flies which could make Resident 54 sick.During a review of the facility's P&P titled, Food Brought in by Visitors, dated 5/22/2025, the P&P indicated the proper way to store food brought in by visitors was to:1. Place the food in a food container that is labeled with the resident's name and date received and store in the designated refrigerator.2. Perishable food, when refrigerated, would be discarded after two hours at the bedside.3. When refrigerated, the food would be labeled, dated, and discarded after 48 hours if not consumed.

Based on observation, interview, and record review, the facility failed to ensure the Fall Risk Assessment was updated and accurately reflected the health status for two of 16 sampled residents (Resident 105 and Resident 82), and ensure the List of Residents with Special Needs and Resident Belongings List was updated to reflect upper and lower dentures were received for one of six sampled residents (Resident 28). These deficient practices had the potential to place Residents 105 and 82 at an increased risk for a fall, and resulted in the loss of Resident 28's dentures placing Resident 28 at risk for compromised nutritional intake due to impaired chewing ability, impaired communication, and increasing the potential for unmet needs and a decline in overall health and well-being. Findings: a. During a review of Resident 105's admission Record, the admission Record indicated Resident 105 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 105's diagnoses included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 105's History and Physical (H&P), the H&P indicated Resident 105 had the capacity to understand and make decisions. During a review of Resident 105's Minimum Data Set (MDS- a resident assessment tool), dated 12/16/2025, the MDS indicated Resident 105 had moderate cognitive (ability to think and understand) impairment. The MDS indicated Resident 105 had moderately impaired vision. The MDS indicated Resident 105 required supervision from staff for toileting, dressing, and personal hygiene. The MDS indicated Resident 105 required moderate assistance for bathing. During a concurrent interview and record review on 3/24/2026 at 9:40 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 105's Fall Risk Evaluation dated 3/18/2026 was reviewed. The Fall Risk Evaluation indicated Resident 105's vision status was adequate. LVN 2 stated Resident 105 was visually impaired and required orientation to objects in his environment. LVN 2 stated the vision status section of Resident 105's Fall Risk Evaluation should have indicated poor instead of adequate. LVN 2 stated accurate fall risk evaluations were important to ensure staff knew the appropriate interventions and level of assistance residents required. During a concurrent interview and record review on 3/24/2026 at 9:52 a.m. with Registered Nurse (RN) 1, Resident 105's Ophthalmology note (branch of medical science dealing with the structure, functions, and diseases of the eye) dated 3/3/2026 and Fall Risk Evaluation dated 3/18/26 were reviewed. Resident 105's Ophthalmology note indicated Resident 105 was blind in his right eye. Resident 105's Fall Risk Evaluation indicated Resident 105's vision status was adequate. RN 1 stated Resident 105's Fall Risk Evaluation was inaccurate and should have indicated poor vision instead of adequate. RN 1 stated inaccurate fall risk evaluations placed residents at an increased risk for falls. During an interview on 3/26/2026 at 9:21 a.m. with the Director of Nursing (DON), the DON stated resident assessments should be accurate. The DON stated accurate assessments were important to ensure nursing staff knew the appropriate interventions to implement for residents. During a review of the facility's policy and procedure (P&P) titled, Fall Management Program dated 11/11/2025, the P&P indicated, As part of the admission and re-admission Assessment, the licensed nurse will complete a fall risk evaluation and document interventions on the Resident's care plan. During a review of the facility's LVN Job Description, the job description indicated, Records care information accurately, timely and concisely. b. During a review of Resident 82's admission Record dated 3/26/2026, the admission Record indicated Resident 82 was admitted to the facility on [DATE]. Resident 82's diagnoses that included but not limit to: history of falling, diabetes, muscle weakness, and hypertension (high blood pressure). During a review of Resident 82's MDS dated [DATE], the MDS indicated Resident 82 had history of fall, and history of a fracture (broken bone) prior to admission. During a review of Resident 82's Fall Risk Evaluations, dated 1/20/2026 and 2/28/2026, both evaluations indicated Resident 82 was a high risk for fall. During a review of Resident 82's post-fall evaluation dated 2/28/2026, the evaluation indicated on 2/28/2026, Resident 82 had a fall. The evaluation did not indicate the contributing factors for the resident's fall. During a review of Resident 82's post-fall-evaluation dated 3/5/2026, the evaluation indicated on 3/5/2026, Resident 82 had a fall. The evaluation did not indicate all contributing factors for the resident's fall. During an interview on 3/26/2026 at 8:38 a.m. with LVN 1, LVN 1 stated Resident 82 sustained a fall on 3/5/2026. LVN 1 stated she completed the post fall evaluation. LVN 1 stated that the post fall evaluation was not fully completed, noting that several contributing factors were left blank and should have been documented. During an interview on 3/26/2026 at 9:15 a.m. with the DON, the DON stated Resident 82 had two falls, one on 2/28/2026 and one on 3/5/2026. The DON stated it was important to fully complete the post-fall-evaluation, so all factors contributing to Resident 82's fall could be identified, and it would help prevent Resident 82 from falling again. c. During a review of Resident 28's admission Record, the admission Record indicated Resident 28 was admitted to the facility on [DATE]. Resident 28 diagnosis included COPD, amenia (a condition marked by deficiency of healthy red blood cells to transport oxygen in the blood), muscle weakness, gastro esophageal [a muscular tube that connects the throat to the stomach] reflux disease (GERD- a condition in which stomach acid flows back into esophagus causing heartburn), and diabetes. During a review of Resident 28's H&P, dated 10/19/2025, the H&P indicated Resident 28 could make needs known but could not make medical decisions. During a review of Resident 28's MDS, dated [DATE], the MDS indicated Resident 28 cognitive skills for daily decision making was mildly impaired. The MDS indicated Resident 28 required supervision from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent observation and interview on 3/23/26 at 11:21 a.m., with Resident 28, Resident 28 stated wore upper and lower dentures. Resident 28 stated, I have no real teeth. I need my dentures to eat. Resident 28 stated that she had dentures for a few weeks until they went missing. Resident 28 stated she could not remember when her dentures went missing. Resident 28 stated that she informed the nurses she needed her dentures to be able to properly eat. Resident 28 stated, The nurses can't find my dentures and maybe they went missing with the dirty sheets. During a concurrent interview and record review on 3/24/26 at 10:54 a.m., with the Social Services Director (SSD), the Dental Evaluation Report from the facility's contracted mobile dental services dated 12/30/2025, was reviewed. The dental evaluation report indicated Resident 28 received full upper and lower dentures on 12/30/2025. During a concurrent observation and interview on 3/24/26 at 10:54 a.m., with the Social Services Assistant (SSA) and Resident 28, in Resident 28's room, the SSA searched Resident 28's personal belongings for her dentures. The SSA was unable to locate Resident 28's dentures. The SSA stated that Resident 28's dentures were missing. During a concurrent interview and record review on 3/24/2026 at 4:10 p.m., with the Social Services Designee (SSD), the document titled List of Residents with Special Needs, was reviewed. The SSD confirmed that Resident 28 was not identified on the list as having dentures. The SSD stated that Resident 28 received dentures on 12/30/2025 but the list was not updated at that time to reflect this change in status. The SSD stated that residents with special items, including dentures, hearing aids, and glasses, were to be added to the list either upon admission or upon receipt of the items. The SSD stated that the list was maintained in a binder located at each nursing station for staff reference. The SSD stated that it was the responsibility of the Social Services Department to update the List of Residents with Special Needs and to communicate any updates to nursing staff. The SSD stated that once nursing staff was notified, it was their responsibility to initiate or update the resident's belongings list and develop care plans to include the item(s) upon receipt. The SSD stated that this process was not followed for Resident 28, resulting in the omission of dentures from both the special needs list and the resident's belongings record. During a concurrent interview and record review on 3/24/2026 at 4:19 p.m., with the DON, the Dental Evaluation Report dated 12/30/2025 and Resident 28's belongings list dated 10/17/2025, was reviewed. The DON stated that the dental evaluation report indicated that Resident 28 received upper and lower dentures on 12/30/2025 and the belongings list was not updated to reflect Resident 28's dentures. The DON stated that all resident personal items, including dentures, were to be documented and updated on the belongings list upon admission and when new items were received. The DON stated that failure to accurately maintain this list impeded the facility's ability to track and safeguard resident property. The DON stated Resident 28's dentures should have been added to the belongings list when they were obtained and that the absence of documentation reflected a breakdown in facility policy and procedure. The DON stated that staff were responsible for ensuring ongoing updates to residents' belongings and that this oversight contributed to the inability to locate Resident 28's dentures. The DON stated that dentures were essential to a resident's overall health and well-being, as they directly impacted the Resident 28's ability to chew and properly consume food, which could affect the resident's nutritional intake. The DON stated that missing dentures may also impair Resident 28's ability to speak clearly, potentially affecting communication with staff and contribute to overall decline in health status. During a review of the facility's P&P, titled Personal Property dated 10/2/2025, the P&P indicated The facility will ensure that resident's personal property is respected, safeguarded, and properly documented. An inventory of personal belongings will be completed upon admission and updated as necessary to reflect additions, removals or changes. To ensure the facility takes reasonable steps to protect Residents personal property.

Based on observations, interview and record review, the facility failed to ensure one of three sampled residents' (Resident 55) nasal cannula oxygen tubing and humidifier bottle were labeled with a date.This failure had the potential to increase the risk of infection of Resident 55.Findings:During a review of Resident 55's admission Record (AR) dated 3/25/2026, the AR indicated Resident 55 was a [AGE] year-old female, admitted on [DATE], with the diagnosis that included but not limit to: chronic obstructive pulmonary disease (a long lasting lung disease that makes it hard to breathe), respiratory failure (a condition when the lungs cannot get enough oxygen into the body), diabetes (a condition where the body has trouble controlling the amount of sugar in the blood), and heart failure (a condition the heart is not pumping blood as well as it should.)During a review of Resident 55's Minimum Date Set (MDS, a resident assessment tool) dated 2/27/2026, MDS indicated Resident 55 is on oxygen therapy.During a review of Resident 55's physician's order dated 2/20/2026, the order indicated Resident 55 is on oxygen at 2 liters per minute via nasal cannula as needed and for the oxygen tubing should be changed every 7 days.During an observation on 3/23/2026 at 11:18 a.m. in Resident 55's room. Resident 55 was lying on the bed wearing her nasal cannula for oxygen. The oxygen tubing and the humidifier bottle did not have any dates on them.During a concurrent observation and interview on 3/24/2026 at 10:30 a.m. with Registered Nurse (RN) 1 in Resident 55's room. Resident 55 was sitting on the bed reading a book while wearing a nasal cannula for oxygen. The oxygen tubing and humidifier bottle were not dated. RN 1 stated that both items did not have a date on them and should be labeled with a date. RN 1 stated the oxygen tubing must be changed every 7 days. Without a date label, the staff cannot determine if the tubing has been changed, increasing Resident 55's risk of infection.During a review of the facility's policy and procedure (P&P) titled, Oxygen Therapy, dated 10/31/2025, the P&P indicated oxygen tubing should be changed at least every 7 days and labeled with the date of change.

Based on observation, interview, and record review, the facility failed to: 1. Provide services to prevent the development of septic shock for one out of six sampled residents (Resident 259), who had long-term usage of an indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) by failing to ensure the following: 1a. Ensure Resident 259's the urinary drainage was monitored for the presence of sediment (a buildup of particles within the catheter tubing, often caused by factors like dehydration, urinary tract infection [UTI- an infection in the bladder/urinary tract], improper catheter care, or the presence of certain bacteria that promote crystal formation), abnormal color, and foul odor, per the facility's P&P and Resident 259's care plan, for a total of six months. 1b. Ensure a urine culture (a lab test that checks for bacteria in a urine sample) was performed after Resident 259's urine analysis (a lab test that provides information about the appearance, chemical composition, and microscopic contents of a urine sample) results indicated Resident 259 had a urinary tract infection on 10/7/2024. These deficient practices led to the delay in UTI identification, delayed treatment, and a three-day admission to the intensive care unit for a diagnosis of septic shock secondary to a UTI for Resident 259. 2. Provide adequate nephrostomy (a tube that lets urine drain from the kidney through an opening in the skin on the back) care for one of six sampled residents (Resident 95) when: 2a. The nephrostomy bags (a bag that collects urine that drains from a nephrostomy tube) were not placed to gravity (where the urine flows downhill from the nephrostomy tube [inserted in the kidneys] and into the nephrostomy bag and must be positioned below the resident's bladder to allow urine to drain properly) by nursing staff. 2b. Sediment (crystals, bacteria, or blood exited through the urine) was present in the right nephrostomy tubing was not documented by the licensed nurses and the physician was not notified of the sediment as ordered. This failure had the potential to cause avoidable urinary tract infections (UTI - an infection in the bladder/urinary tract) and delay in treatment for Resident 95. Findings: 1. During a review of Resident 259's Admission Record, the Admission Record indicated Resident 259 was originally admitted to the facility on [DATE]. Resident 259's diagnoses included UTI, sepsis, extended spectrum beta lactamase resistance ([ESBL]- a bacterial infection that can occur in the blood, skin and other parts of the body, which can cause frequent urination, burning when urinating, and reddened skin) , hydronephrosis (kidney swelling) with ureteropelvic junction (the area where the ureter [urine tube] connects to the renal pelvis [inner curve of the kidney]) obstruction (a blockage preventing urine from draining properly and causing the kidney to enlarge), renal and ureteral calculus obstruction (a condition where the kidneys swell due to a blockage in the urinary tract caused by kidney stones and ureteral stones), and neuromuscular dysfunction of the bladder (lack of bladder control). During a review of Resident 259's Minimum Data Set ([MDS], a resident assessment tool), dated 9/26/2024, the MDS indicated Resident 259's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was moderately impaired. The MDS indicated Resident 259 was entirely dependent on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 259's care plan titled, Urinary Catheter Care Plan, initiated 6/4/2024, the Care Plan indicated the facility was to monitor Resident 259's urine for color, sediments, amount, and hematuria (blood in the urine), and order laboratory tests, if indicated. During a review of Resident 259's Situation, Background, Assessment, Recommendation (SBAR -a communication tool used by healthcare workers when there is a change of condition among the residents), dated 12/4/2024, the SBAR indicated Resident 259 exhibited generalized weakness, an elevated heart rate of 147 beats per minutes (bpm, normal range 60 -100 bpm), and rapid breathing with the use of accessory muscles (additional muscles used when a resident exhibits difficulty breathing). The SBAR indicated an unspecified licensed nurse elevated Resident 259's head of the bed and administered oxygen via nasal cannula (tubing used to deliver oxygen) at three liters per minute (LPM). The SBAR indicated Resident 259's oxygen saturation (the percentage of oxygen in a person's blood) increased from 88 percent (%) to 98%, (normal range 93-100%). The SBAR indicated Resident 259 was provided cooling measures and administered acetaminophen (fever-reducing medication). The SBAR indicated Resident 259's indwelling urinary catheter drainage bag had large amounts of sediments present. The SBAR indicated Resident 259's physician was notified and the resident was transferred to the general acute care hospital (GACH). The SBAR indicated Resident 259 had the following vital signs (measurements of the body's most basic functions): 1. Respiratory (breathing) Rate of 25 breaths per minute (RR, normal RR 12 to 20 breaths per minute). 2. Blood Pressure was 100/64 millimeters of mercury ([MM HG]- unit of measurement that describes the amount of force blood uses to get through the vessels of the body [normal range of 120-129 [top number] and 80-84 [bottom number]). 3. Temperature of 101.1 Fahrenheit (normal range 97 to 99 degrees Fahrenheit [a unit of measurement]). During a review of Resident 259's Urine Analysis (UA), dated 10/7/2024, the UA indicated Resident 259's urine appearance was cloudy, positive for nitrites (byproducts found in urine when bacteria like Escherichia coli [[E. Coli] - a type of bacteria] are present), and positive for the presence of leukocytes (white blood cells that help your body fight an infection). The UA also indicated Resident 259's physician did not order a urine culture. During a review of Resident 259's GACH Emergency Department (ED) Medical Doctor (MD) Progress Notes, dated 12/4/2024, the notes indicated Resident 259 was brought into the emergency department, on 12/4/2024 at 10:54 a.m. with the following vital signs: blood pressure of 78/54 MM HG, temperature of 102.4 F, heart rate of 145 bpm, respiratory rate of 42 (RR, breaths per minute), and oxygen saturation of 84 percent (%) and was placed on 15 liters per minute via non-rebreather mask (oxygen mask that delivers high concentrations of oxygen). The notes indicated Resident 259 was disoriented and repeatedly asked about the reason for his visit. The notes indicated Resident 259's computed tomography ([CT]- a noninvasive imaging procedure that uses X-rays to create cross-sectional images of the body) scan indicated Resident 259 had a 2.5 centimeter ([CM]- a unit of measurement) left ureter stone (a crystal-like hard stone that gets lodged into ureter [the tube that connects your kidneys to your bladder]) with hydronephrosis and perinephric stranding (a sign of inflammation or obstruction in the kidney or collecting system). The notes indicated Resident 259 was given intravenous (IV, through the veins) fluid, placed on a Levophed (a medication used to maintain blood pressure) and Amiodarone (a medication used to stabilize and control the heart rate) drip, and admitted to the Intensive Care Unit (ICU, a specialized hospital ward that provides critical care and life support to patients who are very ill or injured), on 12/4/2024, for stabilization. The note indicated Resident 259 was diagnosed with sepsis (a life-threatening medical emergency that occurs when the body's immune system has an extreme response to an infection or injury) due to UTI with hypotension (low blood pressure). During a review of Resident 259's GACH UA Laboratory Results, dated 12/4/2024, the results indicated Resident 259's urine appearance was turbid (not clear or transparent because of stirred-up sediment). During a review of Resident 259's GACH Blood Laboratory Results, dated 12/4/2024, the results indicated Resident 259's lactic acid level (a blood test that is used to help diagnose sepsis) was critically high at a value of 4.1 (normal: 0.7-1.9) millimoles per liter ([MMOL/L]- a unit of measurement). The results indicated Resident 259's white blood cell count ([WBC]-a blood test used to indicate the presence of inflammation or an infection) was abnormally high at a value of 15.5 (normal WBC count: 4.5 and 11.0 microliters) microliter ([X10^3/Ul]- a unit of measurement used to report WBC counts). During a review of Resident 259's GACH Urine Culture Laboratory Results, dated 12/4/2024, the results indicated Resident 259 had greater than 100,000 colony forming units per milliliter ([CFU/ML]- a unit of measurement) of E. Coli and Proteus Mirabilis (a type of bacteria). During a review of Resident 259's GACH Progress Notes, dated 12/5/2024, the notes indicated Resident 259 was treated with a Levophed drip 4 milligram (mg, unit of measurement) per 250 milliliters (ML]- a unit of measurement, Amiodarone drip 900 MG /18 ML, and Ceftriaxone (an antibiotic) 1 gram ([GM]- a unit of measurement) IV every 24 hours. During a review of Resident 259's GACH MD Progress Notes, dated 12/10/2024, the notes indicated Resident 259 was downgraded from the ICU to the telemetry unit (a unit that enables continuous tracking of the resident's heartbeat). During a review of Resident 259's GACH Discharge Summary Note, dated 12/11/2024, the note indicated Resident 259 was diagnosed with septic shock secondary to pyelonephritis (kidney infection) and bacteremia (bacteria in the blood) with ESBL E. coli. During an interview on 12/18/2024, at 9:35 a.m., with the facility's Treatment Nurse (TXN) 1, TXN 1 stated she was familiar with Resident 259 and noticed Resident 259's indwelling urinary catheter always had sediments since his initial admission into the facility. TXN 1 stated she did not notify the charge nurse or Resident 259's physician because Resident 259 always had sediments in his urine. During a concurrent record review and interview, on 12/18/2024, at 10:30 a.m., with Registered Nurse (RN) 2, Resident 259's Physician Orders, dated 6/2024 to 12/4/2024, and Medication Administration Record (MAR), dated 6/2024 to 12/4/2024, were reviewed. RN 2 stated the Physician Orders indicated Resident 259 was ordered to have an indwelling urinary catheter from 6/3/2024 to 12/4/2024. RN 2 stated the Physician Orders did not indicate any orders to monitor Resident 259's urine output appearance (presence of sediment, color, foul odor) from 6/3/2024 to 12/4/2024. RN 2 stated the MAR indicated Resident 259's urine output appearance was not documented from 6/3/2024 to 12/4/2024. RN 2 stated it was important for the licensed nursing staff to monitor the appearance of Resident 259's urine output to prevent Resident 259 from developing an infection and sepsis. RN 2 stated the order to monitor the indwelling urinary catheter's urine output was missed, and all licensed nurses were responsible with ensuring the order was inputted and carried out. RN 2 stated the facility may have delayed the treatment of Resident 259's UTI because the licensed nurses did not effectively monitor Resident 259's urine output appearance. During a concurrent record review and interview, on 12/18/2024 2:00 p.m., with RN 2, Resident 259's UA, dated 10/7/2024, was reviewed. RN 2 stated it was important to order a urine culture if a UA was positive so the resident could receive the proper antibiotics for treatment of the UTI. RN 2 stated MD 1 was made aware of the positive UA. RN 2 stated MD 1 did not order a urine culture because MD 1 was conservative when it came to prescribing antibiotics for Resident 259. RN 2 stated because Resident 259 did not present with any other signs and symptoms of a UTI antibiotics were not prescribed. During an interview, on 12/18/2024, at 3:31 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 259's urine output appeared foggy at various times (CNA 1 could not recall the dates). CNA 1 stated she did not notify the charge nurses because she believed the charge nurses already knew Resident 259's urine output normally appeared that way. During an interview, on 12/19/2024, at 10:06 a.m., with Physician 1, Physician 1 stated that he was Resident 259's attending physician, a urologist (a medical doctor who specializes in the diagnosis and treatment of diseases and conditions of the urinary tract system) and the facility's Medical Director. Physician 1 stated that the expectation of the licensed nurses regarding the care of a resident with an indwelling urinary catheter was to monitor for the signs and symptoms of an infection. Physician 1 stated that it was important to monitor the urine output appearance to identify the signs of an active urinary infection and to avoid sepsis. Physician 1 stated that the order to assess the qualities of the urine output was a part of the order set for all residents who had an indwelling foley catheter. Physician 1 stated that he met with the nursing staff to educate them on the importance of monitoring the appearance of the urine output and always reminded the staff not to underestimate the presence of precipitate (a buildup of particles), and cloudiness of the urine. Physician 1 expected that he would have been notified of these kinds of changes for Resident 259. During an interview, on 12/19/2024, at 11:53 a.m., with the Director of Nursing (DON), the DON stated it was important that the licensed nurses assessed the qualities and characteristics of a resident's urine output for cloudiness, presence of sediment and odor every shift so that the care of the resident was not delayed and to decrease the potential for sepsis. The DON stated Resident 259's order to assess the urine output was missed and there was no documentation of a baseline assessment to verify that Resident 259's urinary output improved or worsened over time. The DON stated a urine culture should have been ordered so that Resident 259 could have received treatment in a timely manner even if Resident 259 was asymptomatic (exhibiting no signs and symptoms of a medical condition). The DON stated the lack of assessment of Resident 259's urinary output and advocacy for a urine culture led to a delay in treatment, diagnosis of septic shock, and harm for Resident 259. 48131 2. During a review of Resident 95's Admission Record, dated 12/18/2024, the admission record indicated Resident 95 was admitted on [DATE] and readmitted on [DATE] with the following diagnoses which included chronic kidney disease (CKD - a longstanding disease in which the kidneys are damaged and cannot filter blood as well as they should leading to renal failure), acute kidney failure (the sudden and rapid loss of the kidney's ability to filter waste and balance fluid in blood), hydronephrosis (a condition where one or both kidneys swell due to a buildup of urine), malignant neoplasm of the bladder (bladder cancer), and retention of urine definition (a condition that makes it difficult to empty the bladder). During a review of Resident 95's History and Physical (H&P), dated 8/9/2024, the H&P indicated Resident 95 had the capacity to understand and make decisions. During a review of Resident 95's MDS, dated [DATE], the MDS indicated Resident 95's cognition was intact. The MDS indicated Resident 95 had an indwelling catheter and required supervision with eating, toileting and personal hygiene, and toileting. During a review of Resident 95's Order Summary Report, dated 10/10/2024, the order summary report indicated and active order to monitor Resident 95's nephrostomy bag for signs and symptoms of infection, noting cloudiness, sediment, blood, and odor and notify if any signs and symptoms were present every shift. During a review of Resident 95's MAR, dated 12/1/2024 through 12/16/2024. The MAR indicated to monitor Resident 95's nephrostomy bag for signs and symptoms of infection, noting cloudiness, sediment, blood, and odor and notify if any signs and symptoms were present every shift. The MAR indicated there were no signs of cloudiness, sediment, blood, or odor from 12/1/2024 through 12/16/2024 for all shifts. During a review of Resident 95's Care Plan titled Nephrostomy Placement Bilateral (both sides) Surgery, initiated on 10/10/2024 and revised on 11/13/2024, the care plan indicated Resident 95's bladder would be adequately emptied without complication as evidenced by no bladder distention, pain/discomfort and no signs and symptoms UTI The care plan interventions indicated to monitor nephrostomy bag for signs and symptoms of infection and notify physician if an signs and symptoms present and provide nephrostomy care per protocol daily and as needed. During a review of Resident 95's Care Plan titled UTI, initiated on 12/8/2024, the care plan indicated Resident 95's would have no complaints of pain or bladder discomfort and would resolve after treatment interventions. The care plan indicated interventions to monitor urine for sediment, cloudiness, odor, blood tinge and amount and report any signs and symptoms to the physician. m bladder would be adequately emptied without complication as evidenced by no bladder distention, pain/discomfort and no signs and symptoms of UTI. The care plan interventions indicated to monitor nephrostomy bag for signs and symptoms of infection and notify physician if an signs and symptoms present and provide nephrostomy care per protocol daily and as needed. During a review of Resident 95's Nursing Progress Notes, dated 2/9/2024, the progress note indicated Resident 95 was started on Rocephin (a medication to treat infections) until 12/15/2024 due to UTI. During an observation on 12/16/2024 at 2:44 p.m., in Resident 95's room, Resident 95 was sitting in a wheelchair with both left and right nephrostomy bags lying on his bed which was positioned higher than his wheelchair. The right nephrostomy tubing contained an off-white, thick milky sediment. During an observation on 12/17/2024 at 1:44 p.m., in Resident 95's room, Resident 95 was sitting in his wheelchair with both left and right nephrostomy bags rolled up into his pants pocket. Resident 95's pocket on the right side was wet from urine leaking from the nephrostomy bag. Resident 95's nephrostomy tubing on the right side showed an off-white, thick, milky sediment. During a concurrent observation, interview, and record review on 12/17/2024 at 1:47 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 observed Resident 95's nephrostomy bag and nephrostomy tubing. LVN 2 also reviewed Resident 95's monitoring log on the MAR, and the nursing progress notes. LVN 2 noted that there was sediment in Resident 95's nephrostomy tubing on the right side and the nephrostomy bags on the left and right side were rolled up and placed inside of Resident 95's pants pockets as he sat in his wheelchair. LVN 2 also noted Resident 95's right pants pocket was saturated with urine leaking from the right nephrostomy bag. LVN 2 stated Resident 95 was recently treated for a UTI and the sediment in the tubing was due to the recent UTI. LVN 2 stated it was her responsibility to monitor the tubing for signs of infection, which included cloudiness, sediment, or blood and document the findings on Resident 95's nephrostomy monitoring log and nursing progress notes during her shift. LVN 2 admitted she had not monitored Resident 95's nephrostomy for sediment in the tubing on 12/16/2024 and this observation was her first time seeing the sedimentation in the right tubing. LVN 2 stated she would notify the doctor immediately since she had been made aware of the sedimentation. LVN 2 reviewed Resident 95's nephrostomy monitoring log. LVN 2 acknowledged that she had been marking N for no sedimentation on Resident 95's nephrostomy monitoring log even though she had not been checking it daily. LVN 2 acknowledged she placed an N for no sediment on Resident 95's nephrostomy monitoring log on 12/16/2024 although she had not checked for sedimentation on that day. LVN 2 stated it was important to monitor Resident 95's nephrostomy tubing and urine output every shift and to call the doctor if sediment was observed in the tubing so that the doctor would be aware of Resident 95's status and write orders if needed. LVN 2 stated it was also important to document the finding in the nursing progress notes and the nephrostomy monitoring log. LVN 2 acknowledged she had not made any notes regarding Resident 95's nephrostomy bags or tubing in the nursing progress notes. LVN 2 also admitted it was inappropriate for Resident 95 to keep his nephrostomy bags and tubing rolled up inside of his pockets. LVN 2 stated the nephrostomy bags should have been positioned to gravity so the urine in the tubing could flow freely into the bags and not back flow into the kidneys. LVN 2 stated if urine flowed backwards into the kidneys, it could lead to further urinary tract infections. During a concurrent interview and record review with LVN 1, Resident 95's nursing progress notes and nephrostomy care plan were reviewed for the month of November and December. LVN 1 stated that Resident 95's primary care physician informed the nurses that it was normal for Resident 95 to have sediment in the tubing because he had bladder cancer. LVN 1 viewed the nursing progress notes and stated he could not find the notes regarding sediment in the nephrostomy tubing to be normal for Resident 95. LVN 1 reviewed Resident 95's nephrostomy care plan and acknowledged the care plan indicated to notify the physician if there was sedimentation in the nephrostomy tubing. LVN 1 stated the physician should have been notified if sedimentation was present in the tubing. During a concurrent interview and record review on 12/17/2024 at 3:09 p.m., with TXN 1, Resident 95's nursing care plan and nephrostomy monitoring log on the MAR was reviewed. TXN 1 stated she was responsible for Resident 95's daily nephrostomy dressings change. TXN 1 stated she had observed sedimentation in Resident 95's tubing every day for the month of December 2024 when performing nephrostomy dressing changes. TXN 1 stated she did not document the sedimentation or call the physician because she had heard from nurses that it was okay for Resident 95 to have sedimentation in his nephrostomy tubing. TXN 1 acknowledged there was no documentation in the nursing progress notes to indicate it was okay for resident to have sedimentation in his tubing. TXN 1 stated Resident 95's nephrostomy instructions should have been documented in the nursing progress notes when the resident returned from his nephrology appointment so that the nursing staff would have something to follow regarding the nephrostomy tubing. TXN 1 reviewed Resident 95's nephrostomy care plan and stated she was not following the care plan interventions for monitoring the nephrostomy bags for signs and symptoms of infection, including monitoring for sediment as indicated because Resident 95 was already on antibiotics for a UTI. TXN 1 admitted she should have followed Resident 95's nephrostomy care plan to ensure Resident 95 did not continue to develop UTIs. During a concurrent observation and interview on 12/19/2024 at 8:04 a.m., with TXN 1 and Resident 95, the nephrostomy dressing changes were observed by TXN 1. Resident 95 was sitting on the edge of his bed with both nephrostomy bags lying on his bed. TXN 1 stated she put Resident 95's nephrostomy bags on the bed to prepare for his nephrostomy dressing changes. Resident 95 stated wanted his nephrostomy bags lying out on the bed or in his pockets because it was easier to get to the bags when he needed to urinate. TXN 1 stated Resident 95 needed more education regarding the care of his nephrostomy bags because he should not have to bother the bags when he needed to urinate. TXN 1 stated, since Resident 95 could also urinate from his penis, he only needed to use the bedside urinal when he had the urge to urinate. TXN 1 stated there was a urinal at his bedside. TXN 1 proceeded to educate Resident 95 in Spanish regarding the care of his nephrostomy bags. TXN 1 stated that she educated Resident 95 that he should not touch the nephrostomy bags when he had an urge to urinate. TXN 1 stated she also explained to Resident 95 the importance of keeping the bags to gravity and not in his pocket to prevent infection. TXN 1 explained that the dignity bag was for his protection and privacy. TXN 1 showed the dignity bag to Resident 95 and how they were to be placed inside of the dignity bag. Resident 95 shook his head in agreement and did not refuse the dignity bags. During a telephone interview on 12/19/2024 at 10:17 a.m., with Physician 1, Physician 1 stated that the white slimy sedimentation noted in Resident 95's nephrostomy tubing was normal for Resident 95, however the sedimentation should have been documented and monitored by the nurse to ensure any changes could be noted for comparisons. Physician 1 stated he would educate the nurses on the proper care of Resident 95's nephrostomies because the nurses are not familiar with the caring for nephrostomies. Physician 1 state he would also educate the nurses on Resident 95's nephrostomy baseline (an initial measurement of a resident's condition and used for comparison over time to look for changes) and inform the nurses that the baseline should be documented. Physician 1 stated the nurses must then notify him (Physician 1) if there were any changes from the baseline. During an interview on 12/19/2024 at 10:42 a.m. with the DON, the DON stated it was important to ensure Resident 95's nephrostomy tubing was at gravity level and not rolled up in his pockets to prevent back flow to the kidneys which would cause an infection. The DON stated Resident 95 was preparing for surgery and could not afford to keep getting UTIs. The DON stated once Resident 95's immune system was compromised, and frequent infections would delay his radiation treatments and upcoming surgery. During review of the facility's policy and procedure (P&P) titled, Catheter - Care of, revised on 6/10/2021, the P&P indicated the purpose of the policy was to prevent catheter associated urinary tract infections while ensuring that residents are not given indwelling catheters unless medically necessary. The P&P also indicated the following: 1. Nursing staff would assess urinary drainage for signs and symptoms of infection, noting cloudiness, color, sediment, blood, odor, and amount of urine. 2. Licensed nurse would notify the attending physician of any signs and symptoms of infection for clinical interventions. 3. Anyone manipulating the catheter site or apparatus must wash their hands thoroughly immediately before and after touching the site or apparatus. 4. The catheter and collecting tube would be kept free from kinking and the collection bag would be kept below the level of the bladder. 5. The catheter will be anchored to prevent excessive tension on the catheter. 6. Documentation of catheter care will be maintained in the resident's medical record. 7. The resident's privacy and dignity will be protected by placing a cover over the drainage bag when the resident is out of bed.

Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved temperatures when the lunch tray line food temperatures were as follows: 1. Quesadillas temperature measurement indicated 120 degrees Fahrenheit ( F, a degree of temperature). 2. Lasagna temperature measurement indicated 126 F . This deficient practice had the potential to place 112 of 115 facility residents who received food from the kitchen at risk of unplanned weight loss, a consequence of poor food intake from food in the kitchen. Cross reference to F812. Findings: During an observation on 12/17/2024 at 11:50 a.m., the dietary staff were observed starting the tray line service for lunch. During a concurrent observation and interview on 12/17/2024 at 12:05 p.m., in the kitchen, with [NAME] 1, a tray of quesadillas and lasagna was observed placed on the shelf away from the stove and steam table (a large metal table or container with openings that held smaller metal pans of food over hot water or steam). [NAME] 1 was observed taking the temperature of the food items using the facility's food thermometer. The food item temperatures were as follows: 1. Quesadillas - 120 F. 2. Lasagna - 126 F. Cook 1 stated the quesadillas were for the alternative menu and the lasagna was for residents receiving a liquid diet. [NAME] 1 stated he placed the quesadillas and lasagna on the shelf because there was no more space on the stove or the steam table. During a concurrent interview and record review on 12/17/2024 at 12:40 p.m. with the Dietary Supervisor (DS), the facility's Policy and Procedure (P&P) titled, Food temperatures, revised on 7/1/2024, was reviewed. The P&P indicated the required temperature for hot food was greater than 140 F. The DS stated the temperature for hot food should be above 140 F. The DS a temperature of 120 F for quesadillas and 126 F for lasagna were unacceptable. The DS stated the quesadillas could be provided to residents with regular and mechanical soft diet (a diet of soft foods that were easy to chew and swallow), and the lasagna was provided to residents who were unable to tolerate a pureed diet (a texture-modified eating plan where all foods were blended, mixed, or processed into a smooth, pudding-like consistency). The DS stated the food would not be palatable for resident because it was cold, and it could potentially increase the risk of poor food intake and unplanned weight lost. During an interview on 12/18/24 at 2:30 p.m. with the DS, the DS stated there was no policy for food palatability or menu planning, and the facility should have a policy addressing the food palatability if there was a concern.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when food temperatures were out of range as follows: 1. Quesadillas measurement indicated 120 degrees Fahrenheit ( F, a degree of temperature). 2. Lasagna measurement indicated 126 F. This deficient practice had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (transfer of bacteria from one object to another) in 112 of 115 medically compromised residents who received food from the kitchen. Cross reference to F804. Findings: During an observation on 12/17/2024 at 11:50 a.m., the dietary staff were observed starting the tray line service for lunch. During a concurrent observation and interview on 12/17/2024 at 12:05 p.m., in the kitchen, with [NAME] 1, a tray of quesadillas and lasagna was observed placed on the shelf away from the stove and steam table (a large metal table or container with openings that held smaller metal pans of food over hot water or steam). [NAME] 1 was observed taking the temperature of the food items using the facility's food thermometer. The food item temperatures were as follows: 1. Quesadillas - 120 F. 2. Lasagna - 126 F. Cook 1 stated the quesadillas were for the alternative menu and the lasagna was for residents receiving a liquid diet. [NAME] 1 stated he placed the quesadillas and lasagna on the shelf because there was no more space on the stove or the steam table. During a concurrent interview and record review on 12/17/2024 at 12:40 p.m. with the Dietary Supervisor (DS), the facility's Policy and Procedure (P&P) titled, Food temperatures, revised on 7/1/2024, was reviewed. The P&P indicated the required temperature for hot food was greater than 140 F. The DS stated the temperature for hot food should be above 140 F, and 120 F for quesadillas and 126 F for lasagna were unacceptable. The DS stated the quesadillas could be provided to residents with regular and mechanical soft diet (a diet of soft foods that were easy to chew and swallow), and the liquid lasagna was provided to residents who were unable to tolerate a pureed diet. During an interview on 12/19/2024 at 11:30 a.m. with the Infection Preventionist Nurse (IPN), the IPN stated hot food cold have bacteria growth if it was less than 140 F. The IPN stated residents might become sick and develop stomach issues from eating hot food outside of the appropriate temperature range.

Based on observation, interview, and record review, the facility failed to ensure the garbage storage area was maintained in a sanitary manner to prevent the harborage and feeding of pests when the outside trash dumpster lids were not closed. This deficient practice had the potential to result in creating harborage and feeding of pests which could lead to diseases and increase the morbidity (the amount of disease in a population) and mortality (the state of being subject to death) among facility residents. Findings: During a concurrent observation and interview on 12/17/2024 at 9:58 a.m., of the outdoor garbage storage area, with the Dietary Supervisor (DS), two trash dumpster lids were observed not closed completely. The DS stated the trash dumpster lids should be closed completely to keep flies away. The DS stated flies transported bacteria and residents might catch bacteria and get sick. During an interview on 12/17/2024 at 1:40 p.m. with the Infection Preventionist Nurse (IPN), the IPN stated the outside trash dumpster lids should be closed completely for infection control prevention. During an interview on 12/18/2024 at 10:40 a.m. with the Administrator (ADM), the ADM stated the facility did not have a policy that specified the outside trash dumpster lids needed to be closed completely, but would formulate one. During a review of the facility's Policy and Procedure (P&P) titled, Garbage and trash can use and cleaning, revised on 10/1/2014, the P&P indicated Food waste will be placed in covered garbage and trash cans.

Based on interview and record review, the facility failed to implement a care plan titled, At Risk/Potential for Aspiration (breathing in a foreign object such as sucking food into the airway) and Choking for one of three sampled residents (Resident 1). According to the care plan interventions, staff will allow enough time for Resident 1 to eat meals, staff should instruct resident to chin tuck (tilt chin down when swallowing to prevent choking), swallow after each bite, swallow to clear throat, and alternate liquid (drinking fluids) and solid. On [DATE], Certified Nurse Assistant (CNA) 1 gave Resident 1 a tamale without following Resident 1's care plan interventions which indicated to instruct resident to chin tuck, swallow after each bite, swallow to clear throat, and alternate liquid and solid. As a result of not implementing the care plan, Resident 1 choked on the tamale and was pronounced dead on [DATE] at 3:28 p.m. On [DATE] at 5:45 p.m., the Assistant Administrator (AADM) and the Director of Nursing (DON) were notified of an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called for the facility's failure to follow and implement Resident 1's care plan, At risk/potential for aspiration/choking. The facility's AADM and the DON were notified of the seriousness of all residents' health and safety being threatened by staff not implementing Resident 1's care plan. An IJ removal plan ([IJRP], an intervention to immediately correct the deficient practices) was requested. On [DATE] at 10:54 a.m., the AADM submitted an acceptable IJRP. After onsite verification if the IJRP was implemented through observation, interview, and record reviews, the IJ was removed on [DATE] at 3:22 p.m., in the presence of the AADM and the DON. The IJRP included the following: 1. On [DATE] and [DATE], the DON/Designees conducted an audit of current residents' care plans and reviewed the most recent ST Evaluations and Discharge Summaries to identify residents at risk for aspiration/choking, to ensure that a care plans for risk for aspiration/choking are developed and implemented accordingly. 48 residents out of total current census of 103 were identified to be at risk for aspiration/choking based on their current diagnoses, diet orders, recent changes of condition, and/or speech therapy evaluation and discharge summary to ensure that residents have a care plan developed and implemented to prevent aspiration/choking. a. 49 residents out of 103 have mechanically altered diets (foods that can be safely and successfully swallowed) who are currently tolerating prescribed diet and care plans have been reviewed and updated. b. 67 residents out of 103 require assistance with eating care plans have been reviewed and updated. c. 72 residents out of 103 have already been evaluated and/or treated by speech therapist within the last 90 days, and recommendations for care plans for safe swallowing were developed and implemented. d. 19 residents out of 103 have a new order for speech therapy evaluation as of [DATE] and recommendations for swallowing safety strategies to minimize or prevent choking or aspiration will be developed and implemented upon receipt of recommendations from the Speech Therapist 2. On [DATE], the DON/Designee developed a Special Needs List Binder at each Nursing Unit. a. A list of 48 residents that were identified to be at risk for aspiration/choking and require supervision during meals were placed in the Special Needs List Binder at each Nursing Unit and Dining Room for Licensed Vocational Nurse (LVNs), CNAs, Registered Nurse (RNs), and other staff to refer to all throughout the shift. a. The Special Needs List Binder at each unit will also contain the CNA Assignments which will show the patients that are assigned to be cared for by each CNA per shift. b. The Special Needs list will contain the list of current residents with their current diets and the required level of feeding assistance. c. During change of shift huddles together with the RN Supervisor, LVN Charge Nurse and CNAs, residents' special needs list will be reviewed and Licensed Nurses will provide guidance and directions to the CNAs on how to care for the patients and to refer to the list to provide the CNAs guide on the aspiration risk and feeding assistance needs of the patients assigned to the CNAs. d. The Licensed Nurses and CNAs including registry staff (staff personnel provided by a placement service on a temporary or on a day-to-day basis, in a facility) will have access to the special needs list binder for all shifts and will use this for reference as a guide on the feeding assistance and supervision needs of the residents for care. e. The Special Needs list will be reviewed and updated by the DON/RNs as resident's level of assistance changes according to the residents' assessments and care plans. 3. Meal Supervisions were provided by the DON, Licensed Nurses, and Department Managers on [DATE] and [DATE] and current residents requiring assistance with meals and/or supervision were provided assistance as per their assessment and care plan. 4.On [DATE], the DON conducted rounds and observation to validate that supervision is provided during mealtimes for the 48 residents identified to be at risk for aspiration/choking. 5.On [DATE] and [DATE], the DON provided an in - service education to the Nursing Staff regarding the facility's policy and procedures for Comprehensive Care Planning, with emphasis on development and implementation of care plan goal and interventions, such as aspiration and choking precautions as recommended by the Speech Therapists to minimize episodes of aspiration and/or choking and ensure safety of residents during meals. 6. On [DATE] and [DATE], the DON/Designee immediately provided an in - service education to the Nursing Staff regarding Aspiration/Choking Precautions. 7. On [DATE], the DON provided an in - service education to the Nursing Staff regarding the policy and procedures for Food Brought in by Visitors, with emphasis on the process of visitors bringing outside food to the nurses first prior to giving to the residents, to minimize/prevent choking/aspiration, and to ensure care plan of residents are implemented safely 8. On [DATE], the Speech Therapist (ST) will initiate an in - service education to the Nursing Staff regarding aspiration precautions and interventions so these interventions can be added to the care plan of residents for staff to refer to on how to care for patients. This in-service will be completed on [DATE]. 9. On [DATE], the DON conducted rounds and observation to validate that supervision is provided during mealtimes for the 48 residents identified to be at risk for aspiration/choking. 10. All the education above will be completed by [DATE] and staff who are unscheduled will be provided in-service of Care Plans upon return to work. 11. Admissions/Readmissions and New Orders for ST Evaluation will be communicated to the Rehabilitation Department; ST will complete the Evaluation as ordered. a. During Saturdays and Sundays- The RN Supervisors assigned at each shift will review new admissions/readmissions, changes of condition, and new orders, to ensure that residents at risk for choking/aspiration and residents newly added to the dining program (program that offers residents choices, assistance and makes mealtimes enjoyable) have a care plan developed and implemented and the diet provided to the residents are appropriate. b.The IDT will review current residents on a dining program, and residents at risk for aspiration/choking weekly and as needed to ensure that Nursing Staff are aware of residents requiring set up and monitoring with meals and to ensure their care plan interventions are implemented as written. A list of these residents will be updated by the DON/Designee weekly and as needed and will be available in the Special Needs List binder at the nurses' station and dining room. 12. The DON/Designee, ST or licensed nurse will conduct observations of 10 residents on a dining program requiring set up and monitoring with meals, and residents at risk for choking/aspiration, daily 7 days/week for 4 weeks then weekly for 2 months, to ensure that assistance is provided by Certified Nursing Assistants and care plan interventions are implemented as written. Any issues identified will be addressed by the DON immediately. 13. The DON or designee will also do a weekly check for 2 months to ensure all active care plans accurately reflect the status of the resident based on the most recent assessments. 14. The DON will present the results of the Dining Program Observation and Choking/Aspiration Care Plan Interventions Implementation to the Quality Assurance and Performance Improvement for review and recommendations monthly for 3 months or until substantial compliance is achieved. 15. The DON will be responsible for monitoring and sustaining compliance. Findings: During a review of Resident 1's face sheet (admission record), dated [DATE], the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease ([COPD], a group of lung diseases that block airflow and make it difficult to breathe), anxiety (mental disorder that causes excessive fear and or worry, feeling nervous and breathing rapidly), dementia (a condition characterized by progressive or persistent loss of intellectual functioning that interferes with daily functioning) and obesity (excessive fat accumulation that presents a risk to health). The face sheet indicated Resident 1 expired on [DATE]. During a review of Resident 1's history and physical (H&P), dated [DATE], the H&P indicated Resident 1 could make needs known but could not make medical decisions. During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated [DATE], the MDS indicated Resident 1 usually understood and was usually able to be understood by others. The MDS indicated Resident 1 required supervision and setup for eating and locomotion (how the resident moves around). The MDS indicated Resident 1 required limited assistance from staff for all other activities of daily living (daily self-care activities) such as bathing, dressing and eating. During a review of Resident 1's care plan titled At risk/potential for aspiration/choking related to Dysphagia (difficulty swallowing), Gastroesophageal reflux disease ([GERD] a condition in which the stomach contents leak backward from the stomach into the food pipe), COPD, and behavior affecting swallowing, initiated [DATE], the care plan interventions indicated allow enough time for Resident 1 to eat meals. The interventions also indicated instruct resident to chin tuck, swallow after each bite, swallow to clear throat, and alternate liquid and solid. During a review of Resident 1's Speech Therapy (ST) Discharge Summary (discharge summary), dated [DATE], the discharge summary indicated for safety, Resident 1's should alternate liquid and solids, and clear her throat by swallowing while eating. The discharge summary indicated Resident 1's prognosis to maintain current level of function was good with consistent staff follow-through. During a review of Resident 1's Situation Background Assessment and Recommendation (SBAR) report, dated [DATE], the SBAR indicated Resident 1 was a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). The SBAR indicated Resident 1 came out of her room on [DATE], choking and after the nurse performed the Heimlich maneuver (a method for forcing an object out the airway of a choking person), Resident 1 became unconscious (a person is unable to respond to people). The SBAR indicated the nurse transferred Resident 1 to her bedroom before assessing and implementing CPR ([CPR] an emergency procedure to restart a person's heart and breathing after one or both suddenly stop). During an interview with Licensed Vocational Nurse (LVN) 2 on [DATE] at 1:59 p.m., LVN 2 stated on [DATE], she (LVN 2) and LVN 1 observed Resident 1 come out of her room to the hallway in her wheelchair, and was having problems breathing, coughing and could not speak. Resident 1 was pointing to her throat. LVN 2 stated, LVN 1 performed the Heimlich maneuver about five times on Resident 1, afterwards Resident 1 became unconscious (a person is unable to respond to people). During a phone interview with Registered Nurse (RN 1) on [DATE] at 1:03 p.m., RN 1 stated when Resident 1 was choking on [DATE], RN 1 saw food particles in Resident 1's mouth that appeared to be a tamale. RN 1 stated she observed a tamale with a bite mark on Resident 1's bedside table. During a phone interview with Certified Nurse Assistant (CNA 2) on [DATE] at 1:30 p.m., regarding Resident 1's care plan, At Risk/Potential for Aspiration/Choking, CNA 2 stated Resident 1 had severe anxiety that caused her (Resident 1) to eat very fast. CNA 2 stated she used to instruct Resident 1 to slow down while Resident 1 ate. CNA 2 stated Resident 1 was to be supervised because Resident 1 ate fast and needed reminders to slow down. CNA 2 did not speak to other interventions listed in the care plan. During a phone interview with Licensed Vocational Nurse (LVN 1) on [DATE] at 3:08 p.m., LVN 1 stated Resident 1 was able to eat independently and did not require supervision while eating. LVN 1 stated Resident 1 usually ate out in the hallway in front of her room and did not have a choking risk. LVN 1 stated he would remind Resident 1 to eat slowly. LVN 1 was not aware of Resident's I care plan, At Risk/Potential for Aspiration/Choking. During a phone interview with CNA 3 on [DATE] at 10:12 a.m., regarding Resident 1's care plan, CNA 3 stated Resident 1 was able to eat independently but tended to eat very quickly and lost her breath while eating, therefore CNA 3 would tell Resident 1 to slow down and breathe. CNA 3 stated she went to the door to grab supplies and Resident 1 came out behind CNA 3 and Resident 1 stated she was choking. CNA 3 stated she alerted other nurses for assistance. During an interview with CNA 4 on [DATE] at 10:39 a.m., CNA 4 stated she often reminded Resident 1 to drink while Resident 1 ate. During an interview with the Speech Language Pathologist ([SLP] a person who prevents, assess, diagnoses, and treats speech, language, and swallowing problems) on [DATE] at 1:03 p.m., the SLP stated Resident 1 had behavior that impacted safe swallowing. The SLP stated Resident 1 had behavior such as eating too fast and taking big bites of food and Resident 1 needed reminders to slow down while eating. The SLP stated when Resident 1 was discharged from ST, Resident 1 had issues with her behavior and impulsivity, eating quickly and needed education and reminders to slow down while eating. The SLP stated Resident 1 required reminders and cueing on safe swallowing strategies such as instructing Resident 1 to chew slowly and swallow after each bite of food. The SLP stated he discussed with nurses about safety and what assistance Resident 1 needed. The SLP stated upon Resident 1's discharge from ST, the SLP informed the nurses Resident 1 ate too fast and required cueing and if not supervised, the resident could cough or choke on food. During a concurrent interview and record review with the DON on [DATE] at 5:05 p.m., Resident 1's care plans were reviewed. Resident 1's care plans indicated Resident 1 was at risk for choking and the interventions included instructing resident to chin tuck, to swallow after each bite, to swallow to clear throat, and to alternate liquid and solid. The DON stated the care plan was developed upon admission by nurse assessments and Resident 1 no longer needed cues or reminders while eating. The DON stated Resident 1 was able to remember the interventions. The DON stated Resident 1 was on the dining program and the purpose of the dining program was to provide residents who were highly functional additional cueing while eating. During a review of the facility ' s policy and procedure (P&P) titled Comprehensive Person-Centered Care Planning dated [DATE], the P&P indicated the facility will develop and implement each resident ' s care plan. The P&P indicated the care plan will address resident-specific health and safety concerns to prevent decline or injury ,and identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. During a review of the facility ' s P&P titled Care Planning, dated [DATE], the P&P indicated a care plan was developed for each resident to meet their medical, nursing, mental and psychosocial needs. The P&P indicated the care plan served as a course of action where a resident, resident ' s family and or guardian, resident ' s attending physician, and the interdisciplinary team work to help the resident move toward resident-specific goals that addressed their medical, nursing, mental, and psychosocial needs.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received immediate basic life support ([BLS] care healthcare professionals provide to anyone who's heart stops beating suddenly), including cardiopulmonary resuscitation ([CPR] an emergency procedure to restart a person's heart and breathing after one or both suddenly stop), when the resident became unresponsive. On [DATE], Resident 1 came out of her room in her wheelchair choking and to seek help. Licensed Vocational Nurse (LVN 1) performed the Heimlich maneuver (a method for forcing an object out the airway of a choking person) and Resident 1 became unresponsive. LVN 1 put Resident 1 into her wheelchair and wheeled the resident into her room and placed the resident on the bed before starting CPR. As a result, Resident 1 received delay in receiving CPR and Resident 1 was pronounced dead on [DATE], at 3:38 p.m. These deficient practices had the potential to affect other residents in the facility in need of timely life saving measures. This failure placed 58 residents residing in the facility, who had a Full Code status, at risk for not receiving CPR timely. On [DATE] at 2:28 p.m., the Assistant Administrator (AADM) and the Director of Nursing (DON) were notified an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called for the facility's failure to ensure basic life support (BLS) was provided to Resident 1, including CPR, immediately. The facility's AADM and the DON were notified of the seriousness of all residents' health and safety being threatened by staff not performing CPR immediately. An IJ removal plan ([IJRP], an intervention to immediately correct the deficient practices) was requested. On [DATE] at 10:54 a.m., the AADM submitted an acceptable IJRP. After onsite verification if the IJRP was implemented through observation, interview, and record reviews, the IJ was removed on [DATE] at 3:22 p.m., in the presence of the AADM and the DON. The IJRP included the following: 1. On [DATE], LVN 1 was educated on how to perform the Heimlich Maneuver. 2. On [DATE]/,d+[DATE], LVN 1 was provided education on emergency response and CPR. 3.On [DATE], an American Heart Association accredited outside vendor for CPR Classes provided an in - service education and competency assessment to 19 Licensed Nurses on Heimlich Maneuver. 4.On [DATE] and [DATE], Licensed Nurses were provided BLS/CPR training by an approved outside vendor accredited by the American Heart Association. 5.On [DATE], the Clinical Education Specialist provided education to the Licensed Nurses on Emergency Response, including but not limited to: a.When one should and should not initiate CPR b.How to conduct an organized code with assigned roles and effective communication c.Documentation requirement during and after a Code d.How to determine irreversible death e.How to conduct high quality CPR going over basics from basic life support training 6.In-services were completed by [DATE] and those licensed nurses who are unscheduled to work, on leave of absence, will receive education upon return to work. 7.On [DATE], the DON and Director of Staff Development (DSD)/Designee conducted an audit of the licensed nursing staff for current certifications of BLS. There were no licensed nurses who did not have current certifications available in their employee files, for a total of 12 RNs, and 24 LVNs. 52 CNAs had CPR certification. 8.There are a total of 58 residents out of 103 who are FULL CODE upon review. 9.As of [DATE], the facility has available BLS Certified Staff ,d+[DATE] to provide CPR in the event of a CODE BLUE Emergency. 10.EMERGENCY RESPONSE: a.Responding to Cardiopulmonary Emergency i.Check the victim for responsiveness, respirations, and pulse. 1.If the victim responds but is injured, follow the facility protocol for first aid or call 911. 2.Verify, or instruct a staff member to verify the code status of the individual. 3.If the resident shows signs of irreversible death, cardiopulmonary resuscitation may be withheld. The physician shall be contacted immediately. 4.If the victim is unresponsive (no movement or response to stimuli, and no pulse or respirations, activate the Emergency response team). 5.Call for help and send someone to contact the EMS or 911 for emergency medical assistance. 6.Send someone for the emergency cart and supplies, and to announce your facility code for medical emergencies. 7.Initiate CPR in accordance with AHA guidelines (see below) immediately at the scene. Residents will not be moved to a different area if the area of emergency has been verified for safety. 8.Continue CPR until the EMS arrives and assumes care of the resident. 11.The DON/DSD will conduct Code Blue Drills every 3 months to ensure that staff are aware and trained in all emergency procedures, administering CPR, and responding to Residents who are choking and who become unresponsive. 12. Registered Nurses (RN) and Licensed Nurses as part of their responsibilities will continue to monitor the safety of our residents and will continue to supervise the care of the residents during mealtimes and will be available ,d+[DATE] to provide Basic Life Support/CPR in the event of a Code Blue Emergency. The DON will also be immediately notified. 13. The DON/Designee will conduct a review of residents weekly for 4 weeks then bimonthly for 2 months who had code blue emergencies and became unresponsive after choking to ensure that Registered Nurses and Licensed Vocational Nurses initiated CPR immediately without delay. Identified concerns will be immediately addressed and reported to DON for follow-up and resolution as warranted. 14.The DON will present the results of Code Blue Emergency Response audits to the Quality Assurance and Performance Improvement for review and recommendations monthly for 3 months or until substantial compliance is achieved. 15.The DON will be responsible for monitoring and sustaining compliance. Findings During a review of Resident 1's face sheet (admission record), dated [DATE], the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease ([COPD], a group of lung diseases that block airflow and make it difficult to breathe), anxiety (mental disorder that causes excessive fear and or worry, feeling nervous and breathing rapidly), dementia (a condition characterized by progressive or persistent loss of intellectual functioning that interferes with daily functioning) and obesity (excessive fat accumulation that presents a risk to health). The face sheet indicated Resident 1 expired on [DATE]. During a review of Resident 1's history and physical (H&P), dated [DATE], the H&P indicated Resident 1 could make needs known but could not make medical decisions. During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated [DATE], the MDS indicated Resident 1 usually understood and was usually able to be understood by others. The MDS indicated Resident 1 required supervision and setup for eating and locomotion. The MDS indicated Resident 1 required limited assistance from staff for all other activities of daily living. During a review of Resident 1's order summary report (Medical Doctor (MD) orders), dated [DATE], the MD orders indicated CPR. During a review of Resident 1's Situation Background Assessment and Recommendation (SBAR) report, dated [DATE], the SBAR indicated Resident 1 was a full code. The SBAR indicated Resident 1 came out of her room choking and after the nurse performed the Heimlich maneuver, Resident 1 became unconscious (a person is unable to respond to people). The SBAR indicated the nurse transferred Resident 1 to her bedroom before assessing and implementing CPR. During an interview with Licensed Vocational Nurse (LVN) 2 on [DATE] at 1:59 p.m., LVN 2 stated on [DATE], she (LVN 2) and LVN 1 observed Resident 1 come out of her room to the hallway in her wheelchair, and was having problems breathing, coughing and could not speak. Resident 1 was pointing to her throat. LVN 2 stated, LVN 1 performed the Heimlich maneuver about five times on Resident 1, after which Resident 1 became unconscious. LVN 2 stated Resident 1 was placed in her wheelchair and pushed back to her room. LVN 2 stated Resident 1 was placed on her bed, and assessed before CPR was started on the resident. During a phone interview with Registered Nurse (RN 1) on [DATE] at 1:03 p.m., RN 1 stated on [DATE] at approximately 3 p.m., RN 1 saw staff performing the Heimlich maneuver on Resident 1. RN 1 stated when Resident 1 became unconscious, RN 1 assisted LVN 1 with placing Resident 1 in her bed. RN 1 stated she assessed Resident 1 in her bed and determined Resident 1 did not have a pulse, placed the resident on a back board and started CPR in Resident 1's bed. During a phone interview with LVN 1 on [DATE] at 3:08 p.m., LVN 1 stated on [DATE] at approximately 3 p.m., he performed the Heimlich maneuver on Resident 1 in the hallway because the resident was choking. LVN 1 stated while he was performing abdominal thrust on Resident 1, Resident 1 lost consciousness. LVN 1 stated he sat Resident 1 in her wheelchair, pushed Resident 1 back to her room and carried Resident 1 to her bed. LVN 1 stated RN 1 assessed Resident 1 and determined Resident 1 did not have a pulse and initiated CPR. LVN 1 stated he did not start CPR on the floor because Resident 1's room was a few steps away and he moved Resident 1 to her room out of concern for the resident's privacy. During an interview with RN 1 on [DATE] at 2:03 p.m., RN 1 stated on [DATE] during the incident, staff, including RN 1, did not start CPR in the hallway because the staff felt CPR could be properly done with the resident in bed. During a concurrent interview and record review on [DATE] at 2:15 p.m., with the DON, the facility's policy, and procedure (P/P) titled Choking-Heimlich Maneuver dated [DATE] was reviewed. The DON stated per the P/P, if a resident became unconscious in the hallway, CPR was supposed to be initiated in the hallway right away. The DON stated the nurses should not have taken Resident 1 to her room and place Resident 1 in bed before starting CPR. During a review of an online article titled, American Heart Association 2020 CPR and Emergency Cardiovascular Care Committee Guidelines, per the article, the adult basic life support algorithm for healthcare providers indicated to verify for scene safety, check for responsiveness, shout for nearby help, look for no breathing or only gasping and check pulse simultaneously (at the same time). The guidelines further indicated if there was no breathing, or only gasping, with no pulse, to immediately begin CPR and perform cycles of thirty chest compressions (the act of applying pressure to someone's chest to help blood flow) and two breaths. https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines. During a review of the facility's P/P titled Choking-Heimlich Maneuver, dated [DATE], the P&P indicated if a victim became unresponsive or if staff encountered an unconscious choking victim, the victim should be lowered to the ground and start CPR immediately. The P/P indicated to not check for a pulse and perform compressions to relieve the obstruction. During a review of the facility's P/P titled Cardiopulmonary Resuscitation, dated [DATE], the P&P indicated the facility shall ensure properly trained personnel in CPR were available immediately to provide basic life support, including CPR.

Based on interview and record review, the facility failed to provide supervision (oversight, encouragement, or cueing) from staff for one of four sampled residents (Residents 4). Resident 4 was given a hot cup of noodle soup and left unsupervised. This deficient practice resulted in Resident 4 spilling hot noodle soup on herself and sustained third (3rd), ([full thickness], a burn that cause damage to the top layer, middle layer, and layer of fat underneath the skin) ) to fourth (4th) degree ([full thickness] burns, that affect all layers of the skin and also structures below the skin, such as the bone, and muscles) to the left inner arm and left breast. Findings: During a review of Resident 4's Admission Record (Face Sheet), the Face Sheet indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's disease (a brain disorder that affects movement, often including tremors.), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), hemiplegia (paralysis of one side of the body) and hemiparesis (partial paralysis) affecting left dominant side, muscle weakness and dysphagia (difficulty swallowing). During a review of Resident 4's history and physical (H/P) dated 11/12/2022, the H/P indicated Resident 4 had the capacity to understand and make decisions. During a review of Residents 4's Minimum Data Set ([MDS], a standardized assessment and care screening tool) dated 2/7/2023, the MDS indicated Resident 4 was able to understand, and be understood by others. The MDS indicated Resident 4 required a one-person physical assist and supervision by staff when eating. The MDS also indicated Resident 4 required extensive assistance (resident involved in activity, staff provide weight-bearing support) for bed mobility, dressing and personal hygiene, and was totally dependent on staff for transfer and toileting. During a review of Resident 4's Care Plan titled, Resident requires assistance with bed mobility, transfer and eating initiated on 11/11/2022. The care plan was related to lack of upper body coordination and control, limitation of joint mobility, presence of mood/behavioral issues and lack of safety awareness and judgment. The interventions included nursing staff will assist Resident 4 with activities of daily living (ADLs, essential tasks that each person needs to perform, on a regular basis, to sustain basic survival and well-being, such as bathing, eating, toileting, dressing). During a review of Resident 4's Care Plan titled Potential for injury from tremors and individual movements due to Parkinson's disease initiated on 11/11/2022, the interventions indicated staff should invite Resident 4 to activities which do not depend on dexterity (skill in performing tasks, especially with the hands), listen to resident when verbalizing concerns over disease symptoms and address issues raised, monitor the environment for possible padding of side rails and special chair needs if involuntary movements put resident at risk for injury. During a review of Resident 4's Investigation Summary for Change of Condition (COC) dated 4/28/2023, the Investigation Summary indicated on 4/27/2023 at approximately 10:20 p.m., Certified Nurse Assistant (CNA) 3, heated up a cup of noodle soup and left it on Resident 4's bedside table for the resident to eat. The Investigation Summary indicated CNA 3 informed Resident 4 to allow the noodle soup to cool down before eating and CNA 3 left the resident unattended. The Summary also indicated Resident 3 spilled the soup on her gown onto her left chest and left arm when she tried to grab the cup of noodle soup to feed herself. The Investigation Summary indicated Resident 4 was found to have open blisters on her left chest and left arm. During a review of Resident 4's COC Evaluation dated 4/28/2023, the COC indicated Resident 4 complained of itchiness and burning sensation to the left chest and left arm. The COC indicated Resident 4 was assessed to have redness and blisters to the left chest and left arm. During a review of Resident 4's Physician Orders dated 4/28/2023, the orders indicated the following: 1. Left chest open blister: cleanse with Normal Saline ([NS], solution with salt and water), pat dry, apply Silvadene cream (medication to prevent and treat wound infections in residents with serious burns) and leave open to air daily for 21 days. 2. Left upper arm open blister: cleanse with NS, pat dry, apply Silvadene cream and cover with a dry dressing daily for 21 days. During a review of Resident 4's Wound Assessment and Plan dated 5/4/2023, the Wound Assessment and Plan indicated Resident 4 had the following 3rd degree burns: 1. Left inner arm full thickness with fat layer exposed; wound measured at 8 centimeters ([cm], unit of measurement) length x 13 cm. width x 0.2 cm. depth with large amount of exudate (drainage). 2. Left breast full thickness with fat layer exposed; Wound measured at 8 cm. length x 17 cm. width x 0.2 cm. depth with large amount of exudate. The Wound Assessment and Plan also indicated treatment orders included xeroform (mesh occlusive dressing), cleanse wound with NS or sterile water, cover with dry clean dressing, abdominal pad and gauze wrap and change as indicated and as needed. Additional treatment included Silvadene to wound bed daily. During a review of Resident 4's GACH emergency room (ER) Records dated 5/9/2023 and 5/10/2023, the Records indicated Resident 4 had increased tremors and presented to the ER with left upper arm and left breast burns that occurred as a result of spilling a hot cup of noodles onto the left upper body. During a review of Resident 4's GACH Physician Progress notes dated 5/10/2023, the progress notes indicated Resident 4 had a left axillary 3rd degree burn, due to scalding water two weeks ago from instant noodle soup. During a review of Resident 4's Nursing Narrative Note dated 5/9/2023, at 10:19 p.m., the notes indicated Resident 4 had a left upper arm and left breast thermal burns that occurred as a result of spilling a hot cup of noodles onto the left upper body. During a review of Resident 4's Nursing Narrative Note (GACH) dated 5/10/2023 at 6:18 pm, the notes indicated Resident 4 was observed with two large burn wounds located at left breast and left upper arm (medial presentation), and the wounds appeared to have slough (dead tissue that needs to be removed from the wound for healing to take place) on both areas suggesting 3rd to 4th degree burns , with the left breast leaning towards 4th degree and possibly higher. The notes also indicated Resident 4 had weakness and tremors in both hands which may be contributory to spillage of the soup. During an interview on 5/11/2023 at 12:55 p.m., with CNA 1, in the facility, CNA 1 stated, Resident 4 needed supervision such as observing how the resident ate, and not leave the resident unattended, while eating. Resident 4 was on aspiration (when food or liquid enters resident's airway and lungs) precautions and Resident 4's hands would shake while eating. CNA 1 stated she observed Resident 4 with redness to the left chest area and blister on the left arm on 4/28/2023 in the morning while she was repositioning the resident. CNA 1 stated Resident 4 informed CNA 1 that she spilled soup on herself. During a concurrent interview and record review on 5/11/2023 at 4:00 p.m., with Registered Nurse (RN) 1, Resident 4's Progress Notes (PN) dated 4/2023 were reviewed. RN 1 stated, Resident 4's PN indicated Resident 4 required visual monitoring during mealtimes, and the resident should not be left unattended for safety. RN 1 stated it was the nurses' responsibility to prevent Resident 4 from accidents and injuries including choking, aspirating, and spilling food on herself which could cause hospitalization and health deterioration for Resident 4. During a telephone interview on 5/19/2023 at 10:45 a.m. with CNA 3, CNA 3 stated on 4/27/2023 at approximately 10 p.m., Resident 4 asked her (CNA 3) for a cup of noddle soup. CNA 3 stated after preparing the noodle soup, she (CNA 3) elevated Resident 4's head of the bed and put the soup at the resident's bedside table. Resident 4 was instructed to throw the empty noddle cup in the trash, after the resident finished eating. CNA 3 stated she was not aware Resident 4 was on precautions for aspirations and it did not occur to her that Resident 4 would get burned because there was only a little amount of liquid in the noodle soup. CNA 3 stated she left Resident 4's room and when she returned 15 minutes later, Resident 4 was asleep and CNA 3, did not see the cup of noodles on the resident's table. CNA 3 stated she did not see any wetness, or noodles on Resident 4's gown. During a telephone interview on 5/19/2023 at 11 a.m. with CNA 4, CNA 4 stated on 4/28/2023, at approximately 4:30 a.m., during care, Resident 4 stated she felt a burning sensation on her left arm and left breast. CNA 4 stated she observed the resident's left breast and left arm were very red and looked like a big blister popped out. CNA 4 stated Resident 4 did not complain of pain. CNA 4 stated she notified the charge nurse (LVN 1) of the blisters on Resident 4's left breast and arm. During a review of the facility's policy and procedure (P/P) titled, Assistance with ADL Care undated, the P/P indicated it was the policy of the facility to provide assistance to residents with performance of their ADLs, taking into consideration each resident's needs. During a review of the facility's P/P titled, Resident Safety dated 4/15/2021, the P/P indicated the purpose was to provide a safe and hazard free environment. The P/P indicated any facility staff member who identified an unsafe situation, practice or environmental risk factors should immediately notify the supervisor or charge nurse.

Based on interview and record review, the facility failed to follow its Policy and Procedure (P/P), physician orders [REDACTED]. Resident 1, who had a pacemaker (an artificial device for stimulating the heart muscle and regulating its contractions), and was receiving six medications to treat elevated blood pressure and [MEDICAL CONDITION] ((A-fib), is an irregular, rapid heart rate that causes poor blood flow), had a change of condition. The facility failed to assess and continuously monitor Resident 1's heart rate, blood pressure, and orthostatic [MEDICAL CONDITION] ((OH), is a form of low blood pressure that occurs when standing up from sitting or lying down), to prevent further complications. (Cross Reference F580) These failures resulted in a delay in treatment and services for Resident 1, who was pronounced deceased in the general acute care hospital (GACH), caused by [MEDICAL CONDITION] infarction ((MI), is known as a [MEDICAL CONDITION], caused by a blockage of blood flow to the heart muscle), [MEDICAL CONDITION] (([MEDICAL CONDITION]), is condition that causes the heart to weaken and not pump enough blood to the body's tissues), and [MEDICAL CONDITION] ((CAD), is known as [MEDICAL CONDITIONS], and is the damage or disease in the heart's major blood vessels). Findings: A review of Resident 1's Admission Face Sheet indicated the resident was initially admitted to the facility on [DATE], and re-admitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. block airflow from the lungs, and makes it difficult to breathe), pneumonia (an inflammation of the airspaces in the lungs caused by an infection), and major [MEDICAL CONDITION] (a mental health disorder characterized by persistent sad mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 1's Minimum Data Set (MDS), an assessment and care-screening tool, dated [DATE], indicated Resident 1 was able to report the correct year, month, and day of the week. According to the MDS, Resident 1 required limited assistance of a one-person physical assist with bed mobility, transfers between surfaces, ambulating in the room and corridor, toilet use, and personal hygiene. The MDS indicated Resident 1 had impairment on one side of the upper extremity and used a walker and wheelchair as mobility devices. The MDS indicated the resident was continent (ability to control) of bowel and bladder. A review of Resident 1's History and Physical, dated [DATE], indicated the resident was able to make needs known, but could not make medical decisions. A review of Resident 1's Physician's Telephone Orders, dated [DATE] and timed at 2:15 p.m., indicated to administer to Resident 1 [MEDICATION NAME] (a medication used to treat or prevent heart rhythm problems, such as A-fib), 150 milligrams (mg) orally, three times a day with food, for cardiac (heart) arrhythmia (an irregular beating of the heart). The order indicated to hold the medication for an apical (the lower tip of the heart) pulse (the rhythmic dilation of an artery that results from a heart beat) of less than 60 beats per minute (BPM). The Normal Reference Range (NRR) is 60 to 100 BPM. A review of Resident 1's record, titled Biotronik (a biomedical technology company which develops pacemakers),dated [DATE], and timed at 10:38 a.m., indicated the resident's pacemaker was tested . A review of Resident 1's Physician order [REDACTED]. The orders indicated the following: 1. [MEDICATION NAME] (a medication used to treat fluid retention and swelling), 20 mg, two tablets orally twice a day for [MEDICAL CONDITION]. 2.[MEDICATION NAME](a medication that acts by dilating the blood vessels to reduce blood pressure and prevent chest pain), Extended Release (a prolonged period of time), 30 mg orally daily for hypertension, and hold medication for systolic blood pressure (the top number of a blood pressure reading, which measures the pressure in the blood vessels when the heart beats) less than 110 millimeters of mercury (mm Hg). 3. [MEDICATION NAME] (a medication used to treat high blood pressure), 20 mg orally twice a day for hypertension, and hold medication for SBP less than 110 mm Hg. 4. [MEDICATION NAME], 150 mg orally three times a day for [MEDICAL CONDITION], and to take the medication with food. 5. Xarelto (a medication used to treat and prevent a clot), 20 mg orally every evening for [MEDICAL CONDITION]. 6. Ticagrelor (a medication that thins the blood and prevents a clot from forming), 60 mg orally twice a day for [MEDICAL CONDITION]. 7. [MEDICATION NAME] (a medication used to treat and prevent symptoms caused by lung disease) 0.5 to 2.5 mg per three milliliters (ml) inhaler, via hand held nebulizer (HHN, is an inhaler that sprays a fine, liquid mist of medication), four times a day as needed (prn), for 30 days for shortness of breath ((SOB), is difficult or labored breathing) or wheezing (a high-pitched, [MEDICATION NAME] sound made while breathing and is often associated with difficulty breathing). 8. Oxygen via nasal cannula ((NC), is a device that consists of a plastic tube that fits behind the ears with a set of two prongs placed on the nostril, used to deliver supplemental oxygen or increased airflow), at two to four liters per minute, for SOB. The order indicated to titrate (continuously measure and adjust a dosage or amount delivered) the oxygen delivered to keep the resident's oxygen saturation (the measure of how much oxygen the blood is carrying) above 92 percent (%). The NRR is 95% to 100%. A review of Resident 1's Informed Consent Order Anti-Depressant (medications that help relieve symptoms of depression) Medication, dated [DATE], indicated to administer [MEDICATION NAME] (a medication used to treat depression), five (5) mg orally per day. The order indicated to monitor the resident's blood pressure while sitting and lying, for OH, every week on Sundays, during the 7 a.m. to 3 p.m. shift (day shift). A review of Resident 1's Care Plan titled, Potential SOB, Chest Pains, Irregular Pulse and Elevated Blood Pressure, Related to Compromised Cardiac (heart) Function, Associated with [MEDICAL CONDITION], dated [DATE], indicated the staff's interventions, which included to monitor the resident for episodes of SOB, notify the physician accordingly, monitor for chest pains, pulse and blood pressure as ordered, and report to the physician for any abnormalities promptly. A review of Resident 1's Care Plan titled, At Risk for Decreased Cardiac Output, Related to [MEDICAL CONDITION] Fibrillation, dated [DATE], indicated the staff's interventions, which included to check the resident's pulse before administering medications (Xarelto, Ticagrelor, and [MEDICATION NAME]), and to hold the medications if the resident's pulse was below 60 BPM (NRR is 60 to 100 BPM). A review of Resident 1's Care Plan titled, Potential for Irregular Pulse and Chest Pains secondary to CAD, dated [DATE], indicated the staff's interventions, which included to monitor the resident's vital signs (the clinical measurements, such as the pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a person's essential body functions) and assess for chest pain with SOB or abnormal pulses. A review of Resident 1's Medication Administration Record (MAR), for (MONTH) (YEAR), indicated on [DATE] at 9 a.m., 1 p.m., and 5 p.m., a 150 mg oral tablet of [MEDICATION NAME] was administered to the resident. The MAR did not indicate the resident's pulse rate prior to medication administration. A review of Resident 1's MAR for (MONTH) (YEAR) indicated [MEDICATION NAME], 150 mg oral tablet was administered to the resident on [DATE] to [DATE] at 9 a.m., 1 p.m., and 5 p.m. The MAR did not indicate the resident's pulse rate prior to medication administration. A review of Resident 1's Nurse's Notes, dated [DATE] and timed at 12:15 a.m., indicated the Outgoing Nurse endorsed that the resident had low blood pressure. The note indicated the Licensed Vocational Nurse (LVN 1) checked Resident 1's blood pressure and was low, at ,[DATE] mm Hg, with an elevated heart rate of 146 BPM. The note indicated LVN 1 provided the resident with oxygen therapy of four (4) liters per minute via NC. A review of Resident 1's Nurse's Notes, dated [DATE] and timed at 12:25 a.m., indicated the Registered Nurse (RN 1), rechecked the resident's blood pressure and remained low, at ,[DATE] mm Hg. The note indicated Resident 1 received three (3) liters of oxygen therapy via NC, with oxygen saturation of 97%. A review of Resident 1's Resident Transfer Record, dated [DATE], indicated the resident was transferred to the GACH, via 911 (emergency), due to [MEDICAL CONDITION] (low blood pressure). The record indicated the resident's blood pressure upon transfer was ,[DATE] mm Hg. A review of Resident 1's Prehospital Care Report Summary (Paramedic Run Sheet), dated [DATE], indicated the paramedics arrived at the facility on [DATE] at 12:31 a.m. The summary indicated on [DATE] at 12:33 a.m., the resident's blood pressure was ,[DATE] mm Hg, with oxygen saturation of 100%, respiration of 18 breaths per minute (NRR is 12 to 20 breaths per minute), and an elevated pulse rate of 118 BPM. The summary indicated on [DATE] at 12:54 a.m., the resident's blood pressure was low, at ,[DATE] mm Hg, with oxygen saturation of 99%, respiration of 18 breaths per minute, and a high pulse rate of 123 BPM in a lying position. A review of Resident 1's Emergency Department (ED) Note from the GACH, dated [DATE] and timed at 1:02 a.m., indicated Resident 1 had sudden onset of severe [MEDICAL CONDITION] and palpitations (a sensation that the heart is beating fast, pounding, or skipping a beat) for several hours. The ED note indicated the resident's [MEDICAL CONDITION] and palpitations did not increase or decrease with activity or food, and current medications did not provide relief. The ED note indicated the resident's heart rhythm was Irregularly irregular (abnormal). A review of Resident 1's Ambulatory Assessment/History Report, dated [DATE] and timed at 1:03 a.m., indicated the resident's blood pressure was ,[DATE] mm Hg, pulse rate of 122 BPM, respirations of 20 breaths per minute, with oxygen saturation of 99%, and on four liters per minute (oxygen delivery system not indicated). A review of Resident 1's Electrocardiogram ((ECG), a test that records the electrical signals or activity of the heartbeat) results from the GACH, dated [DATE] and timed at 2:07 a.m., indicated the resident had an abnormal ECG result, which indicated, [MEDICAL CONDITION] with rapid ventricular response (the lower chambers of the heart beats too fast) of 146 BPM. A review of Resident 1's Physician Note from the GACH, dated [DATE] and timed at 5:08 p.m., indicated on [DATE] at 2:10 a.m., the resident remained critical, with laboratory results as followed: 1. Arterial Blood Gas ((ABG), is a test used to measure one's oxygenation status) was significant for an elevated pH (the acidity level of a substance) level of 7.46 (NRR is 7.35 to 7.45), and low [MEDICATION NAME] ((HCO 3), is a form of carbon [MEDICATION NAME] (a gas waste left when the [MEDICAL CONDITION] for energy)) level of 17.1 (NRR is 22.0 to 26.0 millimoles per liter (mmol/L)). 2. Brain Natriuretic Peptide ((BNP), is a hormone in the blood produced by the heart muscle, related to heart failure or cardiac (heart) problems) elevated level of 2460 (NRR is zero to 450 picograms per milliliter (pg/ml)). 3. Lactic Acid (acid produced in muscle cells and red blood cells) elevated level of 2.4 (NRR is 0.7 to 1.9 mmol/L), which is indicative of decreased blood flow and oxygen throughout the body. The Record indicated on [DATE] and timed at 2:18 a.m., code blue (an emergency situation announced in an institution, requiring a team of providers to rush to a specific location and begin immediate resuscitative efforts) was activated due to Resident 1 being pulseless. The Record indicated cardiopulmonary resuscitation (CPR, is a life-saving procedure performed when a person's heartbeat or breathing has stopped) was initiated and the resident was intubated (a medical procedure involving the insertion of a tube into the body), but the cardiac monitor indicated pulseless electrical activity ((PEA), is a condition characterized by unresponsiveness and the lack of palpable pulse in the presence of cardiac electrical activity), and the resident was pronounced deceased on [DATE] at 2:38 a.m. A review of Resident 1's Death Certificate, indicated Resident 1 died on [DATE] at 2:39 a.m., at the GACH. The death certificate listed the immediate cause is an MI, followed by [MEDICAL CONDITION] and CAD. A review of the facility's P/P titled, Change of Condition Notification, revision dated [DATE], indicated a Licensed Nurse would notify the resident's physician when there was a significant change in the resident's physical status, deterioration in health, life-threatening condition, or clinical complication. The P/P indicated in emergencies, such as unexpected SOB, the Licensed Nurse would call the physician, assess the change of condition and determine appropriate nursing interventions. The P/P also indicated the Licensed Nurse would document the date, time, and pertinent details of the incident, and subsequent assessment of the resident on the nursing notes. A review of the facility's P/P titled, Care of Pacemaker, revision dated [DATE], indicated to ensure that all residents with a pacemaker were properly monitored. The P/P indicated to take the resident's apical pulse for one full minute, and to assess the rate, rhythm, and regularity of the pulse. The P/P indicated the physician's orders [REDACTED]. The P/P indicated that for documenting on existing pacemakers, the Licensed Nurse would follow the change of condition procedures. A review of an online drug reference from Lexicomp, titled [MEDICATION NAME], updated [DATE], indicated that the medication could cause new or worsened arrhythmias or heart failure, and for nurses to assess and monitor the resident's vital signs, pacemaker function, and worsening symptoms of heart failure. According to Lexicomp, [MEDICATION NAME] had a Black Boxed Warning ((BBW), is a serious warning put in the labeling of prescription drugs by the Food and Drug Administration (FDA), when there is reasonable evidence of an association of a serious hazard (danger or risk) with the effects of the drug), indicating that the medication could alter the pacing and sensing thresholds of artificial pacemakers. On [DATE] at 9 a.m., during a telephone interview, the Family Member of Resident 1 (FM 1), stated on [DATE], she called the facility in the morning, and the nurse informed her Resident 1's blood pressure was low, while receiving oxygen therapy, because he could not breathe. FM 1 stated she was concerned the nurses allowed the resident's blood pressure to drop and did not immediately intervene. FM 1 stated Resident 1's other family member (FM 2), visited Resident 1 in the facility on [DATE], and left at 10:30 a.m., found the resident receiving oxygen therapy with a low blood pressure, but was alert and able to communicate. FM 1 stated she called the facility on [DATE] in the afternoon, and the nurses informed her the resident was still ok. On [DATE] at 8:50 a.m., during an interview and concurrent record review, LVN 3 stated when a resident had a pacemaker the resident's heart rate should be monitored per nursing practice, even without a physician's orders [REDACTED]. LVN 3 stated the resident's heart rate should be recorded on the MAR, and is crucial to inform the physician to write an order to check the resident's heart rate. LVN 3 stated there was no parameters indicated to check the resident's heart rate on the physician's orders [REDACTED]. LVN 3 stated he should have checked the Resident 1's heart rate prior to administering the medication, and recorded the numerical value on the MAR. On [DATE] at 10:30 a.m., during an interview and concurrent record review, LVN 4 stated that if a resident had a change of condition, the Licensed Nurse should assess the resident, check the resident's vital signs, and call the physician to report the changes. LVN 4 stated interventions completed during the resident's change of condition should be documented on the nursing notes. On [DATE] at 10:52 a.m., during an interview and concurrent record review, RN 2 stated residents with pacemakers taking medications to treat [MEDICAL CONDITION], their apical pulse should be checked and was usually recorded on the MAR. RN 2 stated the resident's heart rate should be checked prior to administering the medication, even without physician's orders [REDACTED]. RN 2 stated if a resident had [MEDICAL CONDITION] and SOB, the Licensed Nurse should stabilize the resident first, and then notify the physician immediately after. On [DATE] at 10:52 a.m., during an interview and concurrent record review, RN 2 stated if a resident had [MEDICAL CONDITION] and SOB, the Licensed Nurse should stabilize the resident first, and then notify the physician immediately after. On [DATE] at 1:45 p.m., during a telephone interview, LVN 1 stated Resident 1's blood pressure was low at the beginning of his work shift on [DATE] (11 p.m. to 7 a.m., night shift). LVN 1 stated the resident's heart rate should be monitored and recorded every shift and he stated he administered oxygen therapy on Resident 1 initially because the resident's oxygen saturation was low. LVN 1 stated he was prompted to check the resident's blood pressure at the start of his shift because the prior nurse endorsed that Resident 1's blood pressure was low. On [DATE] at 3:38 p.m., during an interview, RN 1 stated on [DATE], Resident 1's blood pressure was low (approximately ,[DATE] mm Hg), and had a high pulse rate. RN 1 stated the resident's oxygen saturation level was low initially, but improved after the resident received his prescribed breathing treatment. RN 1 stated she did not receive report from the previous nurse (3 p.m. to 11 p.m., evening shift) that the resident was hypotensive. On [DATE] at 4:30 p.m., during an interview and concurrent record review, LVN 2 stated on [DATE], during her shift (3 p.m. to 11 p.m.), Resident 1 did not complain of any discomfort. LVN 2 stated she recorded the resident's blood pressure on the MAR on [DATE] and [DATE], but did not record the resident's heart rate. LVN 2 stated [MEDICATION NAME] is a very dangerous medication and must always check the resident's heart rate. LVN 2 stated she was unsure if she checked the resident's apical pulse prior to the medication administration. LVN 2 stated on [DATE] and [DATE] at 9 a.m. and 5 p.m., [MEDICATION NAME] was not administered to Resident 1 because his blood pressure was low. LVN 2 stated, The resident was on too many medications to lower his blood pressure. On [DATE] at 4:55 p.m., during an interview and concurrent record review of Resident 1's MAR for (MONTH) (YEAR), the Director of Nursing (DON) stated Resident 1 was not checked for OH on [DATE] as ordered. The DON stated that the nurses probably missed it.

Based on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 1) was free from unnecessary drugs. Resident 1, who had a history of [REDACTED]. The facility's nurses were also not following physician's orders [REDACTED]. and procedure regarding monitoring pain medication effectiveness. These failures resulted in Resident 1 exhibiting shortness of breath (SOB) and wheezing requiring an increase in respiratory treatments, and later resulted in Resident 1 requiring a steroid inhaler for the increased episodes in shortness of breath (SOB), wheezing, and a decrease in O2 saturation down to 75 percent ((% )normal reference range (NRR) is 95%-100%). Resident 1 was receiving large amounts of MS, without an adequate indication for its use and had the potential to result in addiction, respiratory depression, and the potential of the black boxed warning for a fatal (death) respiratory depression. Findings: A review of Resident 1's discharge summary from a general acute care hospital (GACH), for the resident's admission from 3/18/15-3/26/15, prior to his admission to this skilled nursing facility (SNF), indicated Resident 1 was not treated, during the GACH stay, for chronic pain with [MEDICATION NAME] sulfate (MS). A review of a Combined Home Medication and Inpatient Medication Reconciliation Order Form, indicated the nurse would list and clarify, as well as possible, the following medications reported as taken by the resident prior to admission. It stipulated the physician would indicate whether to continue the drug, note any changes, and sign the bottom. The form indicated, if no indication was made, the drug will not be continued without further orders. [MEDICATION NAME] Release (ER) tablet 100 milligram (mg) at 6 a.m. and 6 p.m., and MS Intermediate Release (IR) 15 mg orally whenever necessary (PRN) were listed, but was not checked to indicate to be continued. A review of Resident 1's GACH's discharge medication list did not include for Resident 1 to receive MS after discharge. A review of Resident 1's SNF Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED].(kg/m), a measurement obtained by dividing a person's weight by the square of the person's height). A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, with a reference date of 5/25/15, indicated the resident had the ability to understand and be understood with good memory recall. Under Sectional G/Functional Status, it indicated that the resident required extensive assistance in bed mobility, transferring, walking in the room, and all other activities of daily living (ADLs), except for eating, which the resident only required supervision. According to the MDS, the resident utilized a wheelchair for locomotion. A review of a type-written consult note, by a pain control physician, MD2, dated 4/7/15, indicated Resident 1 was complaining of severe pain in legs with tightness, but refused to take the [MEDICATION NAME] medication (a diuretic use to remove excess body fluid). MD2 documented the pain from Resident 1's legs was the result of [MEDICAL CONDITION] (an accumulation of excess fluid in body tissues) and MD2 also indicated there was a concern about Resident 1 receiving large doses of MS. MD2 documented under the Plan; discuss opiate tolerance (MS), dependence abuse, diversion and possibilities of addiction, although Resident 1 wished to continue the high doses of MS. MD2 changed the MS to [MEDICATION NAME] (an anti-[MEDICAL CONDITION] medication used to treat neuropathic pain (a result of damage to peripheral nerves, often causes weakness, numbness and pain)) 100 milligram (mg) three times a day. A review of Resident 1's physician's orders [REDACTED]. There was also an order [REDACTED]. The physician's orders [REDACTED]. According to the physician's orders [REDACTED]. On 5/19/15, the MS PRN order was increased again to MS IR 30 mg Q6 hours for breakthrough pain, in addition to the Q12 ATC 100 mg of MS. A review of Resident 1's Medication Administration Record [REDACTED]. MS IR 30 mg was given at 10 a.m., at 2 p.m. (within 4 hours), and at 9 p.m., without an adequate indication for its use, in addition, Resident 1 received the routine 100 mg of MS at 6 a.m. and 6 p.m., (for a total dose of 290 mg of MS within 15 hours on 7/1/15, from 6 a.m. to 9 p.m.). According to the physician's orders [REDACTED].) every four hours whenever necessary (PRN) for wheezing. Resident 1 received the respiratory treatment the following times: For May 2015, 7 PRN treatments were given for SOB For June 2015, 34 PRN treatments were given for SOB. For July 2015 (7/1-8, 2015), 2 PRN treatments were given for SOB/wheezing. A review of the physician's orders [REDACTED]. [REDACTED]. On 7/6/15 at 8:55 a.m., upon entering Resident 1's room, an O2 tank was observed by the resident's bed. During an interview, Resident 1 stated that he used the oxygen when he had problems with breathing. Resident 1 stated he had breathing problems because of his medical conditions of [MEDICAL CONDITION] and [MEDICAL CONDITION]. When Resident 1 was asked how staff monitored his oxygen levels, he stated, The last time they checked my oxygen saturation was over a month ago. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's Medication Administration Records (MAR) indicated the resident's oxygen saturation levels were documented as checked every day, on each shift, for the months of May, June, and July 2015. On 7/6/15 at 9:55 a.m., while in Resident 1's room, a licensed vocational nurse (LVN 1) was observed checking Resident 1's blood pressure (B/P) and O2 saturation measurements, prior to his medication administration. LVN 1 stated checking the resident's B/P and O2 saturation was necessary before the resident received his medications. During the observation, Resident 1 questioned LVN 1 why she was checking his oxygen saturation, because it had not been checked the day prior or in a long time. At approximately 10:05 a.m., on 7/6/15, once LVN 1 administered Resident 1's medication, she was interviewed outside the resident ' s room. LVN 1 stated she was Resident 1's nurse the day prior on 7/5/15. LVN 1 was asked if she checked Resident 1's O2 saturation on 7/5/15 and she stated, No, I did not check the resident's oxygen saturation, I'm sorry. However, a review of the MAR for 7/5/15 indicated LVN 1 documented a saturation percentage on the MAR indicated [REDACTED]. LVN 1 was shown the MAR for the month of 7/2015, which indicated she had signed several times indicating Resident 1's O2 saturation was 98%, although she did not check it. A review of a declaration written by LVN 1, dated 7/6/15, and a concurrent interview, indicated LVN 1 would sign Resident 1's MAR indicated [REDACTED]. LVN 1 stated she would write an oxygen percentage, although she did not check Resident 1's saturation. LVN 1 stated and wrote on the declaration that she understood the importance of checking Resident 1's O2 saturation as it related to the resident's [DIAGNOSES REDACTED]. LVN 1 concluded she was aware that MS can depress the resident ' s respiratory system. A review of Resident 1's MARs for the following months, indicated Resident 1 received the following amounts of MS, which included ATC and PRN: For May 2015: Resident 1 received 7,115 mg of MS. For June 2015: Resident 1 received 7,230 mg of MS. For July 2015 ((8 days) 7/1-7/8/15): Resident 1 received 1,960 mg of MS. Resident 1 received a total of 16, 305 mg of MS for 69 days. On 7/6/15 at 10:15 a.m., during an interview, LVN 2 stated, In the last three weeks the resident (Resident 1) had asked for the breathing treatments more, which the resident stated the [MEDICATION NAME] had been helping him a lot. LVN 2 stated Resident 1 refused [MEDICATION NAME] because it makes him have to urinate every 30 minutes and it was hard for the resident to get back from the patio, where he smokes all day, to his room. LVN 2 was asked about necessary documentation for Resident 1's PRN MS dosages and he stated he was never told he had to document the need for the PRN administration of the MS. LVN2 stated he would not write on the back of the MAR indicated [REDACTED]. LVN 2 stated he would only document on the back of the MAR indicated [REDACTED]. During a concurrent review of Resident 1's physician medication orders, LVN 2 stated, I do not see parameters for the PRN [MEDICATION NAME] on the physician's orders [REDACTED]. LVN 2 stated, When the resident (Resident 1) had pain in his arm I would give him the [MEDICATION NAME] for any general pain. We should notify the physician if we see PRN medication ([MEDICATION NAME]) given at the same time each day, because the physician may need to change the MS order. LVN 2 stated he was trained by (LVN 1) and that the entire facility's licensed nurses were trained to only document the PRN [MEDICATION NAME] medication administration on the Pain Assessment Flow Sheet and not on the back of the MAR indicated [REDACTED]. A review of the facility's policy, dated 8/4/07 and titled, Policy and Procedure Medication Administration Record [REDACTED] 1. All refused medications. 2. PRN medications, including results thereof (i.e. reason for giving PRN medication, effectiveness or ineffectiveness, etc.). 3. Initials written in error. 4. Others as deemed appropriate. The policy also stipulated the facility's director of nurses and/or pharmacy consultant shall conduct a review of the MARs on a monthly, and as needed basis, to determine adherence to documentation requirements of medication administration. A review of the facility's undated policy and procedure titled, Medication Ordering and Receipt, indicated, Upon receipt of a physician's orders [REDACTED]. Any medication order or dose that appears to be inappropriate considering the resident's age, condition or diagnosis, or identified allergies [REDACTED]. Medication orders specify the following : .(8) [DIAGNOSES REDACTED]. At 11:35 a.m., on 7/6/15, during an interview, LVN 1 was questioned about the MS 30 mg she gave twice on 7/1/15, before the physician's prescribed time. LVN 1 stated she did give the MS 30 mg at 10 a.m. and 2 p.m., instead of the prescribed PRN Q 6 hours. LVN 1 stated she did realize the physician ordered it to be given Q 6 hours and there was no new order to give it sooner than six hours prescribed time. LVN1 stated she should have called the physician to receive an order to give the MS 30 mg prior to the six hours. LVN 1 also stated since the order did not specify the type and/or location of pain, she gave Resident 1 MS 30 mg for any and all pain (i.e., complaint of arm pain). LVN 1 denied observing Resident 1 exhibiting any physical signs and symptoms of pain, such as grimacing, fidgeting, rubbing and/or massaging any painful area. On 7/7/15, at 10:24 a.m., a telephone interview was conducted with Resident 1's physician (MD1). MD 1 stated oxygen saturation monitoring was needed for the resident due to his known episodes of SOB. MD1 stated that Resident 1 recently had an episode of SOB with a drop in his O2 saturation to 75%, MD1 stated that was why it was important for him to know what Resident 1's O2 saturation levels were. A review of a Monthly Prescribing Reference (MPR), dated October 2015, indicated a major contraindication for MS use was respiratory depression, having a [DIAGNOSES REDACTED]. According to the MPR, under Warnings/Precautions for MS use, indicated an increased risk of fatal respiratory depression, abuse potential, especially when administering it routinely and an accidental exposure may result in a fatal overdose. It also indicated if the resident had a [MEDICAL CONDITION] disease, e.g. [MEDICAL CONDITION], to monitor closely for respiratory depression, which LVN 1 was falsely documenting Resident 1's O2 saturation as prescribed by the physician.

Based on observation, interview and record review the facility failed to provide the necessary care and services as stipulated in its policy and procedure, physician's orders [REDACTED]. 1. For Resident 2, the facility failed to accurately reassess, re-evaluate for the continued need of a routine narcotic pain medication ([MEDICATION NAME]) and document the resident's onset, level, duration of pain, and if any non-pharmacological interventions (relaxing techniques;music; deep breathing etc.) were provided to relieve Resident 2's pain, as stipulated in Resident 2's plan of care. Resident 2 was receiving [MEDICATION NAME] 50 milligrams (mg) three times a day (TID), a total of 4,500 mg every month for a total of three years, since 10/4/12, in addition to receiving other pain medications, such as [MEDICATION NAME] (a narcotic pain medication) 55/325 mg one tablet whenever necessary (PRN) for pain management of the resident's abdominal pain. Resident 2 was observed on several occasions (1/7/16 at 8:35 a.m., 1/8/16 at 8:55 a.m., and at 9:23 a.m.) being lethargic (inactive and slow), drowsy, and sleeping most of the day. Resident 2 was unable to engage in activities of daily living (ADL). 2. For Resident 3, the facility failed to re-evaluate the resident's ongoing need to receive [MEDICATION NAME] 50 mg two times a day (BID) for pain routinely since 10/2015. Resident 3 was observed drowsy and sleepy, with the inability to participate in ADLS, such as eating and hygienic care. These deficient practices resulted in Resident 2 exhibiting adverse consequences (abdominal pain/gas) from the long-term use of [MEDICATION NAME] without an adequate indication for its use. These deficient practices also resulted in a decline in their quality of life for both Residents 2 and 3, as exhibited by their drowsiness and inability to participate in ADLs. 3. Resident 19 had a physician's orders [REDACTED]. This deficient practice put Resident 19, who had risks for falls, at risk for falling from the bed and wheelchair. Findings: 1. A review of Resident 2's admission Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's [DIAGNOSES REDACTED]. for long-term nutrition), gastro-[MEDICAL CONDITION] reflux disease, (occurs when stomach acid or stomach content, flows back into your food pipe ) and dementia (a progressive loss of brain function affecting memory, thinking and behavior). A review of Resident 2's Minimum Data Set (MDS), an assessment and care screening tool, dated 12/4/15, indicated Resident 2 had severe cognitive (ability to think and reason) impairment with a clear speech, sometimes able to make needs known and/or understand others. According to the MDS, Resident 2 was totally dependent (full staff performance) requiring a one-person assist with bed mobility, eating and personal hygiene. The MDS indicated Resident 2 was sleeping a lot, felt tired and had little energy nearly every day (12 to 14 days during the assessment). On 1/5/16 at 4 p.m., during an initial tour of the facility, Resident 2 was observed sleeping with the GT feeding continuously infusing. On 1/6/16 at 8 a.m., and 1/7/16 at 8:35 a.m., Resident 2 was observed in her room sleeping. Resident 2 was approached and an attempt was made to wake-up the resident and speak loudly to her in her native language (Tagalog), but Resident 2 would open her eyes and go immediately back to sleep. On 1/8/16 at 8:55 a.m., during a concurrent interview and observation, Resident 2 was unable to be awakened by speaking loudly and touching the resident. The resident's name was called out loudly and she opened her eyes and pointed at her stomach gesturing she was having pain. Resident 2 did not speak, but went back to sleep. During an interview with a certified nursing assistant (CNA 10), who was Resident 2's primary care giver for over two years, stated she had often observed Resident 2 being so drowsy and sleepy. CNA 10 stated Resident 2 would stay awake for two to three hours during her shift (7 a.m. to 3 p.m.) and the resident would attend activities in the dining room from 9:30 am to 11:30 a.m., but slept during the activities. In a concurrent observation and interview, on 1/8/15 at 9:23 a.m., a registered nurse (RN 2) stated Resident 2 was still asleep and she was difficult to arouse, even with a loud voice and/or touching. RN 2 stated, This is her usual way, she was always sleepy and drowsy, but not lethargic. When she goes to activities, she would sleep, we put her there to wake her up, but most of the time she just wanted to be left in bed. On 1/8/15 at 9:40 a.m., during an interview, the facility's activity staff assistant stated Resident 2 attended activities, but was always drowsy and sleepy. On 1/8/16 at 4:20 p.m., during a concurrent interview and record review, the activity director (AD) stated Resident 2 sometimes goes to the activity, but usually just to watch the television. The AD stated if Resident 2 could not go to the activity room they would make in-room visits. However, a review of Resident 2's activity log from 9/2015 through 12/2015, indicated there was no documentation of activities provided to Resident 2, including in-room visits. A review of the physician's orders [REDACTED]. According to Resident 2's Medication Administration Record (MAR), Resident 2 received [MEDICATION NAME] 50 mg TID a day, for a total of 4,500 mg every month for over three years, since 10/4/12 to 1/7/16, in addition to [MEDICATION NAME] ordered whenever necessary (PRN) pain medication. The MAR also indicated Resident 2 received [MEDICATION NAME] when the resident's pain level was assessed and documented as 0/10. There were no documentation of Resident 2's location and onset of pain and/or if any non-pharmacological interventions were attempted or provided prior to and after [MEDICATION NAME] was administered as stipulated in the facility's policy and Resident 2's plan of care. On 1/12/16, at 1:40 p.m., in a concurrent interview and record review, a licensed vocational nurse (LVN 6) stated, Resident 2 was always complaining of abdominal pain while receiving [MEDICATION NAME] TID routinely. LVN 6 was asked where was Resident 2's documentation for a pain assessment such as the location, the onset of pain, and if any other interventions were provided to relieve Resident 2's pain, LVN 6 answered, We do not document anything on the MAR, except the pain level every shift because the medication was given routinely, if the pain was relieved by the end of the shift, then we document it as 0/10. We are supposed to document the pain assessment and interventions in the nursing progress notes. A review of the nurse's progress notes, from January 2015 through 1/7/16, indicated there was no documented pain assessment prior to and after the administration of [MEDICATION NAME]. According to Resident 2's plan of care, dated 12/26/15 and titled, Pain, as evident by decreased activity level, grimacing, restlessness, crying and calling out due to contributing condition that included abdominal pain. The staff's interventions included to perform a complete assessment, which included: monitor for level of consciousness; evaluate and document the nature and severity of pain; respond to interventions; and to monitor for side effects of the medications. A review of a plan of care for Resident 2, dated 12/20/16 and titled, Alteration in comfort secondary to abdominal pain, indicated the goal was to relieve the resident's pain. The staff's interventions included identifying pain location, quality, and onset. The care plan also indicated the staff would provide non-pharmacological interventions, such as relaxation techniques, guided imagery, deep breathing and proper positioning and to monitor the effectiveness. There was no documented evidence a non-pharmacological intervention was ever implemented. According to the facility's undated policy and procedure titled Administration of Pain Management, indicated the staff will document and report the side effects of medication to the physician, review the care plan to assess for special needs of the resident, assess and document the intensity of pain prior to administration of medication and one hour after the medication had been administered. The policy also stipulated the staff would implement non-pharmacological interventions and document the resident's response to and effectiveness of the pain medication in the resident's medical record. A review of the Consultant Pharmacist's Medication Regimen Review (MRR), dated from 1/2013 through 1/2016, there was no documented evidence the [MEDICATION NAME] 50 mg tablet TID was reviewed to be considered for dose reduction or discontinuation. There was also no documentation to indicate that other alternative measure or drug regimen was considered, since Resident 2 continued to complain of abdominal pain, which was a side effect and an adverse reaction of [MEDICATION NAME]. On 1/12/16 at 12:18 p.m., during a telephone interview, the pharmacy consultant stated, I reviewed Resident 2's drug regimen and I did not recommend any drug reduction for [MEDICATION NAME], because the nursing staff did not alert me of any adverse effects of [MEDICATION NAME] to the resident. The pharmacist was asked if he was aware that Resident 2 was lethargic and sleeping all the time. The pharmacist consultant stated, No, because I rely on the nursing evaluations. The pharmacist also stated he was not aware Resident 2 had been receiving [MEDICATION NAME] 50 mg TID for over three years with a pain level recorded as 0/10. According to the facility's policy and procedure, dated 2/23/15 and titled, Consultant Pharmacist, the consultant pharmacist job entailed to review the drug regimen for every resident at least monthly and identify inappropriate and unnecessary drugs. A review of the physician's progress notes and the interdisciplinary team ((IDT) a team of facility's staff in charge of the residents' care planning) progress notes, dated January 2015 through 2016, there was no documentation of the reason for Resident 2's continued use of [MEDICATION NAME] 50 mg TID via GT for pain management every day. On 1/12/16 at 1 p.m., during an interview, Resident 2's physician stated Resident 2 always complained of back pain and stomach pain. The physician stated multiple tests had been done to rule out the cause of Resident 2's stomach pain, but the results were negative. The physician was asked if there was any documentation in the physician ' s progress or the IDT progress notes to indicate Resident 2's need for the continuous administration of [MEDICATION NAME] 50 mg since 10/4/12 to the present. The physician stated, Yes, I think we were wrong on that part, we should have reduced the dose of [MEDICATION NAME] to see how she would respond. We should have reassessed and documented her response. A review of the National Institute of Health (NIH) the common side effects of [MEDICATION NAME], included dizziness, weakness, sleepiness, heartburn, indigestion, [MEDICATION NAME] abdomen with stomach pains. According to the NIH, the symptoms of [MEDICATION NAME] overdose included extreme drowsiness and muscle weakness. A review of Resident 2's Radiology Report results indicated the following: On 6/3/13, an abdominal ultrasound was performed due to Resident 2's complain of abdominal pain. The results indicated the pancreas could not be seen clearly due to bowel gas. On 4/10/14, a repeated abdominal ultrasound was done due to Resident 2's continuous complain of abdominal pain. The results indicated the pancreas and aorta could not be visualized due to overlying bowel gas. According to the above ultrasounds, there was excessive bowel gas present in Resident 2's abdomen, which is a common side effect of [MEDICATION NAME] according to the NIH. There was no documentation in Resident 2's clinical record to indicate the facility assessed Resident 2 for other side effects and/or overdose symptoms of [MEDICATION NAME] as listed above. 2. A review of the Resident 3's Admission Face Sheet indicated the resident was admitted to the facility 10/30/15. Resident 3's [DIAGNOSES REDACTED]. A review of a Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/26/15, indicated Resident 3 was able to understand others and make needs known. According to the MDS, Resident 3 had no cognitive impairment, but required total assistance (resident dependent with staff for assistance) with bed mobility, transferring, walking, hygiene, and dressing. On 1/6/16 at 7:45 a.m., Resident 3 was observed drowsy with eyes closed. Resident 3 was heard saying repeatedly, I don't want anymore, while being fed by CNA 9. At 2 p.m., on 1/6/16, Resident 3 was observed sleeping in bed. In an interview, LVN 1 stated, The resident complains of pain to the left foot and receives [MEDICATION NAME] BID routinely and Tylenol (non-narcotic pain medication) PRN. When LVN 1 was asked where she documented Resident 3's pain assessment and interventions provided before and after the pain medication was given. LVN 1 stated, If the pain medication is given routinely then we do not document a pain assessment on the MAR, because it is part of the pain management. But it should be documented in the nursing notes. A review of nursing progress notes, from November 1, 2015 through January 6, 2016, indicated Resident 2 had a pain scale of 0/10, there was no documentation of Resident 2's location of pain, onset, and/or if any interventions were provided to the resident before and after the [MEDICATION NAME] was given. There was also no documented reason why Resident 3, required Tylenol, in addition to concurrently receiving [MEDICATION NAME]. A review of physician's orders [REDACTED]. According to Resident 3's MARs, from 10/2016 through 1/6/16, Resident 3 had a pain level of 0/10 assessed and documented every shift. However, Resident 3 continued to receive [MEDICATION NAME] BID every day. A review of Resident 3's plan of care, dated 12/12/15 and titled, Pain, as evidenced by decreased activity level, grimacing, restlessness, crying and calling out, increased confusion and/or disorientation. The staff's interventions included to perform a complete assessment, monitor for level of consciousness, evaluate and document the nature and severity of pain and response to interventions and monitor for side effects of medication. On 1/12/15 at 2:30 p.m., in a concurrent interview and record review of the pain assessment form used by the facility, the director of nursing (DON) stated, The staff should document the pain level before and one hour after the pain medication is given, including the location, onset, and if any non-pharmacological intervention provided to the resident. The nurses were supposed to document the pain assessment in the nursing progress notes too. The DON continued, The staff is not documenting the pain assessment on the MAR because the medication was given as routine. I will make a new pain assessment form right now that the staff can use to document the pain assessment for pain medications given routinely or as needed. I also told them to get an order from the doctor to hold the pain medication if a resident was too sleepy or drowsy. According to the facility's undated policy and procedure titled, Administration of Pain Management, the staff will document and report the side effects of medication to the physician, will review the care plan to assess for special needs of the resident, assess and document the intensity of pain prior to administration of medication and one hour after the medication had been administered. The policy also stipulated the staff would implement non-pharmacological interventions and document the resident's response and the effectiveness of the pain medication in the resident's medical record. 3. A review of Resident 19's Admission Face Sheet Record, indicated was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 19's [DIAGNOSES REDACTED]. A review of Resident 19's Minimum Data Set (MDS), a resident assessment and screening tool, dated 12/10/15, indicated Resident 19 had short and long-term memory problems, poor in decision-making skills and required cues and supervision. According to the MDS, Resident 19 was totally dependent on staff with bed mobility transferring, dressing, eating, toilet use, and personal hygiene. A review of Resident 19's physician orders, dated 6/16/15, indicated the resident may have a tab alarm while in bed and the wheelchair to alert the staff when Resident 19 was getting up unassisted related poor safety awareness, poor trunk control, generalized muscle weakness, gait instability and cognitive impairment. The physician's orders [REDACTED]. During several observations on 1/7/16 at 9:10 a.m., 1/8/16 at 10:20 a.m., and on 1/11/16 at 9:38 a.m., Resident 19 was sitting on a slightly reclined wheelchair in the dining room without a tab alarm, as prescribed by the physician. On 1/7/16 at 9:15 a.m., during an interview, CNA 9 stated, This is the resident's (Resident 19) assigned wheelchair. On 1/8/16 at 9:55 a.m., the activity assistant stated, The resident's wheelchair was reclined so the resident doesn't fall. At 10:25 a.m., on 1/8/16, a licensed vocational nurse (LVN 5) stated Resident 19 cannot get up on his own and the wheelchair was tilted a bit because Resident 19 has a tendency to lean forward and fall. I think the reclined wheelchair was a restraint because it prevents him from leaning forward and fall. On 1/8/16 at 12:04 p.m., during an interview, a registered nurse (RN 2) stated, We don't have any restraints here in the facility. The resident (Resident 19) uses a tab alarm in bed and in the wheelchair. When the resident (Resident 19) tries to lean forward, the reclined wheelchair would prevent him from leaning forward and falling. However, upon a record review with the RN supervisor there was no order for the wheelchair to be reclined and there was no plan of care for the reclining wheelchair to prevent Resident 19 from leaning and moving forward. The facility failed to implement the physician's orders [REDACTED]. At 10:20 a.m., on 1/11/16, during an interview, a licensed vocational nurse (LVN 11), stated Resident 19 should have a tab alarm on the bed and while up in the wheelchair, because the nurses sign the Medication Administration Record (MAR) to indicate it was in place. LVN 11 observed Resident 19's wheelchair and saw that the tab alarm was not intact, as the physician prescribed. On 1/11/16 at 10:25 a.m., during an interview, the DON stated Resident 19 wheelchair was slightly reclined and that was how it was designed. The DON stated, It was better for the resident to use the reclining wheelchair because of the tendency for him to lean forward and risk for falls due to poor trunk control and poor cognition. During a record review there was no care plan for the use of the reclined wheelchair.

Based on observation, interview, and record review, the facility failed to ensure two of 24 sampled residents (Residents 2 and 3) were free of unnecessary drugs, due to excessive duration, without monitoring and an adequate indication for its use and in the presence of adverse consequences (Cross reference to F309 and F428). 1. Resident 2 was receiving [MEDICATION NAME] (narcotic pain medication) 50 milligrams (mg) three times a day (TID) routinely, totaling 4,500 mg every month for a total of three years since 10/4/12 (excessive duration). In addition, Resident 2 had a PRN (whenever necessary) order to receive [MEDICATION NAME] (narcotic pain medication) for management of abdominal pain. The staff failed to monitor or re-evaluate the need of the continued use of the narcotic medications without an adequate indication for its use in the presence of adverse consequences of abdominal pain and drowsiness. 2. Resident 3 was receiving [MEDICATION NAME] 50 mg two times a day (BID) routinely for over two months for pain since 10/2015, without an adequate indication for its use. There was also no monitoring of pain assessment for the continued use. Resident 3 was unable to participate in activities of daily living (ADLs), such group activities and involvement in care. These failures resulted in Residents 2 and 3 receiving unnecessary drugs, without an ongoing assessment and re-evaluation of the need, in the presence of adverse consequences of side effects of [MEDICATION NAME] for Resident 2, of abdominal pain. Both Residents 2 and 3 had a decreased quality of life due to an inability to engage in ADLs, such as group activities or involvement in care and had the potential to result in an overdose of [MEDICATION NAME]. Findings: 1. A review of Resident 2's admission Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Resident 2's [DIAGNOSES REDACTED]., gastro-[MEDICAL CONDITION] reflux disease (occurs when stomach acid or stomach content, flows back into your food pipe), and dementia (a progressive loss of brain function affecting memory, thinking and behavior). A review of Resident 2's Minimum Data Set (MDS), an assessment and care screening tool, dated 12/4/15, indicated Resident 2 had severe cognitive (ability to think and reason) impairment with a clear speech, sometimes able to make needs known and/or understand others. According to the MDS, Resident 2 was totally dependent (full staff performance) requiring a one-person assist with bed mobility, eating and personal hygiene. The MDS indicated Resident 2 was sleeping too much, felt tired, and had little energy nearly every day. On 1/5/16 at 4 p.m., during an initial tour of the facility, Resident 2 was observed in bed sleeping. On 1/6/16 at 8 a.m. and 1/7/16 at 8:35 a.m., Resident 2 was observed in her room sleeping. Resident 2 was approached and an attempt was made to wake-up Resident 2, by talking loudly in the resident's native language (Tagalog), but Resident 2 would only open her eyes and immediately went back to sleep. On 1/8/16 at 8:55 a.m., during a concurrent interview and observation, Resident 2 was unable to be awakened by speaking loudly and/or touching the resident. During an interview, a certified nursing assistant (CNA 10), who was Resident 2's primary care giver for over two years, stated she had often observed Resident 2 being drowsy and sleepy. CNA 10 stated Resident 2 would only stay awake for two to three hours during her shift (7 a.m. to 3 p.m.). In a concurrent observation and interview, on 1/8/15 at 9:23 a.m., a licensed vocational nurse (LVN 6) stated Resident 2 was still asleep and she was difficult to arouse. LVN 6 stated, This is her usual, she was always sleepy and drowsy. A review of the physician's orders [REDACTED]. According to Resident 2's Medication Administration Records (MARs), Resident 2 received [MEDICATION NAME] 50 mg TID a day, for a total of 4,500 mg every month for over three years, since 10/4/12 to 1/7/16, in addition to other pain medications. The MARs also indicated Resident 2 received [MEDICATION NAME] when the residents pain level was assessed and documented as 0/10. There was no documentation of Resident 2's location and onset of pain and/or if any non-pharmacological interventions were attempted by the staff or provided prior to and after [MEDICATION NAME] was administered, as stipulated in the facility's policy titled, Administration of Pain Management, and Resident 2's plan of care. On 1/12/16, at 1:40 p.m., in a concurrent interview and record review, LVN 7 stated, Resident 2 was always complaining of abdominal pain while receiving [MEDICATION NAME] TID routinely. LVN 7 was asked if Resident 2's pain was assessed, such as the location, onset, and if any other interventions were provided to relieve Resident 2's pain. LVN 7 stated, We do not document anything on the MAR, except the pain levels every shift, because the medication was given routinely. LVN 7 stated if Resident 2's pain was relieved by the end of the shift, then we document it as 0/10. We are supposed to document the pain assessment and interventions in the nursing progress notes. A review of the nurse's progress notes, from January 2015 through 1/7/16, indicated there was no documented pain assessment for Resident 2 prior to and after the administration of [MEDICATION NAME]. According to Resident 2's plan of care, dated 12/26/15, and titled, Pain, as evident by decreased activity level, grimacing, restlessness, crying and calling out due to a contributing condition of abdominal pain. The staff's interventions included to perform a complete assessment, which included: monitor for level of consciousness; evaluate and document the nature and severity of pain; response to interventions; and to monitor for side effects of the medications. There was no documented evidence the facility's staff was implementing this care plan for Resident 2. A review of a Consultant Pharmacist's Medication Regimen Reviews (MRR), from 1/2013 through 1/2016, there was no documented evidence Resident 2's routine [MEDICATION NAME] 50 mg tablet TID was reviewed to be considered for dose reduction or discontinuation. There was also no documentation to indicate that other alternative measures or drug regimens were considered, especially since Resident 2 continued to complain of abdominal pain, which was a side effect and adverse reaction of [MEDICATION NAME], as indicated by the National Institute of Health (NIH). On 1/12/16 at 12:18 p.m., during a telephone interview, the pharmacist consultant stated, I reviewed the resident's (Resident 2) drug regimen and I did not recommend any drug reduction for [MEDICATION NAME], because the nursing staff did not alert me of any adverse effects of the [MEDICATION NAME] to the resident. The pharmacist was asked if he was aware that Resident 2 was lethargic and sleeping all the time. The pharmacist consultant stated, No, because I rely on the nursing evaluations. The pharmacist also stated he was not aware Resident 2 had been receiving [MEDICATION NAME] 50 mg TID for over three years with a pain level recorded as 0/10. According to the facility's policy and procedure, dated 2/23/15, and titled, Consultant Pharmacist, the consultant pharmacist job entailed to review the drug regimen for every resident at least monthly and identify inappropriate and unnecessary drugs. A review of the physician's progress notes and the interdisciplinary team ((IDT) a team involved in overseeing a resident's plan of care) progress notes, dated January 2015 through January 2016, there was no documentation of the reason for Resident 2's continued routine use of [MEDICATION NAME] 50 mg TID via GT for pain management every day. On 1/12/16 at 1 p.m., during a face to face interview, Resident 2's physician stated Resident 2 always complained of back and stomach pain. The physician stated multiple tests had been done to rule out the cause of Resident 2's stomach pain, but the results were negative. The physician was asked if there was any documentation in the physician's progress or the IDT progress notes to indicate Resident 2's need for the continuous administration of [MEDICATION NAME] 50 mg since 10/4/12 to the present. The physician stated, Yes, I think we were wrong on that part, we should have reduced the dose of [MEDICATION NAME] to see how she (Resident 2) would respond, reassessed and documented her response. A review of the National Institute of Health (NIH) indicated the most common side effects of [MEDICATION NAME], included weakness, sleepiness, indigestion, and [MEDICATION NAME] abdomen with stomach pain. According to the NIH, the symptoms of [MEDICATION NAME] overdose included extreme drowsiness and muscle weakness. All of which Resident 2 was exhibiting according to observation, interviews with staff, and review of Resident 2's clinical record. A review of Resident 2's Radiology Report results, dated 6/3/13 and 4/10/14, indicated abdominal ultrasounds were performed due to Resident 2's continuous complaint of abdominal pain. The results indicated the resident's pancreas could not be seen clearly due to bowel gas and the pancreas and aorta could not be visualized due to overlying bowel gas, respectively. According to Resident 2's ultrasounds, there was excessive bowel gas present in Resident 2's abdomen, which was a common side effect of [MEDICATION NAME] according to the NIH. There was no documentation in Resident 2's clinical record to indicate Resident 2's stomach pain with gas was associated as an adverse reaction to the resident's use of [MEDICATION NAME]. There was no indication the facility assessed Resident 2 for these side effects or others and/or overdose symptoms of [MEDICATION NAME] as listed above. 2. A review of the Resident 3's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 3's [DIAGNOSES REDACTED]. A review of Resident 3's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/26/15, indicated Resident 3 was able to understand others and make needs known. According to the MDS, Resident 3 had no cognitive impairment, but required total assistance (resident dependent on staff for assistance) with bed mobility, transferring, walking, hygiene, and dressing. On 1/6/16 at 7:45 a.m., Resident 3 was observed being fed while drowsy with eyes closed. Resident 3 was heard saying repeatedly, I don't want anymore, while continuing to be fed by CNA 9. A review of a physician's orders [REDACTED]. At 2 p.m., on 1/6/16, Resident 3 was observed sleeping in bed. In an interview, LVN 1 stated, The resident complains of pain to the left foot and receives [MEDICATION NAME] BID routinely and Tylenol (non-narcotic pain medication) PRN. LVN 1 was asked did she document Resident 3's pain assessment and interventions provided before and after the pain medication was given. LVN 1 stated, If the pain medication is given routinely then we do not document a pain assessment on the MAR, because it is part of the pain management. But it should be documented in the nursing notes. A review of Resident 3's MARs, from 10/2015 through 1/6/16, Resident 3 had a pain level of 0/10 assessed and documented every shift. According to the MARS, Resident 3 continued to receive [MEDICATION NAME] BID every day. A review of Resident 3's plan of care, dated 12/12/15, and titled, Pain, as evidenced by decreased activity level, grimacing, restlessness, crying and calling out, increased confusion and/or disorientation. The staff's interventions included to perform a complete assessment, monitor for level of consciousness, evaluate and document the nature and the severity of pain. The care plan also indicated to evaluate the resident's response to interventions and monitor for side effects of medication. According to the facility's undated policy and procedure titled, Administration of Pain Management, the staff will document and report the side effects of medication to the physician, will review the care plan to assess for special needs of the resident, assess and document the intensity of pain prior to administration of medication, and one hour after the medication had been administered. The policy also stipulated the staff would implement non-pharmacological interventions and document the resident's response and the effectiveness of the pain medication in the resident's medical record. There was no documented evidence the facility's staff was adhering to this policy for Residents 2 and 3.

Based on interview and record review, the facility failed to ensure Resident 1, who was assessed at risk for elopement (leaving without notice or permission), received adequate supervision by not monitoring his whereabouts and observing his activities when out of bed according to the plan of care, by not checking the resident every two hours and observing him for safety according to the facility's policy and procedure, and by not ensuring the alarm system, that alerted staff when someone exited the front door, was on. On [DATE], Resident 1 eloped from the facility using his wheelchair for locomotion and was found outside a convenient store which was 0.37 miles away from the facility. The resident was found sitting in his wheelchair with a trauma to his forehead and unresponsive. This deficient practice resulted in the resident sustaining a head injury and was pronounced dead on [DATE]. Findings: On [DATE], an unannounced visit was conducted to investigate an entity reported incident regarding Resident 1 who eloped from the facility and sustained a fatal (deadly) fall. On [DATE], a review of the clinical record revealed the resident was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. The resident was self-responsible. The admission Minimum Data Set (MDS - standardized assessment and care planning tool) dated [DATE], indicated the resident was alert, able to understand others and make his needs known, required limited assistance with one person physical assist in locomotion on and off the unit and needed extensive assistance in activities of daily living (ADLs) which included walking in room and corridor. An Elopement Risk assessment dated [DATE], indicated the resident had a score of 15, a total score of 9 to 16 represented some risk for elopement. A care plan was developed on [DATE], for the potential risk of elopement related to the elopement risk score of 15, included goals for the resident to remain in the facility and to maintain safe and independent mobility in a restraint-free environment. The interventions included monitoring his whereabouts, but the frequency of the monitoring was not indicated. A Fall Risk Assessment completed on [DATE], documented the resident had a score of 13 which represented high risk for potential falls. A plan of care developed on [DATE], for the resident's risk for falls and associated injury, had a goal for the resident not to have falls. The approach plan included visual checks and monitoring at least every shift; observing the resident's activities when out of bed and observing the resident's ambulation/gait balance and stability. A physician's orders [REDACTED]. A review of an interdisciplinary team (IDT) note dated [DATE], timed at 2:20 p.m., and signed by the director of nursing (DON), revealed Family Member 1 called the facility asking if the resident was appropriate for discharge since the resident had called her to pick him up from the facility. The DON informed Family Member 1 the resident was not appropriate for discharge because of his condition; that he was still receiving therapy because his gait was unsteady and his behavior was not stable because he was still aggressive and had episodes of striking out at staff members. A Nurse's Notes dated [DATE], timed at 3 a.m., documented by Licensed Vocational Nurse 1 (LVN 1) indicated Certified Nursing Assistant 1 (CNA 1) reported the resident was not in his room, that she searched inside and outside the facility premises but the resident was not found. At 3:30 a.m., LVN 1 further documented that Registered Nurse (RN) supervisor 1 (RN 1) was informed and after further unsuccessful searching for the resident, the RN supervisor asked CNA 1 and LVN 1 to go beyond the facility to look for the resident. LVN 1 documented on [DATE], timed at 4:05 a.m., the resident was found outside a convenient store, by a phone booth, sitting in a wheelchair with blood on his forehead and RN 1 was called. Another nursing note entry by RN 1 timed at 4:11 a.m., indicated the resident was found outside a store sitting in the wheelchair, unresponsive and with blood on the forehead and LVN 1 asked her to go to the location to assess the resident. RN 1 documented at 4:15 a.m., she assessed the resident who had blood on his forehead and a weak pulse. The resident did not wake up and at 4:19 a.m., paramedics (911) were called and arrived with the police at 4:25 a.m. The clinical record also included a document from the County of Los Angeles, Department of Coroner dated [DATE], and signed by the coroner investigator, indicating the Los Angeles County Coroner was conducting an investigation into the death of the decedent (deceased ). The date of death was [DATE]. According to the facility's investigation report, CNA 1 saw the resident sitting on the sofa at the front lobby on [DATE], at 11:30 p.m., but did not see the resident after that time. Laundry Worker 1 saw the resident crossing the street and going towards a convenient store on [DATE], between 3:20 a.m. and 3:30 a.m. After entering the facility, when Laundry Worker 1 learned the staff members were looking for the resident, at approximately 3:45 a.m., she reported seeing the resident. According to http://maps.yahoo.com, the distance between the facility and the convenient store was 0.37 miles. The facility's investigation report further documented LVN 1 and CNA 1 found the resident on [DATE], between 4:02 a.m. and 4:06 a.m. outside a convenient store sitting in the wheelchair near a phone booth. LVN 1 noticed a small amount of blood on the resident's forehead. She checked the resident's carotid artery (the artery that supply blood to the head and neck) and felt a weak pulse. She tried to palpate the radial pulse also, but was unable to feel the pulse because the resident's hand was cold. While performing the assessment, LVN 1 was on the telephone reporting to the night shift supervisor, RN 1, the resident's condition. At 4:15 a.m., RN 1 arrived at the location, assessed the resident as unresponsive and having a weak pulse. RN 1 called 911 emergency services. The paramedics arrived at approximately 4:25 a.m. and pronounced the resident asystole (having no cardiac/heart electrical activity) at approximately 4:30 a.m. The facility's investigation report, further indicated a police officer informed LVN 1 that the store's surveillance camera showed the resident was sitting in his wheelchair outside the convenient store at approximately 1:30 a.m. The resident was pushing his wheelchair towards the direction of the phone booth and fell forward, hitting his forehead on the ground. The police officer informed LVN 1 the cashier from the convenient store helped the resident back to his wheelchair and left him outside. On [DATE], at 3 p.m., during an interview, the director of nursing stated the facility had an alarm system and a one-way door lock system on the front lobby door to ensure the safety of the residents at night. The DON explained once the front door was locked, people from the outside could not go inside the facility, but people from the inside of the facility could still exit. If a resident or staff attempted to exit the facility, the alarm would be activated. The DON explained a key was needed to activate and de-activate the alarm. The DON also stated staff members did not hear the alarm sounding off when the resident left the facility. The DON further indicated he tested the alarm at 5 a.m. and the alarm was working. The DON could not explain why the alarm was not heard by the staff working the 11 p.m. to 7 a.m. shift on [DATE]. On [DATE], at 2:05 p.m., during another interview, the DON confirmed on [DATE], he spoke with Family Member 1 and explained to her the resident was not safe to go out of the facility because of his aggressive behavior. On [DATE], at 2:45 p.m., the DON stated the licensed nurses and the CNAs had to make rounds to check the residents every two hours. The DON could not explain why the resident was not checked for 3. 5 hours (from 11:30 p.m. to 3 a.m.). On [DATE], at 4:10 p.m., during a telephone interview, RN 1 stated the alarm on the front door was to be activated at about 12 midnight after all the evening shift staff members leave the building. RN 1 stated once the front door was secured, RN 1 explained the people from the outside could not enter the facility. However, the people from the inside of the facility could still exit, but the alarm would be activated. RN 1 stated LVN 1 was to turn on the alarm and secure the front door on [DATE]. RN 1 further stated she did not hear the alarm during the shift. RN 1 explained the only way to stop the alarm from activating was for a staff member to physically go to the front lobby door and de-activate the alarm by using a key. Six attempts were made to contact LVN 1 but there was no answer and messages were not returned. LVN 1 was no longer working in the facility since [DATE], after giving a verbal resignation. A review of the facility's policy and procedure titled "Rounds, Licensed Staff," revised on [DATE], indicated the residents will be checked by the nursing staff a minimum of every two hours and to observe the resident for privacy, dignity, and safety. On [DATE], at 10: 45 a.m., during an interview, the DON stated the facility staff had been told to perform rounds every two hours or sometimes every one and a half hours if the resident had special needs. On [DATE], at 12 p.m., during an interview, the director of staff development (DSD) stated the CNAs were instructed to check the residents every one hour and a half (1.5) to a maximum of two hours.