Every finding on record at Menifee Lakes Post Acute

Based on interview, and record review, the facility failed to ensure legal documents were signed by the agent listed in the power of attorney, (POA - a legal document that lets one person (the principal) give another person (the agent) the authority to make decisions or take actions on their behalf), for one of five residents, (Resident 2).This failure had the potential for care or treatment decisions to be made without the legally authorized person. Findings:On [DATE], at 10:04 a.m., an unannounced visit to the facility to follow up on two linked complaints was initiated.A review of Resident 2's medical records indicated resident was admitted on [DATE], with diagnoses of pressure ulcer injury, (injury to skin and underlying tissue resulting from prolonged pressure on the skin), deep tissue injury, (Persistent non-blanchable deep red, maroon, or purple discoloration of intact or non-intact skin Pain and temperature change often precede skin color changes Results from intense and prolonged pressure and shear forces at the bone-muscle interface), depression, (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia, (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), peripheral vascular disease, (PVD - is a slow and progressive circulation disorder), diabetes mellitus type 2, (a chronic condition that affects the way the body uses sugar. The body either resists the effects of insulin - a hormone that regulates the movement of sugar into the cells - or doesn't produce enough insulin to maintain normal sugar levels), spondylosis without myelopathy or radiculopathy, (age-related wear and tear of the spine that causes local stiffness or ache without pressing on the spinal cord (myelopathy) or pinching individual nerve roots (radiculopathy)), cervical, (neck), region, and Myelodysplastic syndrome, (MDS - is a group of blood cancers where the bone marrow fails to make enough healthy blood cells, leading to abnormal, immature cells and low blood counts).A review of Resident 2's History and Physical dated [DATE], indicated resident was alert and oriented x 3 (person, place, and time).A review of Resident 2's Brief Interview for Mental Status, (BIMS - a brief screener that aids in detecting cognitive impairment), indicated a score of 08 (moderate cognitive impairment).On [DATE], at 10:34 a.m., an interview was conducted with Registered Nurse, (RN 2). RN 2 stated that Resident 2 had a BIMS score of 08 to 09, which indicated that Resident 2 had moderate cognitive impairment. RN 2 stated that Resident 2 had a POA, and the agent was (name of agent). RN 2 stated that all legal documents and information regarding Resident 2's medical conditions would go through Resident 2's agent. RN 2 confirmed that the facility's Consent to Treat would need to be signed by Resident 2's agent.On [DATE], at 10:58 a.m., an interview and concurrent record review was conducted with the Medical Record Director, (MRD). Resident 2's Advance Health Care Directive Form dated [DATE], indicated Agent for Resident 2. Consent for Treatment dated [DATE], indicated the document was signed by Resident 2. The MRD confirmed that Resident 2 had an agent for making health care decisions and that Resident 2 signed the Consent for Treatment on [DATE], and confirmed that the agent should have signed the document.On [DATE], at 12:48 p.m., an interview was attempted with Resident 2. Resident 2 was unable to answer questions regarding the POA, or who her agent was. On [DATE], at 12:55 p.m., an interview was conducted with Licensed Vocational Nurse, (LVN 3). LVN 3 stated that he was familiar with Resident 2 as Resident 2 was able to make her needs known. LVN 3 confirmed that Resident 2's agent should have signed any agreements or legal documents pertaining to Resident 2's care.On [DATE], at 1:04 p.m., a concurrent interview and record review was conducted with the facility's Director of Nursing, (DON). The DON reviewed Resident 2's Physician Orders for Life-Sustaining Treatment, (POLST - a form that consists of a set of medical orders to address a limited number of critical medical decisions), dated [DATE], indicated that Resident 2 had signed the document and confirmed that the POLST should have been signed by Resident 2's agent. The DON stated that if the agent was not available the facility staff would get verbal consent with the agent by phone with two witnesses. The DON confirmed that Resident 2's documents should have been signed by the residents' agent and were not.A record review of Resident 2's Advance Health Care Directive Form dated [DATE], indicated that .Resident 2 designated the agent to make medical care decisions for her.Part 2 Instructions for Health Care 2.1 End-Of-Life Decisions: I direct that my health care providers and others involved in my care provide, withhold, or withdraw treatment in accordance with the choice I have marked below (a) Choice Not to Prolong Life. I do not want my life prolonged if (1) I have an incurable and irreversible disease that will result in my death within a relatively short time, (2) become unconscious and to a reasonable degree of medical certainty, I will not regain consciousness or (3) the likely risks and burdens of treatment would outweigh the expected benefits.A review of Resident 2's Physician Orders for Life-Sustaining Treatment (POLST) dated [DATE], indicated .A. Cardiopulmonary Resuscitation (CPR) If patient has no pulse and is not breathing Attempt Resuscitation/CPR. B. Medical Interventions If patient is found with a pulse and or is breathing Full Treatment - primary goal of prolonging life by all medically effective means.In addition to treatment described in Selective Treatment and Comfort-Focused Treatment, use intubation, advanced airway interventions, mechanical ventilation, and cardioversion as indicated. Signature of Patient or Legally Recognized Decisionmaker.By signing this form, the legally recognized decisionmaker acknowledges that this request regarding resuscitative measures is consistent with the known desires of and with the best interest of the subject of this form.Print name contains the signature of Resident 2.Relationship (write self if patient) Self is documented.A review of Resident 2's Consent for Treatment dated [DATE], indicated .By signing this Agreement, the resident consents* to the Facility providing routine nursing, rehabilitation and emergency care as directed by the attending physician, if applicable. From time to time, the Facility may participate in training programs for persons who seek licensure or certification as health care workers. In the course of the participation, care may be rendered to the Resident by such trainees under supervision as required by law. Consent to routine nursing care provided by the Facility shall include consent for care by such trainees. was signed by Resident 2.A review of the facility's policy and procedure titled Residents' Rights Regarding Treatment and Advance Directives revised [DATE], indicated . 1. On admission, the facility will determine if the resident has executed an advance directive. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff. The facility will periodically assess the resident for decision-making abilities and approach the health care proxy or legal representative if the resident is determined not to have decision making capacities. 5. The facility will identify or arrange for an appropriate representative for the resident to serve as primary decision maker if the resident is assessed as unable to make relevant health care decisions. The facility will define and clarify medical issues and present them to the resident or legal representative as appropriate. 7. During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make any changes related to any advance directives.

Based on interview and record review, the facility failed to ensure best practices for medication administration were followed for one of four residents, (Resident 1), when Nadolol, (medication used to treat high blood pressure), 40 mg, (milligrams), two tablets were prepared on June 20, 2026, for the 9 a.m. dosage, the systolic blood pressure, (the top number in a blood pressure reading that measures the maximum force of blood pushing against the artery walls when the heart beats and pumps blood), was taken on Resident 1, was below 110. The medication was held and disposed of in the incinerator. There was no documented evidence of the disposal. This failure caused unneeded medication waste and inaccurate documentation.Findings:On July 21, 2026, at 11:36 a.m., an unannounced visit to the facility for four complaints was initiated. A review of Resident 1's medical records indicated resident was admitted on [DATE], and discharged on July 2, 2026, with diagnoses of abdominal aortic aneurysm, without rupture, (AAA - a procedure to fix a dangerous bulge in the aorta-the body's main artery-running through the abdomen, preventing the weakened artery from rupturing. Repairs are done either via a traditional open incision or minimally invasively using stents), encounter for attention to ileostomy, (a surgical operation that creates an opening called a stoma on the belly wall. It connects the final part of the small intestine (the ileum) to the outside of the body so waste can leave without passing through the colon), diabetes mellitus type 2, (a chronic condition that affects the way the body uses sugar. The body either resists the effects of insulin - a hormone that regulates the movement of sugar into the cells - or doesn't produce enough insulin to maintain normal sugar levels), COPD (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and chronic kidney disease, (the gradual loss of kidney's ability to filter wastes and excess fluids from the blood). A review of Resident 1's History and Physical dated June 15, 2026, indicated resident had decision making capacity.A review of Resident 1's Medication Disposition Record/Pass Log indicated 28 tablets of Nadolol 40 mg were dispensed on June 15, 2026, Quantity of 14 tablets were disposed on June 23, 2026.On July 30, 2026, at 3:41 p.m., a telephone interview was conducted with the DON. The DON stated that Resident 1 had an order for Nadolol 40 mg, (milligrams), and two tablets every day. The DON confirmed that the dosage was to be held if systolic blood pressure was less than 110, and or heart rate less than 60. The DON stated that Resident 1 received the Nadolol two tablets on June 15th to June 19th, and June 22nd, 2026. The DON stated that on June 20th and June 21st the dosage was held due to the blood pressure being out of range. The DON confirmed there should have been 16 tablets left. The DON stated that on June 20, 2026, the Licensed Vocational Nurse (LVN 3), had reviewed the medication order, for Resident 1, the medication was removed from the bubble pack and placed into a medication cup, took Resident 1's blood pressure, and held the medications. The DON stated that LVN 3 disposed of the unused Nadolol 40 mg. two tablets in the incinerator. The DON stated that there was no documentation for the two wasted tablets. On July 31, 2026, at 5:57 a.m., a telephone interview was conducted with Licensed Vocational Nurse, (LVN 4). LVN 4 stated that on June 20, 2026, she prepared Resident 1's Nadolol 40 mg, two tablets. LVN 4 stated that she brought the medication to the bedside, checked Resident 1's blood pressure, (BP) and pulse. LVN 4 stated that Resident 1's systolic blood pressure (SBP) was 107 so the medication was held. LVN 4 stated that she took the Nadolol 40 mg two tablets into the medication room and disposed of the two tablets in the incinerator. LVN 4 denied that she documented the wasted medication in Resident 1's medical record, nor did she document the wasted medication On July 31, 2026, at 9:28 a.m., a telephone interview was conducted with the Pharmacy Consultant, (PHARM). The PHARM stated that best practices for medication administration would be to check the vital signs prior to preparing the medications. The PHARM stated that if the medication was wasted and disposed of, there should have been documentation in Resident 1's medical record.A review of Resident 1's Order Summary Report dated June 14, 2026, indicated Nadolol Oral Tablet 40 MG (Nadolol) Give 2 tablet by mouth one time a day for HTN [hypertension - high blood pressure] Hold if SBP [systolic blood pressure] < [less than] 110 OR HR [heart rate] <60 (beat per minutes)A review of Resident 1's Medication Administration Record dated June 2026, indicated the following Nadolol Oral Tablet 40 MG (Nadolol) Give 2 tablet by mouth one time a day for HTN Hold if SBP <110 OR HR <60.doses were documented as given with the nurses' initials and a checkmark on June 15th to June 19th and June 22nd, 2026. On June 20th, the number 11 was coded Vitals Outside of Parameters for Administration BP 107/66 P 89. On June 21st the number two was coded Hold/See Progress Notes BP 109/56 P 82. A review of the facility's policy and procedure titled Medication Administration revised December 19, 2022, indicated . 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. 10. Review MAR to identify medication to be administered.11. Compare medication source (bubble pack, vial, etc.) with MAR [Medication Administration Record] to verify resident name, medication name, form, dose, route, and time.a. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects.13. Remove medication from source, taking care not to touch medication with bare hand.14. Administer medication as ordered in accordance with manufacturer specifications.15. Observe resident consumption of medication.17. Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR.19. Report and document any adverse side effects or refusals.20. Correct any discrepancies and report to nurse manager.A review of the facility's policy and procedure titled Destruction of Unused Drugs revised August 3, 2023, indicated .4. The actual destruction of drugs conducted by our facility must be witnessed by.b. Non-controlled Medication: i. Consultant pharmacist; or ii. Licensed nurse.A destruction record must be maintained for all drugs destroyed. The actual destruction of drugs conducted by our facility must be witnessed by facility staff as per state requirements.The following information shall be included on this record:a. The name of the patient;b. The date the medication was destroyed;c. The prescription or lot number of the medication;d. The name, strength, and quantity of the medication being destroyed;e. The method of destruction.g. The signature of the consultant pharmacist or licensed nurse destroying the non-controlled medications.6. Our facility utilizes a waste disposal service or reverse distributor to destroy dangerous drugs and controlled substances.

Based on interview, and record review, the facility failed to ensure one of four residents, (Resident 1), was not given an unnecessary medication GlycoLax Powder, (medication used to treat occasional constipation by retaining water in the stool to soften it and increase bowel movement frequency), 17 gram by mouth three times a day for constipation for two days. This failure had the potential for Resident 1 to have abdominal discomfort, increased watery stool, and dehydration.Findings:On July 21, 2026, at 11:36 a.m., an unannounced visit to the facility for four complaints was initiated.A review of Resident 1's medical records indicated resident was admitted on [DATE], and discharged on July 2, 2026, with diagnoses of abdominal aortic aneurysm, without rupture, (AAA - a procedure to fix a dangerous bulge in the aorta-the body's main artery-running through the abdomen, preventing the weakened artery from rupturing. Repairs are done either via a traditional open incision or minimally invasively using stents), encounter for attention to ileostomy, (a surgical operation that creates an opening called a stoma on the belly wall. It connects the final part of the small intestine (the ileum) to the outside of the body so waste can leave without passing through the colon), diabetes mellitus type 2, (a chronic condition that affects the way the body uses sugar. The body either resists the effects of insulin - a hormone that regulates the movement of sugar into the cells - or doesn't produce enough insulin to maintain normal sugar levels), COPD, (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and chronic kidney disease, (the gradual loss of kidney's ability to filter wastes and excess fluids from the blood).A review of Resident 1's History and Physical dated June 15, 2026, indicated resident had decision making capacity.A review of Resident 1's Medication Administration Record dated June 2026, indicated the following: Loperamide HCl Oral Tablet 2 MG Give 1 tablet by mouth two times a day for anti-diarrheal can increase up to 1 tab by mouth 4 times daily for increased ostomy output more than 1 liter a day. Decreased to 1 tab [tablet] by mouth daily if output is decreased. [NAME] (sic) not exceed 4 tabs in 24 hrs. On June 15th 9 a.m., and 5 p.m., doses; and June 16th 9 a.m., and 5 p.m., doses were documented as given. GlycoLax Powder (Polyethylene Glycol 3350) Give 17 gram by mouth three times a day for constipation (in Liquid). On June 15th 9 a.m., 1 p.m., 5 p.m.; and June 16th 9 a.m., 1 p.m., doses were documented as given. On July 21, 2026, at 12:58 p.m., an interview was conducted with the Licensed Vocational Nurse, (LVN 1). LVN 1 stated that the process for reporting a medication error or medication clarification would be do document a Change of Condition notify the doctor, and responsible party.On July 21, 2026, at 2:50 p.m., an interview was conducted with LVN 2. LVN 2 confirmed that for Resident 1, was prescribed Loperamide HCl (hydrochloride) (a medicine to treat diarrhea by slowing down gut movement and helping the body absorb more water from waste), tablet 2 MG (milligrams) four times daily for increased ostomy output more than 1 liter a day. Decreased to 1 tablet by mouth daily if output is decreased. LVN 2 confirmed that Resident 1 was also prescribed GlycoLax Powder (Polyethylene Glycol 3350) 17 gram by mouth three times a day for constipation (in Liquid). LVN 2 confirmed that both medications were administered, and the doctor should have been notified as the medications contraindicated each other. LVN 2 stated that he had not contacted the physician and administered both the Loperamide and GlycoLax Powder. LVN 2 stated that Resident 2's ileostomy bag, (a medical pouch worn outside the body on the abdomen. It attaches to a surgical opening called a stoma, which connects to the end of the small intestine. The pouch collects digestive waste), was emptied two to three times an eight-hour shift, which would be considered normal output.On July 21, 2026, at 3:10 p.m., an interview was conducted with the facility's Director of Nursing, (DON). The DON stated that Resident 1's family member had contacted the facility on July 1, 2026, to question the GlycoLax Powder being administered for two days. The DON stated that the doctor was consulted and the GlycoLax Powder was discontinued on June 16, 2026.A review of Resident 1's Interdisciplinary Care Conference dated July 1, 2026, at 2 p.m., indicated Late Entry.: DON briefly explained to [family member] Resident admitted to facility on 6/14/26. All medications verified with MD [medical doctor]. On 6/16/26 Miralax was identified given to resident for 2 days and was discontinued.On July 21, 2026, at 4:33 p.m., an interview was conducted with the Registered Nurse, (RN 1). RN 1 stated that if a resident had orders to administer Loperamide HCl used to treat diarrhea stool and GlycoLax Powder, used to treat constipation, the physician should have been notified to clarify the orders.A review of Resident 1's Order Summary Report dated June 15, 2026, indicated Loperamide HCl Oral Tablet 2 MG (Loperamide HCl) Give 1 tablet by mouth two times a day for anti-diarrheal can increase up to 1 tab by mouth 4 times daily for increased ostomy output more than 1 liter a day. decreased to 1 tab by mouth daily if output is decreased. [NAME] (sic) not exceed 4 tabs in 24 hrs. There is a potential drug interaction with another medication.A review of Resident 1's Order Summary Report dated June 14, 2026, indicated GlycoLax Powder (Polyethylene Glycol 3350) Give 17 gram by mouth three times a day for constipation (in Liquid)A review of the facility's policy and procedure titled Medication Administration revised December 19, 2022, indicated Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice.a. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects.

Based on interview and record review, the facility failed to provide a resident representative with a copy of the resident's medical records within the required timeframe following a written request for one of three residents reviewed for resident's rights (Resident 1). This failure had the potential to cause unnecessary delay, frustrations, and anxiety for the resident's representative in obtaining the resident's medical information. Findings:On June 9, 2026, an unannounced visit was conducted at the facility to investigate a resident rights issue. A review of Resident 1's admission Record, indicated, Resident 1 was admitted to the facility on [DATE], and was discharged from the facility on April 5, 2026. A review of the facility correspondence related to the medical records request indicated the resident's representative submitted a written request for Resident 1's medical records on May 6, 2026. A review further indicated an invoice was prepared on May 7, 2026, but was not emailed until May 12, 2026. Documentation indicated the requested medical records were transmitted to the resident's representative on May 26, 2026. On June 11, 2026, at 10:52 a.m., an interview was conducted with the Medical Records Assistant (MRA). The MRA stated that she received the request on May 6, 2026, requesting a copy of Resident 1's medical records be released to Resident 1's representative. On June 11, 2026, at 2:20 p.m., an interview was conducted with the Administrator. The Administrator stated requests for medical records are forwarded to the Medical Records Department for processing. The Administrator stated that once payment is received, the requested records are sent within two days. The Administrator stated regarding Resident 1's representative request, he did not know exactly when the payment was received because there was no documentation reflecting the date it arrived at the facility. On June 11, 2026, at 3:35 p.m., a concurrent interview and record review was conducted with the MRA. The MRA stated she informed the resident representative on May 6, 2026, that payment was required, and an invoice was prepared on May 7, 2026. The MRA stated she had many responsibilities and did not email the invoice until May 12, 2026. The MRD stated she was not aware that requests for medical records were time-sensitive, and she did not know that the invoice needed to be sent immediately. The MRA further stated she had not received direction regarding medical records release process. The MRA stated she was informed on May 25, 2026, that payment had arrived and emailed the requested records on May 26, 2026. On June 11, 2026, at 3:56 p.m., during an interview with the Medical Records Director (MRD), the MRD stated residents or resident representatives may request medical records. The MRD stated the requested records should generally be provided within two days. The MRD stated it was important to provide the requested records within the required timeframe because individuals need the records for review and timely access to medical records is a patient's rights. On June 11, 2026, at 4:40 p.m., during an interview with the Business Manager (BM), the BM stated she recalled opening the envelope containing the payment on May 26, 2026, after returning from the holiday weekend. The BM stated she could not determine when the payment had actually been delivered to the facility or placed on her desk because there was no documentation identifying the date the payment was received.

Based on interview and record review, the facility failed to ensure post fall 72-hour monitoring (consistent monitoring of residents, each shift, for any changes from their baseline condition) was completed and documented for three of three residents reviewed for falls.This failure had the potential to delay identification of post-fall complications, changes in neurological status, pain, injury or decline in condition, resulting in delayed physician notification and implementation of necessary interventions.Findings:Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included dementia (decline in mental cognition).A review of Resident 1's Interdisciplinary Care Conference dated February 2, 2026, indicated Resident 1 sustained a witnessed fall on February 1, 2026.A review of Resident 1's Progress Notes indicated there was no documented evidence licensed nurses completed and documented post-fall 72-hour monitoring assessments each shift to monitor for changes from baseline following the falls.Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included abnormalities of gait and mobility.A review of Resident 2's Interdisciplinary Care Conference dated February 10, 2026, indicated Resident 1 sustained an unwitnessed fall on February 9, 2026.A review of Resident 2's Progress Notes indicated there was no documented evidence licensed nurses completed and documented post-fall 72-hour monitoring assessments each shift to monitor for changes from baseline following the falls.Resident 3's record was reviewed. Resident 3 was admitted to the facility on [DATE], with diagnoses which included dementia (decline in mental cognition).A review of Resident 3's Interdisciplinary Care Conference dated March 6, 2026, indicated Resident 3 sustained an unwitnessed fall on March 6, 2026.A review of Resident 3's Progress Notes indicated there was no documented evidence licensed nurses completed and documented post-fall 72-hour monitoring assessments each shift to monitor for changes from baseline following the falls.On March 30, 2026, at 2:55 p.m., an interview was conducted with Licensed Vocational Nurse 1 (LVN). LVN 1 stated falls were considered a change of condition and residents should have been monitored following the falls for any changes from baseline.On March 30, 2026, at 4:20 p.m., a concurrent interview and record review of Residents 1, 2, and 3 were conducted with the Director of Nursing (DON). The DON stated that a fall is considered a change of condition, and according to the facility's practice, licensed nurses should have documented 72 hour monitoring for each shift. The DON stated the importance of monitoring and documenting each shift was to identify any potential changes in a resident's condition from their baseline and to ensure the physician was notified, for appropriate interventions to be implemented.A review of the facility policy and procedure titled, Notification of Changes, dated December 19, 2022, indicated, .ensure the facility.consults the resident's physician.when there is a change requiring notification.significant change in the resident's physical, mental, or psychosocial condition.clinical complications.

Based on interview and record review, the facility failed to ensure a safe and homelike environment for one of four residents reviewed (Resident 1), when the resident's dentures and clothing were not maintained, safeguarded, and accounted for. This failure resulted in Resident 1's dentures and clothing not being available upon transfer to the hospital and had the potential to result in unmet nutritional needs, weight loss, and psychosocial distress. Findings:Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included dementia (decline in mental cognition).A review of Resident 1's Resident's Clothing and Possessions dated September 3, 2025, indicated Resident 1 had one upper denture and one lower denture. The document was signed by the Social Service Director (SSD) and Social Service Assistant (SSA).On March 27, 2026, at 12:31 p.m., an interview was conducted with Certified Nurse Assistant 1 (CNA). CNA 1 stated Resident 1 had upper dentures. CNA 1 stated Resident 1 was not wearing her dentures when she was transferred out of the facility and should have left the facility with her dentures to prevent issues with eating. On March 27, 2026, at 3:15 p.m., an interview was conducted with the Registered Nurse Supervisor (RNS). The RNS stated Resident 1 was transferred to the hospital on February 21, 2026, without her dentures. The RNS stated Resident 1 should have left the facility with her dentures to prevent issues such as inability to eat, weight loss, and psychosocial distress. On March 30, 2026, at 10:58 a.m., a concurrent interview and record review was conducted with the SSD. The SSD stated the facility was notified of Resident 1's missing dentures on March 4, 2026, by Resident 1's conservator. The SSD stated the Resident's Clothing and Possessions indicated upper and lower dentures. The SSD stated Resident 1's dentures should have been accounted for and placed in safe keeping to prevent psychosocial distress and eating difficulties.Om March 30, 2026, at 12:56 p.m., a concurrent interview and record review was conducted with Director of Nursing (DON). The DON stated Resident 1's dentures were missing and there was no documentation Resident 1 left the facility with her dentures and clothing items. The DON stated belongings should have been kept safe to prevent psychosocial distress and potential dietary modifications.Further review of Resident 1's record indicated no documented evidence the facility tracked, secured, or ensured the transfer of Resident 1's dentures and clothing at the time of transfer to the hospital. A review of the facility policy and procedure titled, Resident Personal Belongings, dated December 19, 2022, indicated, .It is the policy of this facility to protect.and assure the personal belongings and/or possessions are rightfully returned to the resident, or to the resident's representative in the event of the resident's.discharge from the facility.Following the discharge.all personal clothing and items.are to be given to the designated resident representative.

Based on interview and record review, the facility failed to maintain current personnel records for three of three personnel files reviewed (CNAs 1, 2, and 3) when annual performance evaluations were not completed. This failure resulted in not inability to assess staff performance, identify areas needing improvement, and ensure competency in providing resident care. Findings:On March 13, 2026, a review of personnel files for the following CNAs revealed no documented evidence of annual performance evaluations: -CNA 1 was hired on August 16, 2022 -CNA 2 was hired on August 30, 2023 -CNA 3 was hired on February 28, 2024 On March 13, 2026, at 2:55 p.m., a concurrent interview and record review were conducted with the Director of Staff Development (DSD). The DSD stated it was their responsibility to complete performance evaluations for CNAs. The DSD stated there was no documented evidence that annual performance evaluations had been completed for CNA 1, 2, and 3. The DSD stated completing annual performance evaluations is important to ensure staff competency in providing resident care. On March 13, 2026, at 4:45 p.m. an interview was conducted with the Director of Nursing (DON). The DON stated, the DSD is responsible for completing annual performance evaluations for CNAs. The DON stated there were no annual performance evaluations had been completed for CNA 1, 2, and 3 and it should have been completed. The DON stated annual evaluations are necessary to ensure staff are competent in providing appropriate care and meeting residents' needs. A review of the facility policy titled, Evaluation Process, dated December 19, 2022, indicated, .to review the work performance of employees with a formal written evaluation annually. Factors that will be considered.job performance, achieving preset goals, attendance records, adherence to workplace policies.

Based on observation, interview, and record review, the facility failed to ensure the physician was notified of a significant change in condition for one of two residents reviewed (Resident 1), when staff did not notify the physician after the resident alleged that staff handled her roughly. This failure had the potential to result in a delay in medical and psychosocial evaluation and to place the resident at risk for unmet medical and psychosocial needs.Findings: On March 13, 2026, at 10:10 a.m., an interview was conducted with Resident 1's Family Member (FM). The FM stated, during the night of February 25, 2026, Resident 1 reported that a Certified Nursing Assistant (CNA 1) slammed her left arm onto the bed while trying to wake her for brief change. The FM stated Resident 1 expressed she did not feel safe following the incident and wanted to leave the facility. A review of Resident 1's admission Record dated March 13, 2026, indicated an admission date of September 17, 2025, with diagnoses which included contracture of the left elbow, wrist, and hand (tightening of the muscles, tendons, or tissues that restrict normal joint movement). A review of Resident 1's History and Physical dated September 18, 2025, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's medical record indicated no documented evidence that the physician was notified following the allegation of abuse on February 25, 2026. On March 13, 2026, at 2:32 p.m., an interview was conducted with the Registered Nurse Supervisor (RNS). The RNS stated, on the morning of February 25, 2026, she was made aware of an incident between Resident 1 and CNA 1 when Resident 1 reported that CNA 1 was rough with her during perineal care (cleaning of the genital and anal areas). The RNS stated this alleged incident was considered a change of condition and the physician should have been notified. On March 13, 2026, at 4:45 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated, staff are expected to notify the physician of significant changes in condition, including allegations of abuse to ensure timely interventions. The DON stated the licensed nurse should have reported the change in condition to Resident 1's physician. A review of the facility policy and procedure titled, Notification of Changes, dated December 19, 2022, indicated, .facility must inform the resident, consult with the resident's physician.when there is a change requiring such notification.Significant change in the resident's physical, mental, or psychosocial condition.

Based on interview and record review the facility failed to ensure an allegation of abuse was reported immediately, but not later than two hours after the allegation was made for one of two residents reviewed for abuse (Resident 1) when the Registered Nurse Supervisor (RNS) did not report an allegation after becoming aware of the incident. This failure resulted in a delay initiating an investigation and implementing protective measures, placing Resident 1 at risk for potential ongoing abuse. Findings: On March 13, 2026, at 10:10 a.m., an interview was conducted with Resident 1's family member (FM). The FM stated during the night of February 25, 2026, she (Resident 1) reported to him a certified nursing assistant (CNA1) slammed her left arm on the bed while trying to wake her for a brief change. The FM stated Resident 1 expressed that she did not feel safe following the incident and wanted to leave the facility. A review of Resident 1's admission Record dated March 13, 2026, indicated an admission date of September 17, 2025, with diagnoses which included contracture of the left elbow, wrist, and hand (tightening of the muscles, tendons, or tissues that restrict normal joint movement). A review of Resident 1's History and Physical dated September 18, 2025, indicated Resident 1 had the capacity to understand and make decisions. Further review of Resident 1's record indicated there was no documented evidence in the electronic medical record that the allegation was reported to the DON, Administrator, State Agency within two hours after the allegation was made. On March 13, 2026, at 2:32 p.m., an interview with the Registered Nurse Supervisor (RNS) was conducted. The RNS further stated on the morning of February 25, 2026, she was made aware of an incident between Resident 1 and CNA 1 when Resident 1 reported CNA 1 was rough with her during perineal care (cleaning of the genital and anal areas). The RNS stated this incident was considered an allegation of abuse and should have been reported to the DON immediately and to the State Agency. The RNS stated it was the expectation from the staff that allegation of abuse should be reported to the DON. The RNS stated she did not report the incident to the DON and to State Agency. The RNS stated timely reporting is important to ensure appropriate monitoring, assessment, and intervention for the resident. On March 13, 2026, at 4:45 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated staff expectation was to report any allegations of abuse to the DON and administrator within two hours. The DON stated Resident 1's allegation against CNA 1 was considered an allegation of abuse and it should have been reported to the State Agency. The DON stated the reporting is necessary to ensure timely notification of appropriate parties, completion of an assessment, monitoring of the resident, and initiation of an investigation. A review of the facility policy titled, Abuse, Neglect, and Exploitation, dated December 19, 2022 indicated, .to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation.Reporting of all alleged violations to the Administrator, state agency.and to all other required agencies.Immediately, but not later than 2 hours after the allegation is made.

Based on interview and record review the facility failed to ensure a timely assessment and monitoring of a resident following an allegation of abuse for one of two residents reviewed for abuse (Resident 1), when Resident 1 was not assessed for pain and emotional distress after the resident reported that a staff member slammed her arm during care. This failure resulted in a delay in identifying potential injury and unmet needs, placing Resident 1 at risk for untreated pain and undetected physical and psychosocial harm. Findings:On March 13, 2026, at 10:10 a.m., an interview with Resident 1 was conducted. Resident 1 stated during the night of February 25, 2026, Certified Nurse Assistant (CNA) 1 slammed her left arm on the bed while trying to wake her up for a brief change. A review of Resident 1's admission Record dated March 13, 2026, indicated an admission date of September 17, 2025, with a diagnosis which included contracture of the left elbow, wrist, and hand (tightening of the muscles, tendons, or tissues that restrict normal joint movement). A review of Resident 1's History and Physical dated September 18, 2025, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's record indicated there was no documented evidence that Resident 1 was assessed following the incident for injury, pain, or emotional distress. In addition, there was no documented evidence of monitoring or interventions initiated following the reported incident. On March 13, 2026, at 2:32 p.m., an interview was conducted with the Registered Nurse Supervisor (RNS). The RNS stated during the morning of February 25, 2026, she was made aware of an incident that had occurred between Resident 1 and CNA 1. The RNS stated the resident reported that CNA 1 was rough during care. The RNS stated this incident was considered a change of condition. The RNS stated, the resident should have been assessed and monitored. The RNS stated no assessment, or monitoring was completed for Resident 1. The RNS stated it was important to complete a change of condition and notify the physician to have interventions in place to manage and adequately monitor Resident 1 for injuries, pain, and emotional distress. On March 13, 2026, at 4:45 p.m., during an interview and concurrent record review with the Director of Nursing (DON), the DON stated the licensed nurses were expected to complete a change of condition when a concern is identified with a resident, notify the physician, and perform an assessment and monitoring. The DON stated a change of condition was not completed for Resident 1 for the above alleged incident and should have been. The DON stated it was important to complete a change of condition to identify the concern, notify the physician, assess the resident, and provide monitoring for pain and distress. A review of the facility policy and procedure titled, Notification of Changes, dated December 19, 2022, indicated, .facility must inform the resident, consult with the resident's physician.when there is a change requiring such notification.Significant change in the resident's physical, mental, or psychosocial condition.

Based on interview and record review, the facility failed to provide a written summary of the baseline care plan for one of one resident reviewed (Resident C).This failure had the potential for Resident C not to be aware of the facility's plan of care for Resident C.Findings:On January 27, 2026, at 10:10 a.m., an unannounced visit to the facility was conducted to investigate quality care and treatment issues.A review of Resident C's admission Record indicated Resident C was admitted to the facility on [DATE], with diagnoses which included congestive heart failure (heart disease) and angina pectoris (a type of temporary chest pain).A review of Resident C's History and Physical dated September 26, 2024, indicated Resident C has the capacity to understand and make decisions.On January 29, 2026, at 11:41 a.m., the MDS (Minimum Data Set- an assessment tool) Nurse was interviewed, the MDS nurse stated the baseline care plan is completed within 72 hours. The nurses would give the resident or the responsible party (RP) a copy of the baseline care plan.On January 29, 2026, at 11:56 a.m., a Licensed Vocational Nurse (LVN 1) was interviewed. LVN 1 stated that she was not familiar with the baseline care plan, as she is not involved in the admissions process.On January 29, 2026, at 12:08 p.m., the Registered Nurse Supervisor (RNS) was interviewed. The RNS stated she was not aware that the baseline care plan was supposed to be completed within 48 to 72 hours, and that residents or the RP were supposed to be provided with a copy of the baseline care plan.On January 29, 2026, at 12:44 p.m., the Director of Nursing (DON) was interviewed. The DON stated the admission nurse would initiate the baseline care plan and department heads would review and complete it within 48 hours, and a copy of the summary of the baseline care plan should be provided to the residents or the RP. The DON further they were not able to do any care plan meeting with the resident, and we have no proof to show that the resident or the RP were provided with a copy of summary of the baseline care plan.A review of facility policy and procedures titled, Baseline Care Plan, dated December 19, 2022, indicated, .The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care. The baseline care plan will be developed:.within 48 hours of resident's admission, include the minimum healthcare information necessary to properly care for a resident.The admitting nurse or supervising nurse on duty will gather information.once gathered, initial goals shall be established that reflects the resident stated goals and objectives.A written summary of the baseline care plan shall be provided to resident and representative.

Based on observation, interview and record review, the facility failed to ensure the call light is within reach for one of three residents reviewed (Resident B). Resident B is at risk of falling. This failure had the potential for Resident B not to be able to call for assistance, which could lead to unassisted attempts to stand and increase the risk of falls. Findings:On January 30, 2026, at 8:17 a.m., during a concurrent observation and interview, Resident B's call light button was observed hanging on the left side of the bed, not within the resident's reach. Resident B stated she would normally use her call light button when she needed help from the staff. Resident B stated she could not locate her call light button.On January 30, 2026, at 8:30 a.m. during interview with Certified Nurse Assistant (CNA) 1, at Resident B's room, CNA 1 stated she missed the call light button for Resident B, and it was placed hanging at the left side of the bed and not within the resident's reach. CNA 1 stated the call light should have been positioned and secured in front of the resident.A review of Resident B's admission Record, indicated Resident B was admitted to the facility on [DATE], with diagnoses which included traumatic subdural hematoma (bleeding inside the brain usually caused by a head injury), history of fall, and abnormality of gait.A review of Resident B's Care Plan titled, Focus-the resident is at risk for fall r/t (related to) h/o (history of) fall prior to admission, unsteady gait/balance.Intervention-Place the resident's call light within reach.Resident needs a safe environment with a reachable call light.On January 30, 2026, at 9:29 a.m., the Director of Nursing (DON) was interviewed. The DON stated that fall-risk residents are discussed during the morning huddle. Additionally, the DON noted that a call light not within reach may present a potential risk for falls.A review of facility policy and procedure titled Call Light Accessibility and Timely Response, dated December 19, 2022, indicated, .Staff will ensure the call light is within reach of resident and secured.A review of the facility policy and procedure titled, Fall Prevention Program, dated December 19, 2022, indicated .Each resident will be assessed for fall risk and receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Fall prevention include, but not limited to: Call light.are within reach.

Based on observation, interviews and record review, the facility failed to reassess a resident for the use of grab bars (Bedrails to provide support and secure handhold) after being readmitted to the facility, for one out of four residents (Resident 1) reviewed for bed rail use. This failure resulted in the Resident 1's inability to use grab bars for repositioning assistance and bed mobility.Findings: On December 8, 2025, an unannounced visit was made to the facility to investigate a Quality-of-Care complaint. On December 8, 2025, at 9:28 a.m., an observation with a concurrent interview was conducted with Resident 1. Resident 1 was observed sitting in a wheelchair at her bedside. There were no side rails or grab bars observed attached on residents' bed. On December 8, 2025, at 10:32 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated it was the facilities policy to assess a resident for the use of bedrails upon admission, re-admission, and at the request of the resident/representative, or nursing staff. The DON stated bedrail/grab bars were used as an enabler for mobility, to grab and assist with repositioning. The DON further stated the use of a bedrail was not appropriate for all residents, as it could pose as a restraint or an entrapment risk. A review of Resident 1's, Patient Information, indicated, resident was admitted to the facility on [DATE], with a diagnosis of Parkinson's Disease (A neurological disorder that affects movement, balance and coordination). A review of Resident 1's, Brief Interview for Mental Status Evaluation (A cognitive assessment), dated, November 17, 2025, indicated Resident 1 had mild cognitive impairment. A review of Resident 1's, Bed Rails, assessment, dated, June 11, 2025, indicated, resident has bed mobility issues due to her cognitive losses, and demonstrates difficulty with bed mobility or moving to a sitting position from the bed, and difficulty with standing/sitting balance. The assessment further indicated, . per (Resident 1's Representative) (resident) fell at home . (representative) requests for grab bar at this time . Recommendations: (Left & Right) Assist . grab bar. A review of Resident 1's, Progress Notes, dated, November 16, 2025, at 7:55 p.m., indicated, resident was transferred to the General Acute Care Hospital (GACH) on November 12, 2025, and readmitted to the facility on [DATE]. There was no documented evidence that Resident 1 was reassessed for the use of bed rails or grab bars following her readmission to the facility on November 16, 2025. On December 10, 2025, at 3:50 p.m., an interview with a concurrent record review was conducted with the DON. The DON stated Resident 1 was admitted to the facility on [DATE], and was assessed for the use of grab bars in bed on June 11, 2025. The DON stated on June 11, 2025, Resident 1's bedrail assessment indicated left, and right grab bars were recommended at the request of resident's representative for Resident 1. The DON stated Resident 1 did not currently have grab bars on her bed. The DON stated resident was transferred out to GACH on November 12, 2025, and was readmitted to the facility on [DATE]. The DON stated Resident 1 was not reassessed for the use of grab bars after her readmission to the facility on November 16, 2025. The DON stated, Resident 1 should have been reassessed for the use of bedrails or grab bars, upon her readmission, as it is the facilities policy to reassess for bedrails. The facilities Policy and Procedure titled, Proper Use of Bed Rails, revised, December 19, 2022, indicated, . Policy: It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails . Ongoing Monitoring and Supervision: . b. A nurse assigned to the resident will complete reassessments in accordance with the facility's assessment schedule, but not less than quarterly, upon a significant change in status .

Based on observation, interview and record review the facility failed to initiate and maintain infection prevention precautions (measures intended to prevent transmission of infectious microorganisms) for a resident with repeated Urinary Tract Infections (UTIs) with the presence of the microorganism Pseudomonas aeruginosa (Pseudomonas - a Multi Drug Resistant Organism [MDRO]) in their urine for one out of three residents reviewed for infection control precautions (Resident 2). This failure had the potential to spread infection to other residents in the facility. Findings: On December 8 & 9, 2025, unannounced visits were made to the facility for infection prevention issues. On December 8, 2025, at 9:02 a.m., an observation and concurrent interview were conducted with Resident 2, who stated she was receiving antibiotics for a UTI and is feeling better. No signage indicating infection prevention precautions was observed outside Resident 2's room. On December 8, 2025, at 3:32 p.m., an interview was conducted with the Infection Prevention Nurse (IPN) who stated the facility's process was to monitor and discuss residents on antibiotics during morning clinical review meetings with the Director of Nursing (DON) and licensed nurses (charge nurse), Monday through Friday. The IPN stated, if a resident's urine Culture & Sensitivity ({C&S}-isolation of microbes in the urine to test for drug resistance and sensitivity) indicated the UTI is caused by a MDRO (Pseudomonas), infection control interventions should be initiated to prevent the spread of the MDRO to other residents. The IPN stated these interventions include placing the resident on either Enhanced Barrier Precautions (EBP - infection control measures used to reduce the spread of MDROs) or Contact Isolation Precautions (CIP - infection control measures used to prevent the spread of infectious organisms transmitted by direct or indirect contact with a resident or their environment). The IPN stated when a resident was placed on CIP, the resident was either moved to a private room, or cohorted (roommates) with the same MDRO until asymptomatic. The IPN stated, when a resident was placed on CIP, the staff must don PPE (personal protective equipment - a specialized clothing or equipment worn by healthcare personnel to protect themselves and others from exposure to infectious agents, body fluids, or other hazards) outside of the resident's room, prior to contact with the resident or their environment. The IPN stated, with both EBP or CIP, a sign will be placed outside of the resident's bedroom door, indicating the type of precaution and the PPE required to enter the resident's bedroom. The IPN further stated, a physician order was needed for these precautions, and she was responsible for ensuring physician orders are received and implemented. The IPN stated implementing infection prevention precautions was important to help prevent the spread of infection to other residents within the facility. A review of Resident 2's, Patient Information, indicated, resident was admitted to the facility on [DATE], with a diagnosis including UTI. A review of Resident 2's, Minimum Data Set (MDS - an assessment tool) dated indicated the resident was cognitively intact (normal cognitive functioning). The following Resident 2's records were reviewed: -The Progress Notes, dated, October 1, 2025, at 10:32 p.m., indicated a Change of Condition (COC) was reported when Resident 2 complained of pain in urination and the physician ordered to obtain urine for test with C&S. -The Progress Notes dated, October 2, 2025, at 3:43 p.m., indicated the result of the urinalysis was referred to the physician with orders to start on antibiotics for UTI; -Resident 2's urine test result with C&S dated October 2, 2025, and reported October 4, 2025, indicated the presence of MDRO pseudomonas in Resident 2's urine. -The Progress Notes, dated October 4, 2025, at 10:56 a.m., indicated the urine test with C&S result was referred to Resident 2's physician with orders to discontinue the current antibiotic order and change to a new antibiotic that is susceptible (expected to be effective in treating the infection) to MDRO. There was no documented evidence indicating that physician's orders were received to start CIP for Resident 1's pseudomonas urine infection. -The Progress Notes, dated November 7, 2025, at 12:30 p.m., indicated Resident 2 was seen and evaluated by her physician and was given an order to be transferred to the acute hospital for evaluation due to recurrent UTI.-The acute hospital document dated November 8, 2025, indicated Resident 2 was brought to the acute hospital to be evaluated for UTI. The document further indicated a urine test was done on November 8, 2025, and the C&S results reported November 10, 2025, indicated the presence of pseudomonas in Resident 2's urine; and-The facility progress notes, dated November 11, 2025, at 5 p.m., indicated Resident 2 was re-admitted back to the facility from the acute hospital with new orders for antibiotics for UTI. There was no documented evidence indicating that physician's orders were received to initiate an EBP or CIP for Resident 2's pseudomonas urine infection identified in November 10, 2025. On December 8, 2025, at 3:32 p.m., an interview with concurrent record review was conducted with the IPN. The IPN stated: -Resident 2's urine test with C&S result reported on October 4, 2025, indicated Resident 2 was diagnosed with UTI and the C&S result indicated the MDRO pseudomonas was present in her urine. -CIP physician orders should have been obtained and implemented following the C&S result and this was not done; and -Placing Resident 2 on CIP due to UTI with MDRO pseudomonas in the urine was important because the resident was considered infectious and the CIP will help avoid the spread of infection. On December 9, 2025, at 1001 a.m., a follow up interview with a concurrent record review was conducted with the IPN. The IPN stated: -Resident 2 was re-admitted to the facility from the acute hospital on November 11, 2025, with the diagnosis of UTI. -The acute hospital urine C&S result, reported on November10, 2025, indicated MDRO pseudomonas in Resident 2's urine. -The facility should have started infection prevention intervention like EBP when Resident 2 was readmitted on [DATE]; and -The facility did not receive physician orders to place Resident 2 on EBP upon re-admission on [DATE]. On December 10, 2025, at 3:30 p.m., an interview with a concurrent record review was conducted with the DON. the DON stated: -The facility monitored residents for infections and initiated precautions by reviewing admission orders, COC, and urine C&S results with the IPN during clinical review meetings; -The clinical review meeting information will be reported to the physician, and infection prevention orders will be received and initiated. -A resident identified with an MDRO UTI will be placed on EBP if a symptomatic or CIP if symptomatic. -On October 4, 2025, Resident was diagnosed with a symptomatic UTI caused by pseudomonas, CIP was not implemented, and a physician's order was not obtained to initiate it. -On November 11, 2025, Resident 2 was readmitted to the facility from the acute hospital for continued treatment of an asymptomatic UTI. On December 8, 2025, Resident 2 was diagnosed with UTI with the presence of pseudomonas in the urine (reported November 10, 2025). An EBP should have been initiated upon admission, and it was not done. In addition, a physician's order was not obtained to implement an EBP upon re-admission to the facility; and -On December 9, 2025, a physician's order was received to begin EBP interventions for Resident 2 to prevent the spread of infection. -On December 9, 2025, at 3:03 p.m., an interview was conducted with the DON, who stated the process to place a resident on infection prevention precautions such as EBP and CIP includes receiving a Drs order. The DON further stated if a Drs order is not received to place a resident on infection prevention precautions, then it cannot be verified the precautions were initiated. A review of the facilities Policy and Procedure (P&P), titled, Enhanced Barrier Precautions,, revised, June 17, 2024, indicated, . Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms . 8. Important MDROs may include . d. Multidrug-resistant Pseudomonas aeruginosa . 9. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility . A review of the facilities, P&P, titled, Transmission-Based (Isolation) Precautions, revised, July 18, 2023, indicated, . Policy: It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens modes of transmission . Contact precautions . measures . intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment . 1. Facility staff will apply Transmission-Based Precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission .

Based on observation, interview, and record review, the facility failed to ensure, for one of four residents reviewed (Resident 1), to monitor blood sugar level, assess meal intake percentage, or ensure proper communication among staff for a resident admitted with diabetes (abnormal blood sugar level). This failure had the potential to cause adverse health effects. Findings: On April 3, 2025, Resident 1's record was reviewed. Resident 1 was admitted to the facility with a diagnosis which included, type 2 diabetes mellitus with ketoacidosis (uncontrolled blood glucose levels in the body), chronic kidney disease, stage 3 (weakened kidney function), and acquired absence of left leg below knee. A further review of Resident 1's clinical admission form dated April 3, 2025, indicated, there was no documentation of Resident 1's baseline blood glucose level and oral intake upon admission. A review of Resident 1's physician order dated April 4, 2025, indicated, .Humulin R U-500 KwikPen subcutaneous Solution Pen-injector 500 unit/ml (insulin regular [human]) inject 110 unit subcutaneously in the morning for DM .before breakfast . A review of the Medication Administration Record (MAR) for the month of April 2025, indicated Resident 1 received insulin at 7:00 a.m. with a blood glucose level of 99. A review of Resident 1's change of condition notice dated April 4, 2025, at 8:47 a.m. indicated, .At 7:45am resident found unresponsive. Opened eyes but no verbal response when stimulated with sternal rub. V/S (vital signs) 144/76 PR (pulse rate) 105 o2 (oxygen saturation - how much oxygen the blood is transporting throughout the body) at 92% T 97.6 RR 18 BS (blood sugar) 25. Given glucagon (medical glucose) shot at 7:55 and BS was 32 after 15 minutes. Before the 2nd dose of glucagon shot as ordered by MD at 8:05am, resident started to response and verbally responsive, able to say name when asked. After 15 minutes of 2nd glucagon shot BS went up to 53. Resident more alert and responsive and able to drink orange juice. Continue to give OJ (orange juice) and given Breakfast. At 8:35am BS checked again and went up to 82. MD (physician) ordered to hold all insulin at this time and continue to monitor . On April 24, 2025, at 3:06 p.m., an interview was conducted with the Licensed Vocational Nurse (LVN) 1. LVN 1 stated he was informed Resident 1 had diabetes and was alert, as reported by the Registered Nurse (RN 1). LVN 1 stated he was unsure whether Resident 1 had received nourishment before admission or what his baseline blood glucose level was. LVN 1 stated he administered insulin to Resident 1 as per the physician's order. On April 24, 2025, at 3:30 p.m., an interview was conducted with the Registered Nurse (RN) 1. RN 1 stated she did not document Resident 1's last meal or blood glucose level and did not communicate the information to LVN 1. RN 1 stated according to admission protocol, it was necessary to record the last meal, check blood glucose levles, offer a snack to diabetic resident during admission, and relay this information to the assigned LVN. RN 1 stated, she should have done so. On April 24, 2025, at 4:03 p.m., an interview was conducted with RN 2. RN 2 stated blood glucose levels should always be checked upon admission for diabetic residents. RN 2 stated, the facility practice includes assessing if the resident has eaten, offering a snack, and documenting the intake. RN 2 stated, she could not recall receiving any blood glucose information from the hospital and remembered that Resident 1 was an unstable diabetic. RN 2 stated, administering insulin without prior food intake increases the risk of hypoglycemia (low blood glucose). On April 24, 2025, at 4:34 p.m. a concurrent interview and record review was conducted with Director of Nursing (DON). The DON stated, the admission assessment should include documentation of blood glucose levels and the last meal intake for diabetic residents. The DON stated, the clinical admission form dated April 3, 2025, had no documented blood glucose level and meal intake. The DON stated, there was a potential risk for hypoglycemia and hyperglycemia (high blood glucose) for diabetic residents and there should have been documentation and communication regarding the intake and blood glucose levels for Resident 1. On April 29, 2025, at 11:06 a.m. an interview was conducted with LVN 2. LVN 2 stated, during the endorsement rounds for Resident 1, she was informed by LVN 1 that Resident 1 was alert, diabetic, and had no overnight issues. LVN 2 stated Resident 1 was sleeping and unresponsive during the endorsement when both LVNs 1 and 2 entered the room on April 4, 2025. LVN 2 stated, she was not informed about Resident 1's last meal or blood glucose levels. LVN 2 stated, if she had been aware of the resident's sensitivity to insulin, she would have checked the blood glucose before the morning medication pass. LVN 2 stated, administering insulin without prior food intake poses a risk of hypoglycemia. A review of the facility policy and procedure titled, Nursing Care of the Resident with Diabetes Mellitus, dated 2022, indicated, .Recognize, manage, and document the treatment of complications commonly associated with diabetes .Hypoglycemia .many of these symptoms can also be caused by other conditions, for example adverse consequences due to medications or fluid and electrolyte imbalance .it should not just be assumed that these symptoms are related to diabetes, without carefully investigating and reporting other potential causes .kidney disease .nerve damage .foot complications .Glucose Monitoring .the physician will order the frequency of glucose monitoring .residents whose blood sugar is poorly controlled or those taking insulin may require more frequent monitoring, depending on the situation .Documentation .percentage of meals consumed .blood sugar results and other pertinent laboratory studies . A review of the facility policy and procedure titled, Hypoglycemia Management, dated 2022, indicated, .Hypoglycemia .compliance guidelines .residents that have a diagnosis of diabetes or on medications that could lower the blood sugar should have orders for glucose monitoring and treatment of hypoglycemia, unless otherwise ordered by the practitioner .the blood sugars(s) and treatment will be documented as per facility protocol (e.g., resident chart, MAR, eMAR, etc.) . 44270 Based on observation, interview, and record review, the facility failed to ensure, for one of four residents reviewed (Resident 1), to monitor blood sugar level, assess meal intake percentage, or ensure proper communication among staff for a resident admitted with diabetes (abnormal blood sugar level). This failure had the potential to cause adverse health effects. Findings: On April 3, 2025, Resident 1's record was reviewed. Resident 1 was admitted to the facility with a diagnosis which included, type 2 diabetes mellitus with ketoacidosis (uncontrolled blood glucose levels in the body), chronic kidney disease, stage 3 (weakened kidney function), and acquired absence of left leg below knee. A further review of Resident 1's clinical admission form dated April 3, 2025, indicated, there was no documentation of Resident 1's baseline blood glucose level and oral intake upon admission. A review of Resident 1's physician order dated April 4, 2025, indicated, .Humulin R U-500 KwikPen subcutaneous Solution Pen-injector 500 unit/ml (insulin regular [human]) inject 110 unit subcutaneously in the morning for DM .before breakfast . A review of the Medication Administration Record (MAR) for the month of April 2025, indicated Resident 1 received insulin at 7:00 a.m. with a blood glucose level of 99. A review of Resident 1's change of condition notice dated April 4, 2025, at 8:47 a.m. indicated, .At 7:45am resident found unresponsive. Opened eyes but no verbal response when stimulated with sternal rub. V/S (vital signs) 144/76 PR (pulse rate) 105 o2 (oxygen saturation - how much oxygen the blood is transporting throughout the body) at 92% T 97.6 RR 18 BS (blood sugar) 25. Given glucagon (medical glucose) shot at 7:55 and BS was 32 after 15 minutes. Before the 2nd dose of glucagon shot as ordered by MD at 8:05am, resident started to response and verbally responsive, able to say name when asked. After 15 minutes of 2nd glucagon shot BS went up to 53. Resident more alert and responsive and able to drink orange juice. Continue to give OJ (orange juice) and given Breakfast. At 8:35am BS checked again and went up to 82. MD (physician) ordered to hold all insulin at this time and continue to monitor . On April 24, 2025, at 3:06 p.m., an interview was conducted with the Licensed Vocational Nurse (LVN) 1. LVN 1 stated he was informed Resident 1 had diabetes and was alert, as reported by the Registered Nurse (RN 1). LVN 1 stated he was unsure wheher Resident 1 had received nourishment before admission or what his baseline blood glucose level was. LVN 1 stated he administered insulin to Resident 1 as per the physician's order. On April 24, 2025, at 3:30 p.m., an interview was conducted with the Registered Nurse (RN) 1. RN 1 stated she did not document Resident 1's last meal or blood glucose level and did not communicate the information to LVN 1. RN 1 stated according to admission protocol, it was necessary to record the last meal, check blood glucose levles, offer a snack to diabetic resident during admission, and relay this information to the assigned LVN. RN 1 stated, she should have done so. On April 24, 2025, at 4:03 p.m., an interview was conducted with RN 2. RN 2 stated blood glucose levles should always be checked upon admission for diabetic residents. RN 2 stated, the facility practice includes assessing if the resident has eaten, offering a snack, and documenting the intake. RN 2 stated, she could not recall receiving any blood glucose information from the hospital and remembered that Resident 1 was an unstable diabetic. RN 2 stated, administering insulin without prior food intake increases the risk of hypoglycemia (low blood glucose). On April 24, 2025, at 4:34 p.m. a concurrent interview and record review was conducted with Director of Nursing (DON). The DON stated, the admission assessment should include documentation of blood glucose levels and the last meal intake for diabetic residents. The DON stated, the clinical admission form dated April 3, 2025, had no documented blood glucose level and meal intake. The DON stated, there was a potential risk for hypoglycemia and hyperglycemia (high blood glucose) for diabetic residents and there should have been documentation and communication regarding the intake and blood glucose levels for Resident 1. On April 29, 2025, at 11:06 a.m. an interview was conducted with LVN 2. LVN 2 stated, during the endorsement rounds for Resident 1, she was informed by LVN 1 that Resident 1 was alert, diabetic, and had no overnight issues. LVN 2 stated Resident 1 was sleeping and unresponsive during the endorsement when both LVNs 1 and 2 entered the room on April 4, 2025. LVN 2 stated, she was not informed about Resident 1's last meal or blood glucose levels. LVN 2 stated, if she had been aware of the resident's sensitivity to insulin, she would have checked the blood glucose before the morning medication pass. LVN 2 stated, administering insulin without prior food intake poses a risk of hypoglycemia. A review of the facility policy and procedure titled, Nursing Care of the Resident with Diabetes Mellitus, dated 2022, indicated, .Recognize, manage, and document the treatment of complications commonly associated with diabetes .Hypoglycemia .many of these symptoms can also be caused by other conditions, for example adverse consequences due to medications or fluid and electrolyte imbalance .it should not just be assumed that these symptoms are related to diabetes, without carefully investigating and reporting other potential causes .kidney disease .nerve damage .foot complications .Glucose Monitoring .the physician will order the frequency of glucose monitoring .residents whose blood sugar is poorly controlled or those taking insulin may require more frequent monitoring, depending on the situation .Documentation .percentage of meals consumed .blood sugar results and other pertinent laboratory studies . A review of the facility policy and procedure titled, Hypoglycemia Management, dated 2022, indicated, .Hypoglycemia .compliance guidelines .residents that have a diagnosis of diabetes or on medications that could lower the blood sugar should have orders for glucose monitoring and treatment of hypoglycemia, unless otherwise ordered by the practitioner .the blood sugars(s) and treatment will be documented as per facility protocol (e.g., resident chart, MAR, eMAR, etc.) .

Based on observation, interview and record review, the facility failed to provide a recommended diet for Resident 51 after a change in health status. This failure had the potential for Resident 51 to have uncontrolled blood sugar levels and complications from type 2 diabetes mellitus (abnormal high sugar). Findings: Resident 51's record was reviewed. Resident 51 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes mellitus and hospice services (specialized end-of-life care). A review of Resident 51's Interdisciplinary Care Conference, dated December 5, 2024, indicated .Resident discharged from Hospice services and will remain in long term care . A review of Resident 51's Minimum Data Set (an assessment tool), dated July 16, 2024, indicated, Resident 51 had a Brief Interview of Mental Status (BIMS - a tool to assess cognitive function of an individual) score of 15, cognitively intact. A review of Resident 51's Care Plan, initiated on July 16, 2024, indicated, .The resident has Diabetes Mellitus .The resident will have no complications related to diabetes .Interventions .Dietary consult for nutritional regimen and ongoing monitoring . A review of Resident 51's Physician's Orders, dated July 3, 2024, indicated the order for a regular diet (foods with moderate levels of salt, fat and sugar). On March 11, 2025, at 1:50 p.m., an interview was conducted with Resident 51. Resident 51 stated he would like his meals to have less carbohydrates, such as bread, potatoes, and rice. Resident 51 stated he had diabetes, and his blood sugar levels have been fluctuating. On March 11, 2025, at 3:43 p.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 3. LVN 3 stated Resident 51 was admitted under hospice services but was removed from hospice on December 5, 2024, after his condition improved. LVN 3 stated, the resident was diabetic, on a regular diet, and had a recent Hgb A1c (average blood sugar over the past two to three months) of 8.8% (normal value 3.6 to 6). LVN 3 stated there was no documentation that the resident's diet was reviewed or clarified with the physician. LVN 3 stated Resident 51 should have been placed on a controlled carbohydrate (CCHO) diet to manage his diabetes. On March 12, 2025, at 8:55 a.m., a concurrent interview and record review was conducted with the Minimum Data Set Nurse (MDSN). The MDSN stated a significant change assessment was completed for Resident 51 on December 5, 2024, when hospice services ended. The MDSN further stated nursing or dietary staff should have notified the physician to clarify the resident's diet after the change in status. On March 12, 2025, at 11:15 a.m., a concurrent interview and record review were conducted with the Registered Dietitian (RD). The RD stated Resident 51, a diabetic, had a regular diet order. The RD stated during his last quarterly review on March 7, 2025, the resident remained on a regular diet. The RD stated Resident 51 had an Hgb A1c of 8.8% and fluctuating blood sugar levels. The RD stated, he should have consulted with the physician and recommended a controlled carbohydrate diet to help manage the resident's blood sugar and prevent complications from diabetes. A review of the facility's policy and procedure titled Therapeutic Diet Orders, dated December 2022, indicated, .the facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care .therapeutic diet is a diet ordered by a physician, or delegated registered or licensed dietitian, as part of treatment for a disease or clinical condition .each resident's nutritional status is assessed by the interdisciplinary team in accordance with assessment policies .dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed . A review of the facility's policy and procedure titled Notification of Changes, dated September 2022, indicated, .the facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification .significant change in the resident's physical, mental or psychosocial condition .discontinuation of current treatment .

Based on interview and record review, the facility failed to ensure one of five residents (Resident 1) was free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when administered a combination of psychotropic medications with sedating effects, sustained a fall, continued to receive additional sedating psychotropic medications without consideration of the potential additive sedative effects, and sustained a second fall. This failure resulted in unnecessary medications for Resident 1 which increased the potential for medication interactions, adverse reactions, and unidentified risks associated with the use of psychotropic medications that included but not limited to falls, sedation, cognitive (the mental processes involved in thinking, learning, understanding, and remembering) impairment, blurred vision, and respiratory depression. Finding: During a review of Resident 1's admission Record, dated March 13, 2025, the admission Record indicated, Resident 1 was elderly, initially admitted to the facility on [DATE], and was admitted again on December 23, 2024. Resident 1's diagnoses included metabolic encephalopathy (brain function changes that can cause confusion, memory loss and loss of consciousness), fracture (break) of left femur (long bone extending from hip to knee), difficulty walking, schizoaffective disorder (mental health condition with symptoms such as hallucinations and mood changes), anxiety, depression, right eye blindness, and left eye low vision (difficulty seeing). A review of Resident 1's Minimum Data Set (MDS, a care area assessment and screening tool), dated June 27, 2023, and December 28, 2024, indicated the resident had no exhibition of hallucinations/delusions and no physical/verbal behavioral symptoms, had no fall history, had active psychiatric/mood disorder diagnoses, and had received antipsychotic/antidepressant medications. A review of Resident 1's current MDS dated [DATE], indicated the resident had Brief Interview of Mental Status (BIMS - a tool to assess cognitive function of an individual) score of 12 - (moderate cognitive impairment), no exhibition of hallucinations/delusions and no physical/verbal behavioral symptoms, had a fall history, had active psychiatric/mood disorder diagnoses, and had received antipsychotic/antidepressant medications. A review of Resident 1's Order Summary Report, dated March 12, 2025, indicated the following provider orders: - Oxycodone-acetaminophen (a potent controlled medication for pain, which has sedating effects) 10/325 milligram (mg, unit of measurement) every 6 hours as needed for moderate pain (4-6) to severe pain (7-10), started on December 23, 2024; - Quetiapine (an antipsychotic medication for bipolar disorder, depression, and schizophrenia, which has sedating effects) 50 mg one time a day for schizo effective d/o (disorder) m/b (manifested by) auditory/visual hallucinations, started on December 23, 2024; - Trazodone (used to treat depression and anxiety, which has sedating effects) 100mg at bedtime for depression m/b inability to sleep, started on December 27, 2024; and - Gabapentin (used to treat seizures and pain, which has sedating effects) 300 mg two times a day for neuropathy (nerve damage causing numbness), started on January 12, 2025. A review of Resident 1's clinical record indicated, on January 30, 2025, the provider ordered a new medication, Remeron (a hypnotic medication used to treat insomnia, which has sedating effects) 15 mg at bedtime for depression m/b poor PO (oral) intake less than 50 percent (%, unit of measurement). On January 31, 2025, Resident 1 sustained a fall during an Orthopedic (the medical specialty that focuses on injuries to bone, joints, muscles) office visit outside of the facility. A review of the Orthopedic provider's progress notes dated January 31, 2025 at 9 a.m., indicated, .patient took a backward slow tumble while attempting to ambulate (walk) . A review of the Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for Remeron tablets, dated December 2011, retrieved from DailyMed (The contents of DailyMed is provided and updated daily by the U.S. Food and Drug Administration) indicated, Because of the potentially significant effects of Remeron on impairment of performance, patients should be cautioned about engaging in activities requiring alertness .Sedating drugs may cause confusion and over-sedation in the elderly .Caution is indicated in administering Remeron to elderly patients . A review of Resident 1's change of condition progress notes, dated January 31, 2025 at 2 p.m., indicated, Ortho (orthopedic) doc (doctor) told patient to walk .Patient to have proper assistive device and assist for any mobility .continue to monitor. A review of Resident 1's clinical record indicated, on February 7, 2025, the provider ordered a new medication, Ativan (a type of benzodiazepine used to treat anxiety, which has sedating effects) 0.5 mg three times a day for anxiety, m/b verbalization of feeling anxious. A review of Resident 1's Progress Notes - Psychiatry, dated February 18, 2025, indicated, .discontinuing Seroquel (quetiapine) 50 mg daily due to ineffectiveness .Initiating Depakote (used to treat seizures and psychiatric conditions, which has sedating effects) 125 mg BID (twice a day) for mood stabilization .continue Trazodone 100 mg bedtime for sleep maintenance .continue Remeron 15mg qhs (bedtime) for depressive symptoms and poor appetite . A review of Resident 1's clinical record indicated, on February 19, 2025, the provider ordered a new medication, Depakote Delayed Release (Divalproex Sodium) 125 mg tablet, one (1) tablet two times a day for Mood affective disorder m/b poor impulse control yelling. Two weeks later, on March 5, 2025, the provider increased the dose of Depakote Delayed Release (Divalproex Sodium) 125 mg tablet to two (2) tablets two times a day for Mood affective disorder m/b poor impulse control yelling. A review of Resident 1's Interdisciplinary Care Conference -Behavior and Psychotropic Medication Management, dated March 7, 2025 at 2:42 p.m., indicated, continue all current medications, no changes, continue plan of care . On March 8, 2025, Resident 1 sustained a second fall. A review of A review of Resident 1's change of condition progress notes, dated March 8, 2025 at 4:58 p.m., indicated, s/p (status post, after an event) Fall - hit his head c/o (complained of) severe pain .patient observed lying on the floor reassessed patient, stated, He got out from his bed from sleep, went to get his wheel chair, lost his balance and fell on the ground, able to move all his extremities, however he complained of severe pain, Patient was medicated with Oxycodone 10 mg as ordered. [Doctor] was notified with orders; Transfer to [hospital] for further evaluation and treatment . Further review of the PI for Remeron tablets, dated December 2011, retrieved from DailyMed, indicated, .impairment of motor skills produced by Remeron has been shown to be additive with those caused by diazepam (a type of benzodiazepine like Ativan, used to treat anxiety, which has sedating effects). Accordingly, patients should be advised to avoid diazepam and other similar drugs while taking Remeron . A review of PI for Ativan (lorazepam) tablets, dated May 2023, retrieved from DailyMed, indicated, Elderly or debilitated patients may be more susceptible to the sedative effects of lorazepam .Drug Interactions: The benzodiazepines, including lorazepam, produce increased CNS (Central Nervous System)-depressant effects when administered with other CNS depressants such as .antipsychotics, sedative/hypnotics, anxiolytics, antidepressants, narcotic analgesics (pain medications), anticonvulsants (medications to treat seizures) .Concurrent administration of lorazepam with valproate (Depakote) results in increased plasma concentrations (drug levels) and reduced clearance of lorazepam. Lorazepam dosage should be reduced to approximately 50% when co-administered with valproate .Geriatric Use .the incidence of sedation and unsteadiness was observed to increase with age . A review of PI for Depakote delayed-release (divalproex sodium) tablets, dated January 2025, retrieved from DailyMed, indicated, Divalproex sodium is .comprised of sodium valproate and valproic acid .Somnolence (drowsiness) in the elderly can occur .Depakote dosage should be increased slowly and with regular monitoring for fluid and nutritional intake .Co-administration of valproate can affect the pharmacokinetics (how the body interacts with administered medications) of other drugs (e.g. [example] diazepam .) by inhibiting their metabolism (when your body processes/breaks-down medications) . During an interview on March 12, 2025 at 11:53 a.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated she cared the for Resident 1 for approximately two (2) months. LVN 5 stated Resident 1 was at risk for falls, needed assistance to walk, and needed to be monitored to ensure he would not get up unassisted. During an interview on March 12, 2025 at 11:59 a.m. with the Certified Nursing Assistant (CNA), the CNA stated she had witnessed Resident 1 get out of bed and crawl on his knees one time. The CNA stated she had not witnessed Resident 1 fall. The CNA stated she was aware the resident fell before and had seen his bruises. During an interview on March 12, 2025 at 12:08 p.m. with LVN 3, LVN 3 stated Resident 1 was able to stand on his own and if he was told not to stand due to the fall risk he would stand up and walk outside the door. LVN 3 stated Resident 1 was not combative and mildly confused. During an interview March 12, 2025 at 12:38 p.m. with the Assistant Director of Nursing (ADON), the ADON stated she was not aware of Resident 1's falls on January 31, 2025 or March 8, 2025. The ADON acknowledged the resident was at risk for falls and stated he needed assistance to walk. During an interview on March 12, 2025 at 1:20 p.m. with the Director of Nursing (DON), regarding Resident 1's fall on January 31, 2025, the DON stated the fall occurred outside of the facility during an office visit that was witnessed by the Orthopedic doctor. The DON acknowledged the resident was taking a combination of potentially sedating medications including Remeron, Ativan, Depakote, oxycodone-acetaminophen, trazodone, and gabapentin. When asked whether the facility asked the pharmacist to review Resident 1's medication regimen to see if the fall could have been attributed to the medications, the DON stated a medication review was not requested. The DON said, We don't think the medications affected the fall. The DON stated Resident 1 fell because he was asked to stand and walk. Regarding Resident 1's second fall on December 8, 2025, the DON stated the resident was taken to the hospital. The DON acknowledged the resident's medications had potential side effects and drug interactions. During a telephone interview on March 12, 2025 at 2:03 p.m. with the Medical Director (MD), the MD stated he was directly involved in Resident 1's care. The MD stated all psychotropic medications were managed by the Psychiatrist and the Psychiatry Nurse Practitioner (NP); and they updated him when changes were made to Resident 1's psychotropic medications. Regarding Resident 1's recent falls, the MD stated he was aware Resident 1 was currently hospitalized due to a fall on March 8, 2025 and he was aware of the previous fall on January 31, 2025. The MD reviewed Resident 1's current medications and acknowledged the resident was currently taking a combination of potentially sedating medications including Remeron, Ativan, Depakote, oxycodone-acetaminophen, trazodone, and gabapentin. The MD acknowledged the combination of medications could have had the potential for additive sedation. When asked if a pharmacist should have reviewed Resident 1's medications after the fall on January 31, 2025, the MD stated the pharmacist should have reviewed the medications. During a telephone interview on March 13, 2025 at 9:03 a.m. with the Consultant Pharmacist (CP), the CP stated during the monthly Medication Regimen Review (MRR), all medications for all residents were reviewed for appropriateness (timing, with or without food, parameters, monitoring), potential adverse effects, and potential drug-drug interactions. The CP stated he was not informed by the facility when Resident 1 fell on January 31, 2025. The CP stated he was unaware Resident 1 had another fall on March 8, 2025. The CP reviewed Resident 1's current medications and acknowledged the resident was currently taking a combination of potentially sedating medications including Remeron, Ativan, Depakote, oxycodone-acetaminophen, trazodone, and gabapentin. The CP stated if he was informed that Resident 1 fell on January 31, 2025, he would have recommended additional monitoring for increased risk of falls, dizziness and sedation when the medications were taken together. During a telephone interview on March 13, 2025 at 9:41 a.m. with the Psychiatry Nurse Practitioner (NP), the NP stated he was Resident 1's mental health primary provider and worked with the Psychiatrist to manage Resident 1's psychotropic medications. The NP stated he recently saw Resident 1 on February 18, 2025 and acknowledged the resident was currently taking a combination of potentially sedating medications including Remeron, Ativan, Depakote, oxycodone-acetaminophen, trazodone, and gabapentin. The NP stated he was informed that Resident 1 had a fall on January 31, 2025 but had not been informed Resident 1 sustained another fall on March 8, 2025. A review of the facility's policy and procedures (P&P) titled, Use of Psychotropic Medications, dated December 19, 2022, indicated, The effects of psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as but not limited to .during the pharmacist's monthly medication regimen review .during significant change .The resident's response to the medication (s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record . A review of PI for Trazodone tablets, dated February 2024, retrieved from DailyMed, indicated, Warnings and precautions .Potential for Cognitive and Motor Impairment .adverse reactions .blurred vision, syncope (dizziness), drowsiness, fatigue .drug interactions .CNS Depressants: Trazodone .may enhance effects of .other CNS depressants . A review of PI for quetiapine (Seroquel) tablets, dated January 2025, retrieved from DailyMed, indicated, Most common adverse reactions .somnolence, dizziness . A review of PI for Gabapentin tablets, dated August 2023, retrieved from DailyMed, indicated, Warnings .Somnolence/Sedation and Dizziness .adverse reactions .Somnolence, dizziness, fatigue .drug interactions .Respiratory depression and sedation, sometimes resulting in death, have been reported following coadministration of gabapentin with opioids (e.g. [example] .oxycodone .) A review of PI for Oxycodone/acetaminophen tablets, dated January 2024, retrieved from DailyMed, indicated, Risks from concomitant (combined) use with Benzodiazepines or other CNS depressants profound sedation, respiratory depression, coma, and death may result from the concomitant use of oxycodone and acetaminophen tablets with benzodiazepines and/or other CNS depressants, including .non-benzodiazepine sedatives/hypnotics, anxiolytics .antipsychotics .Because of these risks, reserve concomitant prescribing of these drugs for use in patients for whom alternative treatment options are inadequate.

Based on interview and record review, the facility failed to ensure provision of pharmacy services met the needs of the residents when Residents 54 and 182 were missing documentation for the administration of controlled substance (CS, those with high potential for abuse and addiction) medications. The CS medications were signed out of the Antibiotic or Controlled Drug Record Medication (count sheet, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate they were administered to the residents. Additionally, the CS medication was wasted (not administered to the resident and discarded) without two licensed nurses' documentation on the count sheet according to the facility's policy for Resident 54. These failures resulted in inaccurate accountability of CS medications, which had the potential for misuse or diversion. Findings: During an interview on March 11, 2025 at 10:05 a.m. with the Director of Nursing (DON), the DON stated the facility's process for CS medication administration and wasting was as follows: - Nursing staff should have assessed the resident's pain to verify the quality and location; - Offered non-pharmacologic intervention (NPI) and if NPI ineffective nurse should have given the CS pain medication; - During administration, nurse should have removed the CS pain medication from the cart and signed the count sheet and documented on the administration on the resident's MAR; - If CS pain medication was not given, nursing staff should have wasted with another nurse; and - If wasted, nursing staff should have documented in a progress note as not given and documented on the count sheet as wasted with another nurse that witnessed the waste. Resident 54 had a physician's order, dated December 29, 2024, for Ativan (lorazepam, a potent controlled medication for anxiety) 1 mg (milligram, unit of measurement), 1 tablet by mouth every 6 hours as needed for anxiety m/b (manifested by) fidgety in bed. During a concurrent interview and record review on March 11, 2025 at 11:57 a.m. with LVN 3, a review of Resident 54's Count Sheet for Ativan 1 mg tablet and MAR dated February 2025 indicated the nursing staff signed out one tablet on February 26, 2025 at 6 a.m. but did not document the administration on the MAR. LVN 3 stated facility's process for CS medication administration required nursing staff to have documented the administration on Resident 54's MAR and the Count Sheet. LVN 3 acknowledged one Ativan 1 mg tablet for Resident 54 was unaccounted in February 2025. Additionally, Resident 54's Count Sheet for Ativan 1 mg indicated one tablet was wasted on March 6, 2025 and did not have a second nurse witness documented on the Count Sheet. LVN 3 stated the nurse should have had another nurse sign on the Count Sheet as a witness for Resident 54's wasted Ativan 1mg tablet on March 6, 2025. Resident 182 had a physician's order, dated March 1, 2025, for hydrocodone-acetaminophen (a potent controlled medication for pain) 5/325 mg, 1 tablet by mouth every 4 hours as needed for moderate pain 4-6. A review of Resident 182's Count Sheet for hydrocodone-acetaminophen 5/325 mg tablet and MAR dated March 2025 indicated the nursing staff signed out one tablet on March 6, 2025 at 15:28 (3:28 p.m.) but did not document the administration on the MAR. During a concurrent interview and record review on March 13, 2025 at 1:28 p.m. with the DON, Resident 54's Count Sheet for Ativan 1 mg tablet and MAR dated February 2025; and Resident 182's Count Sheet for hydrocodone-acetaminophen 5/325 mg tablet and MAR dated March 2025 were reviewed. The DON acknowledged Resident 54 had one Ativan 1 mg tablet unaccounted in February 2025 and one Ativan 1 mg tablet wasted on March 6, 2025 without two nurse signatures on the Count sheet. Additionally, the DON acknowledged Resident 182 had one hydrocodone-acetaminophen 5/325 mg tablet unaccounted in March 2025. The DON stated it was important to have accurate CS accountability and documentation because these were controlled medications, and it could have led to diversion. A review of the facility's policy and procedures (P&P) titled, Medication Administration, dated December 19, 2022, indicated, Sign MAR after administered .If medication is a controlled substance, sign narcotic book. A review of the facility's P&P titled, Controlled Substance Administration & Accountability, dated June 5, 2023, indicated, In call cases, the dose noted on the usage form or entered into the automated dispensing system must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug Record, or other facility specified from and placed in the patient's medical record .The Controlled Drug Record (or other specified form) serves the dual purpose of recording both narcotic disposition and patient administration .The Controlled Drug Record is a permanent medical record document and in conjunction with the MAR is the source for documenting any patient-specific narcotic dispensed from the pharmacy .Two licensed staff must witness any disposal or destruction of a controlled substance and document same on the Drug Disposition Record, Controlled Drug Record, or via the automated dispensing system .

Based on interview and record review, the facility failed to ensure, six of nine residents reviewed for Advance Directive (AD - written statement of a person's wishes regarding medical treatment) (Residents 9, 29, 46, 50, 51, 58) had the following: 1. A copy of the AD available in the resident's record for Resident 9; and 2. The resident or their resident representative had been provided information regarding the formulation of an AD for Residents 29, 46, 50, 51, and 58. These failures had the potential to result in the ADs for Residents 9, 29, 46, 50, 51, and 58 not being readily accessible to staff and physicians, which could lead to the residents' wishes regarding medical treatment being unknown and ultimately not honored. Findings: 1. Resident 50's record was reviewed. Resident 50 was admitted to the facility on [DATE]. A review of Resident 50's Physician Orders for Life-Sustaining Treatment (POLST), dated May 4, 2023, indicated, Resident 50 did not have an AD. A review of Resident 50's Minimum Data Set (MDS - an assessment tool), dated January 6, 2025, indicated Resident 50 had Brief Interview of Mental Status (BIMS - a tool to assess cognitive function of an individual) score of 13 (intact cognitive response). A review of the Social Service assessment dated [DATE] indicated, .Advance Directives .DPOA (Durable Power of Attorney) for healthcare .agent .(name of representative). There was no documented evidence a copy of the DPOA was placed in Resident 50's medical record or was there evidence the resident or resident representative (RP) was provided information about the right to formulate an AD. On March 13, 2025, at 12:50 p.m. a concurrent interview and record review were conducted with Social Services Assistant (SSA) 1. SSA 1 stated the social service assessment indicated Resident 50 had a DPOA and that an AD had been reviewed. SSA 1 stated if a resident had an AD and DPOA, copies should be obtained and placed in the resident's medical record. SSA 1 stated no follow up had been conducted to indicate whether Resident 50 had an AD or DPOA. SSA 1 further stated Resident 50's AD and DPOA should have been available and accessible to the staff and physician. 2. Resident 9's record was reviewed. Resident 9 was admitted to the facility on [DATE]. A review of the Social Service assessment dated [DATE], indicated, an AD and POLST were marked as available. A review of Resident 9's Physician Orders for Life Sustaining Treatment (POLST), dated June 29, 2024, indicated, .Advance Directive .available and reviewed .health care agent if named in advance directive .name .(name of representative) . There was no documented evidence in Resident 9's medical record that a copy of the AD was obtained and made accessible to staff and the physician. On March 13, 2025, at 12:50 p.m. a concurrent interview and record review were conducted with Social Services Assistant (SSA) 1. SSA 1 stated a social service assessment was conducted for all residents upon admission and that the assessment should include notations indicating whether an AD was discussed. SSA 1 stated if a resident had an AD, a copy of the AD should be obtained and placed in the resident's medical record. SSA 1 stated Resident 9 was indicated to have had an AD but it was not available in the resident's record. SSA 1 further stated Resident 9's AD should have been available and accessible to both staff and the physician. 44505 3. On March 12, 2025, at 2:15 p.m., during an interview with Resident 29, Resident 29 stated she does not have an advance directive and would like to have one so they would know her wishes. A review of Resident 29's 'ADMISSION RECORD, indicated Resident 29 was admitted to the facility on [DATE] with diagnoses which included spinal stenosis (narrowing of the spine). A review of Resident 29's HISTORY AND PHYSICAL EXAMINATION, dated June 16, 2024, indicated, Resident 29 was alert and oriented to person, place, time and event. A review of Resident 29's Social History Assessment, dated December 26, 2023, did not indicate Resident 29 had an AD. A further review of Resident 29's medical records indicated there was no documented evidence Resident 29 and or RP were provided information and education regarding AD. On March 13, 2025, at 12:55 p.m., during a concurrent interview and review of Resident 29's medical record with SSA 1, she stated Resident 29 had no AD and was not provided with resources and education. SSA 1 further stated Resident 29 should have been provided with resource and education and documented in the medical records. 4. A review of Resident 46's 'ADMISSION RECORD, indicated Resident 46 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm of prostate (prostate cancer). A review of Resident 46's POLST dated February 29, 2024, did not include information regarding Advance Directive. A review of Resident 46's Advance Directive Acknowledgment, dated March 4, 2024, indicated, .I HAVE NOT executed an 'Advance Directive' . A review of Resident 46's Social History Assessment, dated March 11, 2024, did not indicate Resident 46 had AD. A review of Resident 46's, HISTORY AND PHYSICAL EXAMINATION, dated March 24, 2024, indicated Resident 46 was awake, alert, oriented to person, place and time. A further review of Resident 46's medical record indicated no documented evidence Resident 46 and or RP had been provided information and education regarding AD. On March 13, 2025, at 12:55 p.m., during a concurrent interview and review of Resident 46's medical record with SSA 1, she stated Resident 46 did not have an AD and was not provided with resources and education. SSA 1 further stated Resident 46 should have been provided resources and education and this should have been documented in the medical records. 50309 5. Resident 58's record was reviewed. Resident 58 was admitted to the facility on [DATE]. A review of Resident 58's MDS, dated [DATE], indicated Resident 58 had BIMS score of 14 - cognitively intact. A review of Resident 58's POLST, dated March 22, 2024, indicated, .No Advance Directive .discussed with legally recognized decision maker (daughter) . A further review of Resident 58's medical records indicated the resident was not provided information or education about formulating an AD. On March 13, 2025, at 1:02 p.m. a concurrent interview and record review were conducted with Social Service Assistant (SSA) 1. SSA 1 stated, a social services assessment was conducted for all residents upon admission and that the assessment should include notations indicating whether an AD was discussed. SSA 1 stated, if a resident had an AD, a copy should be placed in the resident's medical record. SSA 1 stated, Resident 58 did not have an AD and there was no documentation in the resident's medical record indicating that education, information, or follow-up regarding the formulation of an AD had been provided to the resident or the RP. 6. Resident 51's record was reviewed. Resident 51 was admitted to the facility on [DATE]. A review of Resident 51's MDS, dated [DATE], indicated, Resident 51 had BIMS score of 15 - cognitively intact. A review of Resident 51's POLST, dated July 2, 2024, indicated, .Advanced Directive not available . A further review of Resident 51's medical records indicated the resident was not provided information or education about formulating an AD. On March 13, 2025, at 1:02 p.m. a concurrent interview and record review was conducted with SSA 1. SSA 1 stated the social service assessment was conducted for all residents upon admission and that the assessment should have notations which indicated the AD was discussed. SSA 1 stated if the resident had an AD, a copy of the AD was placed in the resident's record. SSA 1 stated Resident 51 had no AD and there were no documentations in the resident's medical records whether education, information and a follow up regarding formulating an AD were provided to the resident or RP. A review of the facility Policy and Procedure titled, Residents' Rights Regarding Treatment and Advance Directives, dated December 2022, indicated, .the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident, if cognitively able to, would like to formulate an advance directive .the facility will provide information and education .the facility will provide the resident or resident representative information, in a manner that is easy to understand, about the rights to refuse medical or surgical treatment and formulate an advance directive .should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff .

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. For Residents 36 and 57, nursing staff failed to properly clean and disinfect shared blood pressure (BP-pressure of blood in blood vessels) cuffs, stethoscopes, and glucometers (blood glucose meter to measure and display the amount of sugar (glucose) in your blood) according to the disposable Sani-Cloth Prime disposable wipe manufacturer's specified contact time (the time the resident equipment was to be in contact with the disposable wipes to kill micro-organisms). 2. For Resident 18, the neurotherapy treatment nurse (healthcare provider who examines brain activity and function) did not wear personal protective equipment (PPE - equipment, such as gloves and gown, used to protect against infection or illness) when providing therapy to Resident 18 on enhanced barrier precaution (EBP-an infection control intervention to reduce transmission of multidrug-resistant organisms [MDRO- bacteria that have become resistant to multiple antibiotics). These failures had the potential for the vulnerable residents to be exposed to cross-contamination and the development of infections. Findings: 1. During a medication pass observation on March 10, 2025 at 9:15 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 was observed using a shared manual BP cuff and stethoscope to measure Resident 57's BP. LVN 4 was observed wiping the shared manual BP cuff and stethoscope with a Sani-Cloth Prime disposable wipe and said, Those are our one-minute wipes. LVN 4 did not disinfect the manual BP cuff and stethoscope according to the manufacturer specified contact time. During a medication pass observation on March 10, 2025 at 12:20 p.m. with LVN 3, LVN 3 was observed using a shared glucometer to measure Resident 36's concentration of blood glucose. LVN 3 was observed wiping the glucometer with a Sani-Cloth Prime disposable wipe and did not disinfect the glucometer according to the manufacturer specified contact time. LVN 3 said, This is a one-minute Sani-Cloth. When asked to describe what one-minute meant, LVN 3 stated it meant to wipe and wait for one minute. LVN 3 said, Drying time is one minute. During an interview on March 11, 2025 at 8:57 a.m. with the Infection Preventionist (IP), the IP stated the expectation was for nursing staff to have used the one-minute Sani-Cloth Prime disposable wipe to sanitize equipment shared between residents such as BP cuffs, stethoscopes and glucometers. When asked to describe what one-minute meant, the IP stated, nurses should have wiped down the shared equipment and waited one minute for the product to be efficient. When asked if nurses were expected to keep the shared equipment wet when wiping with the Sani-Cloth Prime disposable wipes, the IP said, No. During the same interview, the IP reviewed the manufacturer's labeled instructions on the Sani-Cloth Prime disposable wipe bottle and acknowledged nursing staff should have been instructed to keep equipment wet for one (1) minute to achieve contact time when they wiped shared resident care equipment according to the manufacturer's instructions. The IP stated it was important to follow the manufacturer's instructions to ensure the wipe worked effectively to kill the organisms. During an interview on March 11, 2025 at 10:01 a.m. with the Director of Nursing (DON), the DON stated the expectation was for nursing staff to follow the disposable wipe manufacturer's instructions for contact time when they wiped shared resident care equipment. The DON stated it was important to follow the manufacturer's instructions to disinfect and kill bacteria to prevent the spread of infections. During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Equipment, dated December 19, 2022, the P&P indicated, Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC (Centers for Disease Control and Prevention- a nationally recognized disease control and prevention organization) recommendations in order to break the chain of infection .Reusable multiple-resident items are items that may be used multiple times for multiple residents. Examples include stethoscopes, blood pressure cuffs .Non-critical items come in contact with intact skin, but not mucous membranes. These items require cleaning followed by low/intermediate-level disinfection (i.e. [example], use of EPA [Environmental Protection Agency, protects human health and the environment by enforcing environmental laws] - registered disinfectants) following manufacturer's instructions .Staff shall follow established infection control principles for cleaning and disinfecting reusable, non-critical equipment .Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident .Multiple-resident use equipment shall be cleaned and disinfected after each use .Only EPA-registered disinfectants with kill claims for the common organisms found in the facility . During a review of the manufacturer's instructions for contact time for the Sani-Cloth Prime disposable wipes provided by the facility, the manufacturer's instructions indicated, Contact time .thoroughly wet surface. Allow surface to remain visibly wet for one (1) minute. Let air dry. 50309 2. On March 10, 2025, at 11:04 a.m., during an observation of the Neurotherapy Nurse (NN), the NN was observed entering Resident 18's room without wearing an isolation gown while providing contact care and applying an electroencephalogram headset (EEG - a device that uses sensors (electrodes) to measure and record the brain's electrical activity). On March 10, 2025, at 11:07 a.m., during a concurrent observation and interview of the NN inside Resident 18's room with the Assistant Director of Nursing (ADON), the ADON stated the NN was not wearing an isolation gown, and stated the NN should have worn an isolation gown to prevent the spread of infections. On March 10, 2025, at 11:12 a.m., during an interview with the NN, the NN stated she forgot to check the sign on the door and forgot to wear PPE. The NN further stated she should have worn an isolation gown to protect the resident and prevent the spread of germs. On March 11, 2025, at 3:45 p.m., an interview with the Infection Preventionist nurse (IP) was conducted. The IP stated her expectation was for all staff to follow the designated precaution protocols designated for each resident and to wear the appropriate PPE as indicated. The IP further stated the NN should have worn PPE to prevent the spread of infections to residents. A review of Resident 18's medical record was conducted. Resident 18 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke), dysphagia (difficulty swallowing), gastrostomy status (an opening into the stomach for food). A review of Resident 18's Order Summary, dated March 12, 2025, included enteral feed (tube feeding) and enhanced standard precaution r/t gastrostomy tube use . A review of Resident 18's care plan titled, Resident on Enhanced Barrier Precautions R/T G Tube use, included the interventions, Apply Enhanced Barrier Precautions to prevent the spread of infections for specific care activities such as: Morning and Evening Care, Toileting and Changing Incontinence Briefs, Caring for Devices and Giving Medical Treatments, Wound Care, Mobility Assistance and Preparing to Leave the Room and Cleaning and Disinfecting the Environment . A review of facility policy and procedure titled, Enhanced Barrier Precautions, dated December 19, 2022, indicated, .it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .EBP/ESP are indicated for residents with any of the following .indwelling medical devices (e.g .feeding tubes .) .make gowns and gloves available prior to performing task .enhanced barrier precautions should be followed outside the resident's room .

Based on interview, and record review, the facility failed to ensure residents received treatment and care in accordance with the professional standards of practice for two of three sampled residents (Residents 1 and 2) when: 1. Resident 1 was not provided assistance during mealtimes based on the resident's comprehensive assessment. Resident 1 needed limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs or non-weight bearing assistance) during meals. This failure resulted for Resident 1 to choke on his food and subsequently died while at the facility. 2. Resident 2 was not assessed and monitored when Resident 2 had a heart rate below normal (normal heart rate ranges from 60 to 100 beats per minute) at a rate of 55 bpm (beats per minute) (Irregular - new onset) on [DATE]. This failure had the potential to result in the delay in treatment which could cause further deterioration in the resident's condition. Findings: 1. A review of Resident 1's record indicated the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's care plan dated [DATE], indicated, . (name of the resident) has an ADL (activities of dailiy living) self-care performance deficit r/t (related to) [CONDITION(S)] ([CONDITION(S)] - stroke) with left sided weakness .Interventions/Tasks .EATING: The resident requires limited assistance by staff . A review of the Resident 1's history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] .DIAGNOSIS .dysphagia . On [DATE], at 3:24 p.m., during an interview, Certified Nursing Assistant (CNA) 2 stated he served Resident 1 a burrito which consisted of rice, beans, and meat at the time the choking incident happened. The CNA stated he left the resident after serving the burrito. He went back into the resident's room in less than ten minutes of leaving the resident's room and saw the resident with his head down. CNA 2 stated Resident 1 was on a regular diet and required supervision with eating. On [DATE], at 9:58 a.m., during an interview, Licensed Vocational Nurse (LVN 2) stated she was at the nurses' station, when she heard yelling coming from Resident 1's room. She stated she went to the room, and she saw Resident 1 choking and was trying to catch his breath. LVN 2 stated Resident 1 had difficulty opening his mouth, with food stuff coming out of his mouth. On [DATE], at 1:48 p.m., a Family Member (FM) was interviewed. The FM stated Resident 1 should never been left alone to eat. The FM stated whenever they visit the resident, she would cut the food for the resident. A review of Resident 1's document titled, Speech Therapy SLP (Speech Language Pathology) Discharge Summary, dated [DATE], indicated, .Discharge Recommendations .Strategies .To facilitate safety and efficiency, it is recommended the patient use the following strategies and/or maneuvers during oral intake: alternation of liquid/solids, bolus size modifications, general swallow techniques/precautions and rate modifications upright posture during meals . A review of the quarterly Minimum Data Set (an assessment tool) dated [DATE], indicated Resident 1 required limited assistance with eating. A review of Resident 1's progress notes dated [DATE], indicated, Around 1730 (5:30 p.m.) CNA(certified nursing assistant) went to check on patient, patient was not finished with his food .At around 1740 (5:40 p.m.) went back to check if patient had finished his meal. patient was attempting to cough up food, cna attempted [MEDICATION(S)] maneuver (a first aid procedure used to treat upper airway obstruction by foreign objects), it was unsuccessful, ran to nursing station to alert staff that patient was non-verbal, and possibly choking . A review of Resident 1's document titled, Documentation Survey Report, dated [DATE], indicated, Resident 1 was provided limited assistance during eating on [DATE], 3, 5, 6, 7, 9, 10, 11, 12, 13, 14, 16, 17, 18, 20, and 21, 2021. On [DATE], at 9:34 a.m., during an interview, CNA 3 stated Resident 1 had weakness on one side of the body. CNA 3 stated whenever she served the tray to Resident 1, she would cut the meat for him. CNA 3 stated she would remind Resident 1 to eat slowly. On [DATE], at 1:23 p.m., during an interview, the Director of Staff Development (DSD) stated the charge nurse should be informed for any change in condition of the resident. She stated the resident who had a change in the level of assistance required with eating should have been evaluated. The DSD stated for the safety of the resident, the licensed nurse should assess, notify the physician, and make recommendations to be seen by the therapist. On [DATE], at 2:13 p.m., during an interview, the MDS Nurse (MDSN) stated if a resident required limited assistance with eating, the resident should not be left alone. The MDSN stated the staff should be cueing and observing the resident during mealtime. In a concurrent review of Resident 1's MDS with the MDSN, she verified Resident 1 required limited assistance with eating. She stated the previous MDSN should have informed the staff that Resident 1 required limited assistance with eating. On [DATE], at 1:33 p.m., in an interview and record review with CNA 3, she stated on [DATE], morning shift, the CNA documented Resident 1 required limited assistance with eating. CNA 3 stated for limited assistance with eating, the staff should have an oversight of the resident. She stated Resident 1 should be helped a little bit. CNA 3 stated Resident 1 should be reminded to chew food slowly. On [DATE], at 2:24 p.m., the Interim Director of Nursing (IDON) was interviewed. She stated during the Interdisciplinary Team (IDT) meeting, the MDS nurse would provide information on how much assistance does a resident need during Activities of Daily Living. She stated the staff must be around to help and should not be leaving a resident requiring limited assistance during ADLs. In a concurrent review of Resident 1's MDS assessment, the IDON stated Resident 1 had been requiring limited assistance with eating. She stated the staff should have been with Resident 1 while eating and should have not been left alone. A review of Resident 1's progress notes dated [DATE], indicated, .pronounced dead at 1838 (6:38 p.m.) by paramedics . A review of Resident 1's document titled, Certificate of Death, dated [DATE], indicated, .Cause of Death .Immediate Cause .CHOKING .DESCRIBE HOW INJURY OCCURRED .CHOKED ON FOOD BOLUS . 2. A review of Resident 2's medical record indicated the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the document titled, Weights and Vitals Summary, from [DATE], to [DATE], indicated the following heart rate: - .[DATE] ([DATE]) 19:13 (7:13 p.m.) 60 bpm (beats per minute) (Regular) . - .[DATE] 02:49 54 bpm . - .[DATE] ([DATE]) 19:02 (7:02 p.m.) 100 bpm . - .[DATE] 01:08 52 bpm . - .[DATE] 8:37 60 bpm . - .[DATE] ([DATE]) 18:26 (6:26 p.m.) 55 bpm (beats per minute) (Irregular - new onset) . A review of Resident 2's document titled, Skilled Note, dated [DATE], indicated, .P (pulse) 55 - [DATE] 18:26 (6:26 p.m.) Pulse Type: Irregular - new onset . (normal heart rhythm - regular) A review of Resident 2's record indicated there was no documentation the licensed nurse rechecked, reassessed, and monitored Resident 2 after the resident's pulse was measured at 55 bpm. There was no documentation the physician was notified. A review of Resident 2's document titled, Event Note, dated [DATE], indicated, .Resident noted unresponsive and with no pulse at around 2140 (9:40 p.m.) while passing medications . (name of mortuary) notified and stated they will call us back and will us know when are the (sic) coming to pick up the body . On [DATE], at 2:56 p.m., during an interview, Certified Nursing Assistant (CNA) 1 stated she would refer to the licensed nurse if a resident's heart rate was not normal. She stated she would recheck the resident's heart rate. CNA 1 stated the normal heart rate is 60 to 100 beats per minute. On [DATE], at 2:57 p.m., during an interview, Licensed Vocational Nurse (LVN) 1 stated the physician should be notified when there is a change in the resident's heart rate, which is below the baseline. LVN 1 stated Resident 2 should have been assessed and monitored since the resident's heart rate was 55 beats per minute and the heart rate was irregular. LVN 1 stated whenever a resident had an abnormal heart rate, it was considered a change of condition. She stated the licensed nurse should have rechecked the resident's heart rate and should have notified the physician. LVN 1 stated she did not see any documentation that the nurse notified the doctor and an assessment was conducted. A review of the facility policy and procedure titled, Incident and Reportable Event Management, dated [DATE], indicated, .Incident/Injury .The licensed nurse should assess the resident .The licensed nurse should create an event note and include the following details .The assessment details of the resident .Notification of family or responsible party .Notification of physician . A review of the facility policy and procedure titled, Changes in Resident's Condition or Status, dated [DATE], indicated, .To outline the actions required to address a change in resident's condition or status .The facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status .A facility must immediately inform the resident, consult with the resident's physician; and notify .when there is .a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions .) .

Based on interview and record review, the facility failed to ensure provision of safety and supervision for one of three sampled residents (Resident A) when: 1. Resident A, who had left-sided body weakness, poor trunk (upper body) control, and poor sitting balance, was placed on a commode (movable toilet chair) without adequate physical support to prevent imbalance, leading to the resident's fall onto the floor; 2. Facility staff did not complete a fall risk assessment/evaluation for Resident A during her admission to the facility, as per the facility's policy and procedure for fall prevention and management; 3. Resident A's interdisciplinary team (IDT- group of health care professionals) care plans did not reflect the use of a half-lap tray (device used to provide support to the arm and shoulder when sitting in a wheelchair) to manage the resident's safety due to her left-sided body weakness and neglect (disabling condition following brain damage in which patients fail to be aware of items to one side of space) and did not reflect or indicate the resident's history of fall as identified in the admission assessment; and 4. The facility staff failed to ensure the plan of care for providing total assistance (full staff performance) with toileting was properly implemented for Resident A. These failures resulted in a fall incident for Resident A, requiring re-hospitalization and intensive care treatment and management for sustained injuries from the fall, such as contusion (bruise), abrasion (skin scrape), headache, vomiting, and worsening of the resident's [MEDICAL CONDITION] (bleeding inside the skull or brain). Findings: On (MONTH) 2, (YEAR), an unannounced visit to the facility was conducted to investigate a complaint related to quality of care concerns. Resident A's record was reviewed on (MONTH) 2, (YEAR). Resident A was admitted to the facility on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. The facility's history and physical, dated (MONTH) 15, (YEAR), indicated, .This resident: does not have the capacity to understand and make decisions . The acute care hospital's history and physical, dated (MONTH) 6, (YEAR), indicated, .Patient is a [AGE] year-old .who presented to (the) emergency room with left-sided weakness, sudden onset slurred speech, right side gaze and left-sided vision field loss .Problem list .At risk for falls . The acute care hospital's occupational therapy (applied science and health profession that provides skilled treatment to help individuals achieve and maintain functionality of ADLs- activities of daily living), dated (MONTH) 10, (YEAR), at 2:44 p.m., indicated, .Patient was unable to participate in LE (lower extremity) / UE (upper extremity) dressing. Reported no sensation and no demonstration of movement in L (left) UE/LLE . The facility's Admission Assessment, dated (MONTH) 13, (YEAR), indicated the following, - .history of falls (in the) last 30 days .number of falls: 1 .What was patient doing at time of fall? getting out of shower . - Speech .is slurred, slow or difficult to understand . - Paralysis/Weakness: yes . - Fine motor skills: Is patient able to grasp, hold, feel with hands? No .left sided weakness . - Assistive Devices: bed pan . There was no documented evidence a fall risk assessment/evaluation was completed on Resident A's admission. The baseline care plan titled, At Risk for Falls, dated (MONTH) 14, (YEAR), indicated, .unsteady ambulation .L side weakness .Resident Goal: .will not experience a fall related injury that requires hospitalization through next review .assistive devices in reach .assist with transfers .assist with toileting . The occupational therapy (OT) evaluation notes, dated (MONTH) 14, (YEAR), at 12:56 p.m., indicated Resident A had impairment with strength, sensation, and balance due to severe left side body neglect and flaccidity (soft and hanging loosely or limply). The notes indicated the resident required total assistance from staff with toileting, dressing, and functional transfers. The notes further indicated Resident A was given left half-tray to support her left upper extremity while in the wheelchair. Resident A's interdisciplinary care plans for Falls and Activities of Daily Living-Self Care Deficit did not reflect or indicate the resident's history of fall as identified in the admission assessment. The comprehensive care plans did not reflect the use of the safe adaptive device: half lap tray for support while in the wheelchair. The physical therapy (PT) evaluation notes, dated (MONTH) 14, (YEAR), at 1:11 p.m., indicated Resident A had poor static sitting balance (ability to balance while holding one position) and dynamic sitting balance (ability to balance while moving or changing between positions). The notes indicated the resident required max (maximum) assistance of two persons with transfers. The notes indicated Resident A had poor motor coordination and impaired sensation or sensory processing. The OT treatment progress notes from (MONTH) 14, (YEAR) to (MONTH) 18, (YEAR), indicated Resident A had poor safety awareness, requiring total dependence on staff with toileting in bed. The PT treatment progress notes from (MONTH) 17, (YEAR) to (MONTH) 21, (YEAR), indicated Resident A remained to have poor sitting balance. There was no documented evidence the physical therapists and occupational therapists conducted and/or completed an evaluation, training, or safety clearance with toileting, using a commode or a regular bathroom toilet for Resident A. Resident A's Activities of Daily Living care plan, dated (MONTH) 22, (YEAR), indicated, Resident is at risk of developing complications R/T (related to) the needing (of) total assistance in the following ADLS .toilet use .personal hygiene . The nursing progress notes, dated (MONTH) 23, (YEAR), at 4:34 p.m., indicated, .Summary of Findings: Pt. noted on floor in bathroom .Can's (sic) (CNA- Certified Nursing Assistant) assisting pt. to restroom in back of 300 hall bathroom . while cna (was) standing by (the) door, pt. leaned forward and fell on to (the) floor lying on (her) stomach. Noted with laceration to left eyebrow . The nursing progress notes, dated (MONTH) 23, (YEAR), at 6:21 p.m., indicated, .Late entry .at about 2:40 p.m cna .yelled out to me that they needed help. As I arrived at the back .hall shower, pt. from (room) 313b was lying on (the) floor face down with left arm behind her and right arm in front (of her). Pt. noted with laceration to (her) left eyebrow. When asked pt. what happened she stated she was sitting on (the) toilet and leaned forward and fell .pt c/o (complained of) pain to head and to right elbow .MD notified with orders to send to (the) ER (emergency room ) for EVAL (evaluation) . The document titled, Fall Risk Evaluation, dated (MONTH) 23, (YEAR), indicated, Instructions: To be completed upon admission and quarterly. When resident's total score is 10 or more, interventions should promptly be put in place .Total Score = 17 (A resident who scores a 10 or higher is at risk) . Resident A's general acute care hospital (GACH) record was requested and reviewed on (MONTH) 2, (YEAR). The acute care hospital's emergency notes, dated (MONTH) 23, (YEAR), at 7:47 p.m., indicated, .(Resident A was) transferred here after she fell , hit her head (and) has worsening of her intracranial bleeding .This was a trauma transfer . The acute care hospital's history and physical, dated (MONTH) 24, (YEAR), at 1:38 p.m., indicated, .Chief Complaint/Reason for Consultation: s/p (status [REDACTED].pt was in the bathroom and fall (sic) forward and was brought to (name of GACH 1). She was found to have a 4 X 2.5 cm (centimeters) right basal ganglia bleed (brain bleed) .Pt was transferr(ed) to (name of GACH 2) for trauma. At (name of GACH 2), repeat CT scan 3.5 hours later showed 4.3 X 2.7 cm right basal ganglia bleed .Neurosurgeon was consulted. Pt is admitted to ICU. Pt endorses headache, vomiting X 1, left side paralysis and decrease sensation on left side .contusion/abrasion above her left eye .This patient is critically ill due to vital organ failure including: Intraparenchymal brain hemorrhage (bleeding in the brain), brain compression. The patient has a high probability of imminent or life threatening deterioration due to the above and requires critical care management .including high complexity medical decision making and the assessment, manipulation and support of vital organ functions in an attempt to prevent further clinical decline. This included: brain hemorrhage and compression management . On (MONTH) 2, (YEAR), at 9:52 a.m., Certified Nursing Assistant (CNA) 1 was interviewed regarding Resident A. CNA 1 stated Resident A was alert with periods of confusion and had the tendency of moving while in the wheelchair. CNA 1 stated resident A was not stable with her standing balance, requiring maximum assistance from two staff during transfers. CNA 1 stated Resident A should not be left by herself on a chair. On (MONTH) 2, (YEAR), at 10:23 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed regarding Resident A. LVN 1 stated Resident A had the tendency to lean forward when in a sitting position. On (MONTH) 2, (YEAR), at 10:45 a.m., LVN 2 was interviewed. LVN 2 stated Resident A was noted frequently leaning forward or on her left side. On (MONTH) 2, (YEAR), at 10:53 a.m., the Occupational Therapist (OT) for Resident A was interviewed. The OT stated Resident A was falling on her left side due to left side neglect and poor trunk control. The OT stated Resident A was impulsive and was unsafe to stand. The OT stated Resident A required two persons providing max assistance for transfers. The OT stated Resident A also had poor sitting balance and poor sitting dynamics. The OT stated they used the half lap tray on Resident A's left side to support her arm because she would just drop her arm. The OT stated due to Resident A's poor trunk control and sitting balance, they had not evaluated or attempted the resident for out-of-bed toileting. The OT stated Resident A should require 100 percent support from staff for toileting. When asked about the incident, the OT stated staff should have stayed with the resident, providing support and balance to her body. On (MONTH) 2, (YEAR), at 11:07 a.m., the Physical Therapist (PT) was interviewed. The PT stated Resident A needed max assistance with transfers. The PT stated the latest therapy progress notes indicated the resident still had poor sitting dynamics. The PT confirmed there was no safety evaluation or clearance from the PT or the OT for Resident A to use the toilet or the commode. On (MONTH) 2, (YEAR), at 11:15 a.m., CNA 2 was interviewed. CNA 2 stated she provided care to Resident A while in the facility. CNA 2 stated she used the bed pan for Resident A's toileting needs. CNA 2 stated Resident A was not strong .not able to support herself .not safe for a commode. On (MONTH) 2, (YEAR), at 11:18 a.m., LVN 3 was interviewed. LVN 3 stated she was the licensed nurse assigned to Resident A when the incident occurred on (MONTH) 23, (YEAR). LVN 3 stated her attention was called by a staff for help for a resident who fell in the shower room. LVN 3 stated she saw Resident A lying on her stomach on the floor in the shower room. LVN 3 asked Resident A about the incident, and she stated, I just fell forward. LVN 3 stated she investigated the fall incident. LVN 3 stated prior to Resident A's fall, CNA 3 and CNA 4 assisted the resident to use the toilet in the shower room. LVN 3 stated CNA 4 told her she stayed at the door of the shower room with her body in between the door while Resident A was on the toilet. When asked about ADLs and toileting for newly admitted residents, LVN 3 stated they followed therapy (PT/OT) clearance before getting a resident out of bed for toileting. When asked about Resident A's toileting evaluation, LVN 3 stated she was not aware if the resident was evaluated or cleared by the therapists for the use of the commode or the toilet. On (MONTH) 2, (YEAR), at 11:24 a.m., CNA 3 was interviewed. CNA 3 stated she assisted CNA 4 in transferring Resident A from the wheelchair to the commode in the shower room toilet. CNA 3 stated she left Resident A with CNA 4 while she grabbed the linens outside of the shower room. CNA 3 stated while she was outside she heard a loud noise from the shower room. When asked about the facility's toileting ADL process for new admit residents, CNA 3 stated before they could bring a newly-admitted resident to the toilet, the therapists (PT/OT) would first assess the resident for safety. CNA 3 stated they would use a urinal or a bed pan for the resident temporarily while pending PT or OT evaluation and clearance for toileting. CNA 3 stated she was not aware if the resident was evaluated or cleared by the therapists for toileting. On (MONTH) 2, (YEAR), at 11:33 a.m., the Assistant Director of Nursing (ADON) was interviewed regarding Resident A's fall incident. The ADON stated, based on her investigation, CNA 4 was positioned in between the self-closing door of the shower room when Resident A fell on to the floor. The ADON stated the distance of the shower door to the toilet was approximately 3-4 feet. On (MONTH) 3, (YEAR), at 9:52 a.m., CNA 4 was interviewed. CNA 4 stated she was the CNA assigned for the first time for Resident A on (MONTH) 23, (YEAR). CNA 4 stated she worked a couple of days a month as part time in the facility. CNA 4 stated the fall incident happened around 2:30 p.m. on (MONTH) 23, (YEAR). CNA 4 stated she brought Resident A, with the assistance of CNA 3, to the shower room to use the toilet. CNA 4 stated she stayed in the shower room with her body in between the self-closing door to prop the door open. CNA 4 stated she closed the privacy curtain in front of Resident A. CNA 4 stated Resident A fell too fast onto the floor. CNA 4 stated she did not provide physical support to Resident A's body or trunk while she was sitting on the commode. CNA 4 stated she was not aware of Resident A's history of fall. CNA 4 stated she was not aware if the therapist had cleared Resident A to safely use the toilet or commode without physical support. On (MONTH) 4, (YEAR), at 9:55 a.m., the Registered Nurse Supervisor (RNS) was interviewed. The RNS stated she was the supervisor on (MONTH) 23, (YEAR) when the incident happened. The RNS stated Resident A was not stable to sit by herself as she was constantly sliding while in the wheelchair. The RNS stated she was not aware that the therapists had not done toilet transfers or the use of a commode for Resident A. The RNS stated staff should have used a bed pan temporarily until the therapist had cleared Resident A for safe toilet or commode use. On (MONTH) 4, (YEAR), at 3:23 p.m., Resident A's record was reviewed with the ADON. The ADON confirmed the use of the half lap tray for Resident A while in a wheelchair was not included in the interdisciplinary comprehensive care plans. The ADON confirmed Resident A's fall history was not reflected in the baseline and comprehensive care plans. When asked about the fall risk evaluation of the residents, the ADON stated the fall risk evaluation should be conducted on admission, quarterly, and/or after a fall incident. The ADON confirmed there was no documented evidence a fall risk evaluation was completed during Resident A's admission. The ADON confirmed that staff did not provide total assistance and support to the resident while toileting in the commode. The ADON stated staff should have used a bed pan for toileting until Resident A was evaluated by the therapist to safely use the toilet in the bathroom or shower room. The facility's policy and procedure titled, Falls Management, dated (MONTH) (YEAR), indicated: Policy Each resident will be assessed throughout the course of treatment for [REDACTED]. An interdisciplinary plan of care will be developed, implemented, reviewed and updated as necessary to reflect each resident's current safety needs and fall reduction interventions . Procedure .Assessment of Fall Risk & Care Plan Development .All residents will have a falls (sic) risk assessment completed on admission, following serious injury, after a significant change, quarterly, and as necessary .

Based on interview, and record review, the facility failed to ensure one (Resident A) in a sample of three residents in a universe of 71 residents, was free from unnecessary [MEDICATION NAME] ([MEDICATION NAME] an anticoagulant or blood thinner) doses, when the ordered laboratory test for monitoring therapeutic range (PT-[MEDICATION NAME] Time/INR-International Normalized Ratio) was not carried out. This failure resulted in excessive [MEDICATION NAME] level, extensive bleeding, and hemorrhagic shock (severe fluid loss which makes it impossible for the heart to pump sufficient amount of blood into the body) for Resident A. Findings: On (MONTH) 5, (YEAR), at 10 a.m., an unannounced complaint investigation was conducted at the facility. Resident A's record was reviewed. Resident A,who was [AGE] years old, was discharged from the acute hospital and arrived at the facility on (MONTH) 17, (YEAR) with [DIAGNOSES REDACTED]. Resident A's facility records included copies of records from the acute hospital which indicated: -Acute hospital history and physical, dated (MONTH) 16, (YEAR), XXX[AGE] year old female .[MEDICATION NAME] (significant side effects include [MEDICAL CONDITION] and stroke resulting in serious injury or death) already with supratherapeutic (level greater than would be used for treatment) INR . The document further indicated Resident A's INR on on (MONTH) 15, (YEAR) was critical at 5.5 (normal range is between 0.9 and 1.1). -Acute hospital SUMMARY OF CARE, which included discharge instructions to no longer take [MEDICATION NAME] 1 mg daily, COAGULATION 3/17/2018 05:43:00 INR: 5.8 .PT: 61.7-Normal range between 9.3 and 11.2 . Resident A's facility record further indicated: -Facility history and physical dated (MONTH) 19, (YEAR) indicated, .Pt (patient) was placed on Keflex (antibiotic) for uti (urinary tract infection) and had her [MEDICATION NAME] (used to treat a blood clot in the lungs) held due to elevated INR . The document further indicated Resident A's current medication included [MEDICATION NAME], .Take as directed by Anticoagulation clinic (sic) to thin blood . -physician's orders [REDACTED]. -physician's orders [REDACTED]. -physician's orders [REDACTED]. (continue) [MEDICATION NAME] 2 mg po daily, next INR 3/26/2018 -physician's orders [REDACTED].vaginal bleeding -The Medication Administration Record [REDACTED]. On (MONTH) 5, (YEAR), at 11:45 a.m., Resident A's record was reviewed with the Director of Nursing (DON). The DON stated Resident A was transferred to the acute hospital on (MONTH) 26, (YEAR) because around 1:45 p.m., Resident A was noted to have copious amount of red blood from the vaginal area. The DON stated Resident A belonged to a specific managed care group who had their own anticoagulation clinic that managed all of the [MEDICATION NAME] dosing and monitoring for all residents that were under the managed care group. The DON stated the managed care anticoagulation clinic gave the order to start Resident A's [MEDICATION NAME] 2 mgs daily on (MONTH) 20, (YEAR). The DON stated the physician's orders [REDACTED]. The supplemental order indicated: Last INR Result: INR 2.4 3/20/2018, [MEDICATION NAME] Dosing Instructions: start 2mg daily, Next INR Date: Follow up date: 03/23/2018. The DON stated on (MONTH) 23, (YEAR), the managed care anticoagulation clinic gave the order to continue [MEDICATION NAME] 2 mgs daily for Resident A. The (name of managed care group) Anticoagulation Service Supplemental Order dated, (MONTH) 23, (YEAR), indicated: Last INR Result: INR 2.4 3/20/2018, [MEDICATION NAME] Dosing Instructions: continue 2mg daily, Next INR Date: Follow up date: 03/26/2018. The [MEDICATION NAME] dose was continued based on PT/INR result from (MONTH) 20, (YEAR). Review of Resident A's printed laboratory results and the LAB ORDER LOG FOR (name of managed care group) PATIENTS ONLY with the DON indicated, the PT/INR ordered for Resident A to be drawn on (MONTH) 23, (YEAR) was not carried out. The DON confirmed there was no documented evidence that the facility was aware and followed up on the missed PT/INR ordered for (MONTH) 23, (YEAR). On (MONTH) 5, (YEAR), at 1 p.m., the facility Case Manager (CM) was interviewed with the DON. The CM stated part of her responsibility was coordinating the care of residents that belonged to the managed care group. The CM stated she called the managed care anticoagulation clinic today. The CM stated she was told the PT/INR for Resident A was not carried out on (MONTH) 23, (YEAR), because they (managed care group anticoagulation clinic laboratory) went to the wrong address for Resident A. Both the DON and the CM agreed the facility should have been monitoring Resident A's [MEDICATION NAME] dosing and PT/INR results. Resident A was subsequently admitted to the acute hospital on (MONTH) 26, (YEAR). The acute hospital emergency department records indicated Resident A's INR was 8.2 on (MONTH) 26, (YEAR). The acute hospital emergency department physician note, dated, (MONTH) 26, (YEAR), 3:27 p.m, indicated, .given the severity of bleeding 2 units of fresh frozen plasma (the liquid portion of human blood that has been frozen and preserved, used for blood transfusion) was ordered given her INR of over 8 in the context of heavy vaginal/GI (gastrointestinal) bleeding .Patient dropped her pressure (blood pressure) to become 80 over palp (palpation) .this time the patient remains hypotensive (low blood pressure) .Condition: Serious . The acute hospital history and physical, dated (MONTH) 26, (YEAR), indicated .Bleeding seemingly was so extensive that it was not possible to say if this was vaginal or rectal bleed .Markedly increased INR (due to excessive [MEDICATION NAME]) .[MEDICAL CONDITION], due to recurrent bleeding . The acute hospital physician progress notes [REDACTED].received 3 units of blood and 4 units of fresh frozen plasma . The acute hospital note dated, (MONTH) 28, (YEAR), 3:23 p.m., indicated Resident A's Admission Diagnosis(es): 1.) Extensive vaginal/rectal bleed, 2.) Excessive [MEDICATION NAME] level . Primary Diagnosis: [REDACTED].