Every finding on record at Monterey Palms Health Care Center

Based on interview and record review the facility failed to provide the necessary care and services for two of six residents reviewed (Resident 1 and 2) when:1a. For Resident 1, nursing staff failed to notify the physician of changes in vital signs, as indicated in the physician orders, on December 6, December 13, December 16, and December 22, 2025;1b. For Resident 1, nursing staff failed to administer Milk of Magnesia (medication used for constipation) as indicated in the physician orders on December 1 - 2, December 5 - 6, December 12 - 13, December 15, December 18, and December 25, 2025; and 2. For Resident 2, the facility did not facilitate transportation to a scheduled chemotherapy (drug treatment that uses powerful medications to destroy cancer cells) appointment scheduled on June 22, 2026. These failures placed Resident 1 and Resident 2 at risk for delayed medical intervention and adverse clinical outcomes.Findings:1. On June 25, 2026, Resident 1's medical record was reviewed.The admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included left femur fracture (broken left thigh bone), hypertension (high blood pressure), congestive heart failure (heart muscle is too weak to pump blood efficiently), and abnormal findings of blood (blood components falls outside laboratory standard reference range). The admission record indicated Resident 1 was transferred to the acute care hospital on December 25, 2025.The history and physical dated November 28, 2025, indicated Resident 1 had the capacity to make decisions.The physician orders indicated the following:-November 26, 2025, Vital signs Q (Q-every) shift (Shift 1: 7:00 AM - 3:00 PM, Shift 2: 3:00 PM - 11:00 PM, Shift 3: 11:00 PM - 07:00 AM; and-December 2, 2025, .Monitor for s/s (signs/symptoms) of dehydration (condition of when the body loses more fluids than taken in; s/s - low blood pressure, fast heartrate, dry mouth, decrease in urination, confusion, sunken eyes, and skin that doesn't flatten).The vital sign history was reviewed for the month of December 2025, and indicated the following:On December 6, at 9:41 am, BP: 86/56 (hypotension - low blood pressure top number of BP is below 100);On December 13, at 9:34 am, BP: 90/45;On December 16, at 9:50 am, HR:108 (tachycardia -high HR at or above 100);On December 16, at 12:29 pm, HR:108;On December 16, at 7:22 pm, HR:100; [NAME] December 22, at 6:41 pm, HR:110.There was no documented evidence in Resident 1's medical record that the physician was notified of Resident 1's change in vital signs for the following dates December 6, December 13, December 16, and December 23, 2025, as indicated in the physician order to monitor for s/s of dehydration.The Medication Administration Record (MAR) for the month of December 2025, was reviewed. For .Monitor for s/s of dehydration. the MAR indicated nursing staff initialed Resident 1 had been monitored for s/s of dehydration on the following dates and shifts:On December 6, 2025, 7:00am - 3:00 pm;On December 13, 2025, 7:00am - 3:00 pm;On December 16, 2025, 7:00am - 3:00 pm & Shift 2: 3:00 pm - 11:00pm; [NAME] December 22, 2025, 11:00pm - 7:00 am.The MAR indicated nursing staff initialed monitoring Resident 1 for s/s of dehydration on the above dates. There was no documentation the physician was notified when Resident 1's vital signs indicated Resident 1 was experiencing possible dehydration.The SBAR (Situation Background Assessment Recommendation) dated December 17, 2025, at 10:58 pm, indicated .COC (change of condition) BUN (Blood Urea Nitrogen- lab test that measures kidney function and hydration status) 108 (normal range 7-20) .situation dehydration risk. Narrative Note RECEIVED A CALL FROM (named lab) REPORTING PT (patient) HAVE A CH (sic) BUN 108. MD (physician) Notified.The physician order dated December 18, 2025, indicated .sodium chloride 0.9% (normal saline commonly used for fluid replacement) .2 liters .for dehydration .On June 30, 2026, at 1:05 pm, a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated the facility process for changes in vital signs are for nursing to document the change in vital signs and notify the physician for orders and implement the order. LVN 1 stated Resident 1's vital signs on December 6, December 13, December 16, and December 22, 2025, indicated s/s of dehydration and should have been reported to the physician.On June 30, 2026, at 5:09 pm, a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated the facility process for reporting resident COC (change in condition) are for nursing staff to document the COC, notify the physician of the COC, document and implement the physician order. The DON stated Resident 1's vital signs on December 6, December 13, December 16, and December 22, 2025, indicated s/s of dehydration and should have been reported to the physician. The DON stated the facility process was not followed.On July 21, 2026, at 2:08 pm, a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 stated she was Resident 1's assigned nurse on December 4 and December 6, 2025. LVN 2 stated the facility process for monitoring for s/s of dehydration are to observe the resident for dry lips, tenting of skin (skin that doesn't flatten back right away after being pinched), low urinary output, confusion, low blood pressure and high heart rate. LVN 2 stated the physician order was to monitor Resident 1 for s/s of dehydration. LVN 2 stated Resident 1's vital signs on December 4 and December 6, 2025, indicated s/s of dehydration. LVN 2 stated there was no documented evidence that the physician was notified of Resident 1's vital signs and that she should have notified the physician.1b. On June 25, 2026, Resident 1's medical record was reviewed.The physician orders indicated the following:-December 1, 2025, docusate sodium [OTC-over the counter] capsule; 100 mg (mg-unit of measurement) 1 capsule oral twice daily for bowel regimen; and-December 1, 2025, Milk of Magnesia [OTC] 400 mg/5 ml (ml-unit of measurement) 30 ml oral as needed. Give 30 ml by mouth x 1 (x1 - one time) as needed if no bowel movement in 2 days; and-December 2, 2025, .Monitor for.constipation (difficulty or inability to have a bowel movement) from opioid use (type of pain medication that has side effects of constipation) every shift and follow up with MD (medical doctor) order as indicated.The Vitals Report for the month of December 2025 indicated the following:-December 1, at 1:31 am, Bowel Movement Size: None-December 2, at 2:19 pm, Bowel Movement Size: None-December 3 & 4, indicated no recording of bowel movement-December 5, at 11:00 am, Bowel Movement Size: None-December 6, at 2:30 pm, Bowel Movement Size: None-December 7, 8, 9, & 10, indicated no recording of bowel movement-December 11, at 3:25 am, Bowel Movement Size: None-December 11, at 9:32 pm, Bowel Movement Size: Large-December 11, at 9:33 pm, Bowel Movement Size: Large-December 12, at 10:01 am, Bowel Movement Size: None-December 13, 11:06 am, Bowel Movement Size: None-December 14, 9:36 am, Bowel Movement Size: None-December 15, 5:35 am, Bowel Movement Size: None-December 16 & 17, indicated no recording of bowel movement-December 18, 8:23 pm, Bowel Movement Size: None-December 19, at 1:58 pm, Bowel Movement Size: Medium-December 20, at 10:31 pm, Bowel Movement Size: Small-December 21, at 6:31 am, Bowel Movement Size: Medium-December 22, 23, and 24, indicated no recording of bowel movement-December 25, 2025, Bowel Movement Size: NoneThe Medication Administration Record (MAR) for the Month of December 2025 was reviewed.There was no documented evidence that nursing staff administered the Milk of Magnesia in the month of December 2025, as ordered by the physician.On July 21, 2026, at 2:08 pm, during a concurrent interview and record review. LVN 2 stated the facility process for documentation of bowel movements (BM) are for nursing to document each shift if a resident had a bowel movement or did not have a bowel movement. LVN 2 stated the physician order for Resident 1, indicated administer Milk of Magnesia as need if no bowel movement in 2 days. LVN 2 stated the vitals report indicated Resident 1 did not have a BM on December 1, 2, 5, 6, 12, 13, 15, 18, and December 25, 2025. LVN 2 stated there was no documented entry of a bowel movement on December 3, 4, 7, 8, 9, 10, 16, 17, 22, 23, and December 24, 2025. LVN 2 stated there was no documented evidence within the MAR that nursing administered the Milk of Magnesia. LVN 2 stated nursing staff should have administered the Milk of Magnesia per the physicians order.On July 21, 2026, at 4:30 pm a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated the expectations of nursing staff are to document at the end of each shift if the resident had a bowel movement. The DON stated the expectation is nursing staff are to notify the physician of a resident not having a bowel movement after 3 days. The DON further stated nursing staff should have administered the Milk of Magnesia per the physicians orders and notified the physician of Resident 1's change in bowel pattern.A review of the facility policy and procedure titled, Changes in Resident Conditions, undated, indicated .The resident, attending Physician. are notified when changes in condition or certain events occur. attending Physician resident representative are notified by the Licensed Nurse. when there is.a significant change in the resident's physical, mental or psychosocial status.Changes in condition will be documented in the Change of Condition form or Nurses' Progress notes.2.On June 25, 2026, Resident 2's medical record was reviewed.The admission record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included Intraductal carcinoma in situ of right breast (cancer in the milk ducts of the breast), malignant neoplasm of unspecified ovary (cancer in the ovaries).The history and physical completed by the physician on June 4, 2026, indicated Resident 2 the capacity to make decisions. The (named hospital) AVS (After Visit Summary) dated June 18, 2026, indicated a chemotherapy appointment for Monday, June 22, 2026, at 8:00 am.There was no documented evidence that the facility arranged transportation for Resident 2's chemotherapy appointment for Monday, June 22, 2026.A phone interview was conducted with the (named physician's office) receptionist. The receptionist confirmed Resident 2 did not attend the chemotherapy appointment scheduled for Monday, June 22, 2026.On June 30, 2026, at 1:05 pm, a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated the facility process for appointments are when a resident has been newly admitted or readmitted to the facility nursing staff are expected to read the hospital discharge AVS and work with social services to schedule transportation for those appointments. The AVS dated June 18, 2026, was reviewed. LVN 1 stated the AVS indicated Resident 1 had a scheduled appointment for Monday, June 22, 2026, and Tuesday June 23, 2026. LVN 1 stated there was no documented evidence that transportation was scheduled for Resident 1's appointment on Monday, June 22, 2026, and that transportation should have been scheduled as indicated in the AVS.On June 26, 2026, at 4:31 pm, an interview was conducted with the Social Service Assistant (SSA). The SSA stated the facility process for appointments are for nursing staff to review the AVS and inform social services of the appointments indicated on the AVS. The SSA stated she was not informed by nursing staff to schedule transportation for Resident 2 on June 22, 2025. Social services was only informed to schedule transportation on June 23, 2025.On June 30, 2026, at 2:45 pm, a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated the facility process for coordinating care with outside facilities are when the residents are admitted they will come with admitting orders on the AVS. Nursing staff work with social services to coordinate the appointments and transportation to those appointments. The DON stated the AVS indicated Resident 2 had a chemotherapy appointment for Monday, June 22, 2026, and Tuesday June 23, 2026. The DON stated there was no documented evidence that Resident 2 attended the Monday June 22nd appointment and nursing staff should have worked with social services to assure Resident 2 was at the chemotherapy appointment for June 22nd . The DON stated nursing staff did not follow the facility process and should have followed the facility process for appointments.A review of the facility policy and procedure titled, Referral to Outside Agencies, undated, indicated .Referral for transportation to Outside Services.alternative transportation and/or referral will be coordinated by the Social Service Director/designee and licensed nurses.

Based on interview and record review the facility failed to ensure communication with the physician was entered into the resident's chart for one of six residents reviewed (Resident 2) when nursing staff did not document communication with the physician regarding Resident 2's low hemoglobin (Hgb-red blood cells can't carry enough oxygen to your tissues) laboratory result.This failure had the potential for Resident 2 to have a delay in care due to information not being readily available in the resident's medical record.Findings:On June 25, 2026, Resident 2's medical record was reviewed.The admission record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included Intraductal carcinoma in situ of right breast (cancer in the milk ducts of the breast), malignant neoplasm of unspecified ovary (cancer in the ovaries).The history and physical completed by the physician on June 4, 2026, indicated Resident 2 the capacity to make decisions. The laboratory result dated June 15, 2026, indicated Resident 2's had a critical low Hgb result of 6.7 (normal Hgb values 11-15).The nursing progress note dated June 16, 2026, at 12:29 pm, indicated .Patient was receiving physical therapy when she became dizzy, light headed and weak. PT (physical therapy) reported patients heart rate was 120.vitals BP: 95/53 O2 Sat: 95% on RA, 100 Pulse, 98.4 temp.but appearing slightly pale.Patient was noted to have hemoglobin at 6.7.on 6/16/26, Provider was aware. Notified provider that patient now has symptomatic anemia.New orders to send to ER for further eval and management.There was no documented evidence in Resident 2's medical record that nursing staff communicated with the physician regarding Resident 2's critical low Hgb or that nursing staff received orders from the physician regarding Resident 2's critical low Hgb.On June 30, 2026, at 1:05 pm, a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated the facility process for critical labs are to notify the physician and the family and complete an SBAR (Situation Background Assessment Recommendation). LVN 1 Stated there was no documented evidence of a SBAR or progress note for Resident 2's critical lab value dated June 15, 2026. LVN 1 further stated there was no documented evidence that the physician was notified of Residents 2's critical low Hgb result. LVN 1 stated nursing staff should have notified the physician and documented the notification and physician's orders.On June 25, 2026, at 2:45 pm, a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated the expectation for nursing staff is to notify the physician with critical labs and document the notifications and new orders, if any, in the residents chart (medical record). The DON stated there was no documented evidence in Resident 2's medical record that nursing staff notified the physician of the Hgb 6.7 on June 15, 2026.On June 25, 2026, at 3:30 pm, the DON presented the nurse physician phone that indicated nursing staff text messaged the physician on the facility's nurse physician phone on June 15, 2026, at 8:16 pm, informing the physician of Resident 2's low Hgb of 6.7 and response from the physician to inform Oncology (physician who treats cancer) tomorrow (June 16, 2026) at Resident 2's chemotherapy appointment for orders to repeat Hgb or transfusion (medical procedure which blood is injected directly into the vein). The DON stated the text message between the nurse and the physician was never documented into Resident 2's chart and should have been documented in Resident 2's chart to be readily available for nursing review.A review of the facility policy and procedure titled, General Documentation Guidelines/Utilization of Forms (FOR LICENSE NURSES AND IDT REVIEWS) dated August 2025, indicated .All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record.

Based on interview and record review, the facility failed to provide the resident's diet as ordered by the doctor (Dr) and did not include the resident's preferences and dislikes for one of three residents (Resident 1). This failure resulted in the facility providing Resident 1 with a clear liquid diet (all food in liquid form), instead of a regular diet (solid foods) as ordered and did not include the residents' preferred foods. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis of liver and colon cancer. Resident 1 was discharged from the facility on May 27, 2026. A review of Resident 1's diet order received on May 21, 2026, untimed, indicated .Regular diet . to be served 3 times per day. A review of Resident 1's Communication Slip (a document the nursing staff use to communicate with the dietary staff), dated May 21, 2026, untimed, by the Registered Nurse (RN) indicated, . No Added Salt; CCHO (Controlled Carbohydrates); Clear Liquid Diet, Advance as tolerated . A review of Resident 1's tray card (a card used by dietary staff to prepare the resident's food tray), dated June 4, 2026, indicated, a diet of . No Added Salt; CCHO . the card did not indicate the type of diet or the texture, and did not have Resident 1's preferences or dislikes included on the card. On June 4, 2026, at 2:20 p.m., an interview with the Dietary Supervisor (DS) and record review of Resident 1's diet orders, communication slip dated May 21, 2026, and the undated tray card was conducted. The DS stated she kept a record of the resident's diet communication slips for one year. The DS verified Resident 1 had a diet order dated May 21, 2026, for a regular diet, and Resident 1's communication slip dated May 21, 2026, indicated a No salt added, CCHO, clear liquid diet. The DS verified Resident 1 was served a clear liquid diet from May 21, 2026 to May 27, 2026.The DS stated the process for dietary staff to receive the resident's diet orders and make their food tray includes the following: The nurse receives the resident's diet orders from the Dr and fills out a communication slip from the order;The nurse gives a copy of the communication slip to the DS. The DS will print out a tray card which includes the resident's preferred and disliked foods;The DS will verify the resident's diet information on the tray card matches the communication slip. If the resident is on a clear liquid diet the DS will add by writing Clear liquid diet on the tray card; andThe DS will give the tray card to dietary staff, then dietary staff will prepare the residents food tray.The DS stated she does not verify the resident's diet order against the communication slip. She stated she trusts the nurse gives her the resident's correct diet information on the communication slip.The DS further stated as soon as she receives a communication slip, she reviews the diet information with the resident and verifies their food preferences and dislikes and adds this information to the tray card. The DS verified Resident 1's tray card did not include a list of Resident 1's preferred and disliked foods because Resident 1 was on a clear liquid diet. On June 4, 2026, at 3:14 p.m., a concurrent interview with the Director of Nursing (DON) and record review of Resident 1's diet order and communication slip dated May 21, 2026, was conducted. The DON verified Resident 1 had diet orders for a regular diet, and Resident 1 received a clear liquid diet during her stay at the facility. The DON stated she was not sure why Resident 1's communication slip indicated she was to receive a clear liquid diet. The DON stated when a resident does not receive their ordered diet, the adverse effects could be weight loss and delayed wound healing. A facility policy, titled, Nutrition Care, dated 2018, indicated, . All residents/patients will have a written diet order on admission which has been prescribed by the physician . The facility will serve diets as ordered by the physician .

Based on observation, interview, and record and document review, the facility failed to ensure proper labeling and storage of medications that met the requirements of the facility's policy and procedures consistent with State and Federal law and manufacturer's specifications by: 1. Not maintaining the temperature of the medication room, specified by the drug manufacturers, at or below 77 F (Fahrenheit, unit of temperature measurement) in one of one medication room inspected;2. Storing residents' prescription medications without a pharmacy label in one of two medication carts inspected;3. Storing and not removing timely an expired, open, multi-dose vial of Humulin R (medication to control high blood sugar) in one of two medication carts inspected; and4. Storing two boxes of one medication requiring refrigeration, at room temperature in the drawer of one of two medication carts inspected. These failures had the potential for residents to receive wrong medications and ineffective medication therapy.1. On [DATE], at 2:26 p.m., during an inspection of F Court Medication Room with Licensed Vocational Nurse (LVN) 2, it was noted the room temperature on the thermometer indicated 80 F. There were three emergency kits (E Kits, pre-stocked emergency medication container): IV (intravenous, into vein), IM (intramuscular, into muscle), and oral. These E Kits contained injectable and oral medications urgently needed for residents without delay. There were 31 medications in the IV E Kit, 33 medications in the oral E Kit, and 19 medications in the IM E Kit. During a concurrent interview, LVN 2 confirmed the temperature on the thermometer was 80 F. On [DATE], at 9 a.m., during an interview, the Consultant Pharmacist (CP) stated the medication room temperature should be below 78F. The facility's policy and procedure titled, Storage of Medication, dated, 2007, was reviewed, and it indicated: .Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration . Medications requiring storage at room temperature are kept at temperatures ranging from 15 C (59 F) to 30 C (86 F). Controlled room temperature is defined as 20 C (68 F) to 25 C (77 F) . The manufacturer's prescribing information for some of the medications contained in the E Kits indicated:Ciprofloxacin (oral antibiotic for infection), clindamycin (oral antibiotic for infection), phenytoin (oral medication for seizure), Store at 20 to 25 C (68 to 77 F) .;Prednisone (oral medication for swelling), Store at controlled room temperature 20 to 25 C (68 to 77 F) .;Ceftriaxone (injectable antibiotic for infection) and cefepime (injectable antibiotic for infection) .store Ceftriaxone for Injection sterile powder at room temperature 20 -25 C (68 -77 F) .Cefazolin (injectable antibiotic for infection), Store the unactivated unit at 20-25 C (68-77 F) .;Glucagon (injectable medication to increase blood sugar), Vials of glucagon, as well as the diluent for glucagon, may be stored at controlled room temperature 20 to 25 C (68 to 77 F) .;Epinephrine (injectable medication for severe allergic reactions) and heparin (injectable medication to prevent blood clots), Store between 20 C to 25 C (68 F to 77 F) . 2. On [DATE], at 3:13 p.m., during a medication cart inspection of F Court Medication Cart 2 with LVN 2, the following prescription medications in the cart drawer did not have a pharmacy label: One lidocaine and prilocaine (local applied numbing medication) cream 30 grams (unit of measurement); andOne manufacturer box containing 20 lidocaine (locally applied numbing medication to treat pain) 5% topical patches. During a concurrent interview, LVN 2 confirmed there was no pharmacy label on these two medications. LVN 2 stated without the pharmacy label LVN 2 did not know who the lidocaine patches belonged to. On [DATE], at 9 a.m., during an interview, the CP agreed all prescription medications from the pharmacy should have a pharmacy label. The facility's policy and procedure titled, Medications and Medication Label, dated, 2007, was reviewed, and it indicated: .Medications are labeled in accordance with currently accepted professional principles including appropriate auxiliary and cautionary instructions to promote safe medication use following state and federal laws .Each prescription medication will be labeled to include .Resident's name .Specific directions for use .Prescriber's name .Date medication is dispensed .Expiration or end-of-use date . 3. On [DATE], at 3:13 p.m., during a medication cart inspection of F Court Medication Cart 2 with LVN 2, there was an open 10-ml vial of Humulin R with the open date, 4-9-26. During a concurrent interview, LVN 2 confirmed the open date of the medication indicated it was expired. Guidelines for Labeling and Disposing Multi-Dose medications, undated, was reviewed, and it indicated: .Open Date Requirements .Use open dates ONLY when .The manufacturer or pharmacy instructions state: Discard X days after opening .Common examples include .Insulin pens/vials (28 days after opening) .A multi-dose container must be discarded when .if a pharmacy-Assigned BUD Exists .Discard at the earlier date between: Pharmacy's BUD .Manufacturer expiration date . The facility's policy and procedure titled, Disposal of Medications, dated, 2007, was reviewed, and it indicated: .Discontinued medications .are identified and removed from current medication supply in a timely manner for disposition . 4. On [DATE]. 2026, at 1:49 p.m., during a medication cart inspection of E Court Medication Cart 1 with LVN 1, one partial manufacturer box containing one Trulicity (medication to improve blood sugar control) 3 mg per 0.5 ml pen and one full manufacturer box containing four Trulicity 3 mg per 0.5 ml pens for Resident 31 were stored in the drawer of the cart at room temperature. Each box had a Refrigerate label. The partial box had a pharmacy label with the dispense date of [DATE], and the full box, [DATE]. The manufacturer box for Trulicity indicated, Refrigerate at 36 to 46 F up to the expiration date. Each Trulicity single-dose Pen can be stored unrefrigerated for up to 14 days at a temperature not to exceed 86 F (30 C). Trulicity should not be used past the expiration date . During a concurrent interview, LVN 1 confirmed that it should be refrigerated and when stored at temperature, the medication was good for 14 days. On [DATE], at 9 a.m., during an interview, the CP stated refrigerated Trulicity boxes that were stored in the medication cart at room temp would be a big issue. The CP stated staff should not keep any unopened refrigerated medications in the medication cart. The facility's policy and procedure titled, Storage of Medication, dated, 2007, was reviewed, and it indicated: .Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration . Medications requiring refrigeration or temperature between 2 C (36 F) and 8 C (46 F) are kept in a refrigerator with a thermometer to allow temperature monitoring .

Based on observation, interview, and record review, the facility failed to ensure dietary staff were trained and competent to carry out the functions of the department safely and effectively when1. Diet Aide 1 did not follow standard practice to clean the soil meal cart.2. [NAME] 3 unable performed spoon testing for pureed diet and fork testing for Minced and Moist diet. (Cross reference 805)These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food), choking and/or aspiration and further in a medically compromised 85 out of 85 sample residents who received foods from the kitchen.During a review of FDA (Food & Drug Administration) Food Code, 2022, the FDA Food Code indicated, Failure to maintain clean wash, rinse, and sanitizing solutions adversely affects the warewashing (means the cleaning and SANITIZING of UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT) operation. Equipment and utensils may not be sanitized, resulting in subsequent contamination of food.On May 11,2025, at 9:59 a.m., a concurrent observation and interview were conducted with Diet Aide (DA) 1 at dishwashing area. DA 1 was asked to demonstrate how she cleaned and sanitized soil meal cart. DA 1 showed surveyor she only used sanitizer to sanitize soil meal cart.On May 13, 2026, at 9:31 a.m., an interview was conducted with the Registered Dietitian (RD). The RD stated for standard of practice dietary staff should wash the soil meal cart with detergent ; then rinse the detergent; and sanitized with sanitizer and final step was air dried. The RD explained the soil meal cart could not clean and sanitize properly and effectively by only using sanitizer.During a review of the facility's Job Description titled, STAFFING INSERVICE AND ORIENTATION dated 2025, the Job Description indicated, SUBJECT: FOOD PREPARATION STAFF POLICY: .The staff assists in assuring proper .sanitation and cleaning procedures are followed.RESPONSIBILITIES: .Cleans and sanitizes equipment .using recommended cleaning agents and cleaning methods and following established procedures .2. On May 12, 2026, at 11:39 a.m., [NAME] (CK) 3 was asked to demonstrate spoon test for pureed diet and fork testing for Minced and Moist (MM 5) diet. CK 3 unable to demonstrate. As a result, CK 3 served running Pureed cauliflower during lunch. And all MM 5 modified texture for beef, noodle, cauliflower were not in the right modified texture during lunch. (Cross reference 805)On May 13, 2026, at 9:31 a.m., an interview was conducted with the RD and Dietary Supervisor (DS). The RD stated to ensure Residents received right texture to prevent choking and aspiration, all dietary staff should know and fully applied spoon and fork test for International Dysphagia Diet Standardization Initiative (IDDSI: is a worldwide effort to create a standardized framework for diet modification for people with swallowing difficulties). The DS stated dietary staff and her needed more guidance from the menu company, RD and Speech Therapy for preparing IDDSI modified diet texture.During a review of the facility's Job Description titled, ORIENTATION, INSERVICE AND PERSONNEL MANAGEMENT dated 2025, the Job Description indicated, SUBJECT: COOK JOB DESCRIPTION POLICY: The [NAME] prepares and serves food including texture modified and therapeutic diets according to the facility menu.RESPONSIBILITIES: Prepares food, including modified texture and therapeutic diets.

Based on observation, interview, and record review, the facility failed to ensure1. [NAME] 1 used the right scoop served Minced and Moist meat during lunch on 5/11/2026.2. [NAME] 2 used the right scoop served pureed dessert during lunch on 5/11/2026.3. [NAME] 3 used the right scoop served Beef Stroganoff for Residents on Regular diet, Easy to chew, Soft and Bite Sized, and Minced and moist during lunch on 5/12/2026.4. [NAME] 3 followed recipe preparing pureed cauliflower during lunch on 5/12/2026. Failure to follow recipe resulted in pureed cauliflower unable hold its shape (running) on plate and which compromise swallowing safety and increase the risk of choking and/or aspiration. (Cross reference 805).These failures had the potential to negatively impact on the residents' nutritional status and further compromising residents' medical status.1. On May 11, 2026, at 12:26 p.m., a concurrent observation and the Therapeutic Diet Spreadsheet [the document used to guide dietary staff on food items, portions, and therapeutic diet (is a nutritionally planned diet that is ordered by a physician to meet a specific medical need. It modifies the type, texture, nutrient content, or amount of food to support a patient's treatment plan)] review were conducted at the trayline (the process of plating resident meals according to physician ordered diets). The Therapeutic Diet Spreadsheet indicated, Minced and Moist (MM5) meat used number (#) 6 scoop [6 ounce (oz - a unit for measurement)]. [NAME] (CK) 1 was observed using 2 oz scoop plated MM 5 meat.On May 13, 2026, at 9:31 a.m., a concurrent interview and the Therapeutic Diet Spreadsheet review were conducted with the Registered Dietitian (RD). After reviewing the Therapeutic Diet Spreadsheet, the RD stated CK 1 underserved 4 oz of meat for Residents on MM5 diet. The RD stated underserved 4 oz of meat resulted in Residents on MM 5 diet get less protein and calories per planned menu which did not meet the nutritional needs in accordance with the physician's diet order. The RD expectation was Cooks followed the Therapeutic Diet Spreadsheets. During a review of the facility's provided Diet Type Report (same as physician diet order), dated May 12, 2026, the Diet Type Report indicated, five Residents (Resident 11, 17, 34, 88, and 114) on MM5 diet.During a review of the facility's Policy and Procedure (P&P) titled, MENUS, dated 11/25/2025, the P&P indicated, POLICY: Menus are designed to meet current federal and state regulations, RDAs (Recommended Dietary Allowances), and client-specific needs, including special dietary modifications. They align with medical nutrition therapy trends and are tailored to age, sex, disability, and activity. A Registered dietitian evaluates menus for nutritional adequacy.PROCEDURES: Menus are planned to meet the nutritional needs of the clients in accordance with the physician's diet order, the approved food and nutrition manual, federal and state regulations, and in accordance with the most current edition of the RDA .Menus will provide a variety of foods and indicate standard portions to be served at each meal.Portion sizes served will correspond to the client's prescribed diet.2. A review facility provided the Therapeutic Diet Spreadsheet on Monday (5/11/2026) indicated, Puree diet: pureed fruit used # 10 scoop (3 oz).On May 11, 2026, at 11:22 a.m., a concurrent observation and interview were conducted with CK 2 in the kitchen at Prep area. CK 2 was observed using green scoop (# 12; 2.5 oz) portioned out individual serving pureed fruit into single serving bowl. CK 2 stated he was going to serve the pureed fruit for today lunch.On May 13, 2026, at 9:31 a.m., a concurrent interview and the therapeutic Diet Spreadsheets review were conducted with the RD. After reviewing the Therapeutic Diet Spreadsheet, the RD stated CK 2 underserved 0.5 oz pureed dessert.During a review of the facility's provided Diet Type Report, dated May 12, 2026, the Diet Type Report indicated, three Residents (Resident 8,14, and 84) on pureed diet.During a review of the facility's Policy and Procedure (P&P) titled, MENUS, dated 11/25/2025, the P&P indicated, POLICY: Menus are designed to meet current federal and state regulations, RDAs (Recommended Dietary Allowances), and client-specific needs, including special dietary modifications. They align with medical nutrition therapy trends and are tailored to age, sex, disability, and activity. A Registered dietitian evaluates menus for nutritional adequacy.PROCEDURES: Menus are planned to meet the nutritional needs of the clients in accordance with the physician's diet order, the approved food and nutrition manual, federal and state regulations, and in accordance with the most current edition of the RDA .Menus will provide a variety of foods and indicate standard portions to be served at each meal.Portion sizes served will correspond to the client's prescribed diet.3. On May 12, 2026, at 11:56 a.m., a concurrent observation and the therapeutic Diet Spreadsheet review were conducted at Trayline. The Therapeutic Diet Spreadsheet indicated, Beef Stroganoff: for Regular diet, Easy to chew, Soft and Bite Sized, and Minced and Moist used # 6 scoop (6 oz). There was only a pan of Beef Stroganoff at Trayline. CK 3 stated he was going to use the only pan of Beef Stroganoff to serve Residents who on Regular diet, Easy to chew, Soft and Bite Sized, and Minced and Moist. CK 3 was observed using 4 oz scoop plated Beef Stroganoff.On May 13, 2026, at 9:31 a.m., a concurrent interview and the Therapeutic Diet Spreadsheet review were conducted with the RD. After reviewing the Therapeutic Diet Spreadsheet, the RD stated CK 3 underserved Beef Stroganoff to all Residents except Residents on pureed diet. The RD stated the resulting undeserved Beef Stroganoff was Residents receiving less calories and nutrients per planned menu which did not meet the nutritional needs in accordance with the physician's diet order. The RD stated the bottom line was Dietary staff should follow the Therapeutic Diet Spreadsheets using the right scoop serving food items accordance to therapeutic diets.During a review of the facility's provided Diet Type Report, dated May 12, 2026, the Diet Type Report indicated, total 82 (census 86 minus 1 resident on tube feeding, and 3 Residents on pureed diet) effected by underserved Beef Stroganoff.During a review of the facility's Policy and Procedure (P&P) titled, MENUS, dated 11/25/2025, the P&P indicated, POLICY: Menus are designed to meet current federal and state regulations, RDAs (Recommended Dietary Allowances), and client-specific needs, including special dietary modifications. They align with medical nutrition therapy trends and are tailored to age, sex, disability, and activity. A Registered dietitian evaluates menus for nutritional adequacy.PROCEDURES: Menus are planned to meet the nutritional needs of the clients in accordance with the physician's diet order, the approved food and nutrition manual, federal and state regulations, and in accordance with the most current edition of the RDA .Menus will provide a variety of foods and indicate standard portions to be served at each meal.Portion sizes served will correspond to the client's prescribed diet.4. On May 12, 2026, at 10:48 a.m., a concurrent observation and interview were conducted with CK 3 in the kitchen. CK 3 was observed preparing pureed cauliflower. CK 3 put 4 serving steam cauliflower into blender and then blended the cauliflower. CK 3 then added 3 tablespoon thickener and approximate 2 cups of drained liquid from steam cauliflower into blender and then continued blended the pureed cauliflower. The end product of pureed cauliflower was running unable hold its shape. CK 3 did not refer to recipe when preparing pureed cauliflower.During a review of the facility's provided recipe titled, Cauliflower .Pureed, the recipe did not indicate adding any liquid.On May 12, 2026, at 1:14 p.m., with the RD and Dietary Supervisor (DS), at Food and Nutrition Service office, a test meal was performed for the pureed diet. The RD and DS verified the pureed cauliflower not in right consistency which was too running. The RD stated [NAME] 3 adding too much liquid while preparing the pureed cauliflower.During a review of the facility provided document titled, International Dysphagia Diet Standardization Initiative (IDDSI: is a worldwide effort to create a standardized framework for diet modification for people with swallowing difficulties.) FOOD AND DRINKS CLASSIFICATION AND TESTING, review 2024, indicated, Pureed: Testing info: Holds its shapeDuring a review of the facility's Policy and Procedure (P&P) titled, FOOD PREPARATION, dated 11/25/2025, the P&P indicated, SUBJECT: STANDARDIZED RECIPES. POLICY: Standardized recipes are the most effective tool for the control of food production quality, quantity, consistency and cost. Clients have a right to expect the product to be the same quality each time it is served. PROCEDURES: Standardized recipes will be used for each item prepared as indicated on the menu.

Based on observation, interviews, and record review, the facility failed to ensure the appropriate food textures was provided when1. Residents on pureed diet received grainy pureed beef, lumpy bread and running pureed cauliflower during lunch on 5/12/2026. (Cross reference 802, and 803)2. Residents on Minced and Moist received wrong texture for beef, noodle and cauliflower during lunch on 5/12/2026.3. Residents on Soft and Bite Sized received wrong texture for noodle during lunch on 5/12/2026.4. Resident 88 and 20 received wrong broccoli texture during lunch on 5/11/2026.5. Resident 20 received wrong dessert texture during lunch on 5/11/2026.These failures had the potential to place the residents at risk of aspiration (when food is breathed into the lungs) and choking.1. On May 12, 2026, at 1:14 p.m., with the Registered Dietitian (RD) and Dietary Supervisor (DS), at Food and Nutrition Service office, a test meal was performed for the pureed diet. The following were the test results of different pureed food items:a) The RD verified the pureed beef was not smooth with grainy particles. The RD stated all pureed food items should be smooth with mashed potatoes consistency, and without grainy particles. The DS stated cooks should have left the beef in the blender for a longer period with adding some broth to reach the smooth consistency. The DS stated cooks should taste the pureed food items to ensure no grainy particles before served to residents. The RD and DS stated Residents could have potential risk of aspiration and hard time of swallowing with this kind of grainy particles. b) The RD and DS verified the pureed bread had lumps. The RD stated the pureed bread should be lumps free. The RD stated Residents on pureed diet could choke and resistance to swallow the lumpy pureed bread.c) The RD and DS verified the pureed cauliflower not in right consistency was too running. Observed [NAME] 3 prepared pureed cauliflower. [NAME] 3 adding approximate 2 cups of liquid while preparing 4 servings pureed cauliflower. The RD stated [NAME] 3 adding too much liquid while preparing pureed cauliflower which cause too running and unable hold its shape. The DS stated Resident had potential risk of aspirate or choke on running pureed cauliflower.During a review of the facility's provided Diet Type Report (same as physician diet order), dated May 12, 2026, the Diet Type Report indicated, three Residents (Resident 8,14, and 84) on pureed diet.During a review of the facility provided document titled, International Dysphagia Diet Standardization Initiative (IDDSI: is a worldwide effort to create a standardized framework for diet modification for people with swallowing difficulties.) FOOD AND DRINKS CLASSIFICATION AND TESTING, review 2024, indicated, Pureed: Holds its shape .Smooth with no lumps, .no chewing ability needed.2. During a review of the facility provided diet definition from diet menu, reviewed 2025, the diet menu indicated, IDDSI Food Level 5 Minced and Moist (MM5) .Requires minimal chewing ability and consists of foods that are easy to swallow because they are minced, very soft, and moist .Foods pieces should be no larger than 4 mm (millimeters- unit for measurement) width by 15mm length .Minced pieces of food should fit in between the tines of a fork.On May 12, 2026, at 1:14 p.m., with the RD and DS, at Food and Nutrition Service office, a test meal was performed for MM5 diet. The RD used fork to test the texture of MM5 for beef, noodles and cauliflower. All of the foods items were bigger than the tines of a fork. The RD and DS admitted [NAME] 3 prepared wrong texture for MM5 which could cause choking.During a review of the facility's provided Diet Type Report, dated May 12, 2026, the Diet Type Report indicated, five Residents (Resident 11, 17, 34, 88, and 114) on MM5 diet.3. During a review of the facility provided document titled, International Dysphagia Diet Standardization Initiative FOOD AND DRINKS CLASSIFICATION AND TESTING, review 2024, indicated, Soft and Bite Sized (SB 6): Pieces no bigger than 1.5 cm (centimeters- unit for measurement) x 1.5 cm in sizeOn May 12, 2026, at 1:14 p.m., with the RD and DS, at Food and Nutrition Service office, a test meal was performed for SB 6 diet. The RD admitted SB 6 noodles size were bigger than 1.5 cm x 1.5 cm. The RD stated there was potential risk of choking serving big pieces of noodle. During a review of the facility's provided Diet Type Report, dated May 12, 2026, the Diet Type Report indicated, Seven Residents (Resident 29, 32, 41, 78, 80, 100, and 108) on SB 6 diet.During a review of the facility provided Soft and Bite sized diet definition from diet menu, reviewed 2025, the diet menu indicated, IDDSI Food Level 6 Soft and Bite Sized .This dysphagia diet required some chewing ability. Food provided consists of foods that are easy to swallow because they are soft, tender, moist foods .Food pieces should be no longer than 1.5 cm length by 1.5 cm width for adults.4. On May 11, 2026, at 1:22 p.m., a concurrent dining observation and meal ticket review were conducted with Resident 88 at Assistance Feeding dining room. Resident 88 meal ticket indicated, Minced and Moist (MM5). Observed Resident 88 being served big chunk of broccoli 20 mm length x 20 mm width. On May 11, 2026, at 1:29 p.m., a concurrent dining observation and meal ticket review were conducted with Resident 20 at Assistance Feeding dining room. Resident 20 meal ticket indicated, MM5. Observed Resident 20 being served big chunks of broccoli 30 mm length x 20 mm width. On May 11, 2026, at 1:31 p.m., a concurrent observation and interview were conducted with the DS at Assistance Feeding dining room. The DS used fork to check Resident 88 and Resident 20's served broccoli and stated the served broccoli was too hard and the size was too large. The DS stated Residents 88 and 20 could choke on the served broccoli.During a review of the facility provided diet definition from diet menu, reviewed 2025, the diet menu indicated, IDDSI Food Level 5 Minced and Moist (MM5) .Requires minimal chewing ability and consists of foods that are easy to swallow because they are minced, very soft, and moist .Foods pieces should be no larger than 4 mm width by 15mm length .Minced pieces of food should fit in between the tines of a fork.5. On May 11, 2026, at 1:29 p.m., a concurrent dining observation and meal ticket review were conducted with Resident 20 at Assistance Feeding dining room. Resident 20 meal ticket indicated, MM5. Observed Resident 20 being served with big chunks of can pear.On May 11, 2026, at 1:31 p.m., a concurrent observation and interview were conducted with the DS at Assistance Feeding dining room. The DS used fork to check Resident 20's served pear. Minced pieces of pear could not fit in between the tines of a fork. The DS stated the served pear size was too large. The DS stated Resident 20 on MM5 could choke on the served pear.During a review of the facility provided diet definition from diet menu, reviewed 2025, the diet menu indicated, IDDSI Food Level 5 Minced and Moist (MM5) .Requires minimal chewing ability and consists of foods that are easy to swallow because they are minced, very soft, and moist .Foods pieces should be no larger than 4 mm width by 15mm length .Minced pieces of food should fit in between the tines of a fork.

Based on observation, interview, and record review, the facility failed to ensure residents' food preference were honored for seven out of 30 sampled residents (Resident 12, 41, 46, 66, 88, 101 and 104) during lunch on 5/11/2026 and 5/12/2026.This failure had the potential to result in decreased food intake, further compromising Resident 12, 41, 46, 66, 88, 101 and 104's nutritional and medical status.On May 11, 2026, at 12:13 p.m., a concurrent observation, interview and meal ticket (contains Resident name, room number, physician diet order, Allergies, food like and dislike) review were conducted with Resident 104 and Social Services Assistant (SSA) at dining room. Review Resident 104's meal ticket indicated, Preferences: Ice cream. Observed served food items, there was no ice cream. Resident 104 stated, I want ice cream for my lunch and dinner. SSA confirmed Resident 104 did not receive ice cream with his lunch.On May 11, 2026, at 1:05 p.m., a concurrent observation, interview and meal ticket review were conducted with Resident 46 and Director of Nursing (DON) at dining room. Review Resident 46's meal ticket indicated, Preferences: Ice cream. Observed served food items, there was no ice cream. Resident 46 stated, Yes, I want ice cream. The DON confirmed Resident 46 did not receive ice cream. The DON stated Resident's food preference needed to be honor.On May 11, 2026, at 1:08 p.m., a concurrent observation, interview and meal ticket review were conducted with Resident 41 and the DON at dining room. Review Resident 41's meal ticket indicated, Preferences: Ice cream. Observed served food items, there was no ice cream. Resident 41 stated, They did not give me ice cream. The DON confirmed Resident 41 did not receive ice cream.On May 11, 2026, at 1:17 p.m., a concurrent observation, interview and meal ticket review were conducted with Resident 12 and Licensed Vocational Nurse (LVN) 1 at dining room. Review Resident 12's meal ticket indicated, Preferences: Fortified soup. Observed food items, there was no Fortified soup. LVN 1 confirmed Resident 12 did not receive any soup.On May 11, 2026, at 1:20 p.m., a concurrent observation, interview and meal ticket review were conducted with Resident 101 and Certified Nursing Assistant (CNA) 1 at dining room. Review Resident 101's meal ticket indicated, Preferences: Ice cream. Observed served food items, there was no ice cream. CNA 1 confirmed Resident 101 not being served ice cream.On May 11, 2026, at 1:22 p.m., a concurrent observation, interview and meal ticket review were conducted with Resident 88 and CNA 2 at Assisted Feeding dining room. Review Resident 88's meal ticket indicated, Preferences: Jello. Observed served food items, there was no Jello. CNA 2 confirmed Resident 88 not being served Jello.On May 12, 2026, at 1:22 p.m., a concurrent observation, interview and meal ticket review were conducted with Resident 66 and CNA 3 at Resident 66 bedside. Review Resident 66's meal ticket indicated, Preferences: Ice cream. Observed served food items, there was no Ice cream. Resident 66 stated, I am upset. I want ice cream. Dietary staff put the food preference on my meal ticket with ice cream, and they should honor my preference. CNA 3 confirmed Resident 66 not being served Ice cream.On May 13, 2026, at 9:31 a.m., an interview was conducted with the Registered Dietitian (RD). The RD stated, The facility is residents' home. Residents should honor the food preferences. The RD stated Residents would get upset if they did not get the food preferences as they request. During a review of the facility's policy and procedure (P&P) titled NUTRITION CARE, dated November 25, 2025, indicated, SUBJECT: RESIDENT/PATIENT RIGHTS POLICY: Resident Centered Care. Resident have the right to determine delivery of Nutrition Care, .and food preference. PROCEDURES: Residents/patients have the right to be served food per their individual preferences, .

Based on meal distribution observation, interview and record review, the facility failed to ensure physician ordered diets were followed when:1. Residents on Renal diet being served high sodium and potassium foods during lunch on 5/11/2026.2. Resident 104 on large portion did not receive large portion during lunch on 5/11/2026 and 5/12/2026.3. Resident 104 on No added salt diet being served with salt package during lunch on 5/12/2026.4. Resident 55 on high calories, high protein and high fiber diet did not receive high calories, high protein and high fiber during lunch on 5/11/2026.These failures had the potential negative impact on the residents' medical and nutrition status and in severe instances may result in hospitalization or death.1. On May 11, 2026, at 12:25 p.m., an observation was conducted at the trayline (the process of plating resident meals according to physician ordered diets). Confirmed with [NAME] (CK) 1, there was only one kind of meat (processed ham) and one kind of starch (mashed potatoes) available at the trayline. CK 1 was observed served processed ham and mashed potatoes as an entree to all residents including Residents on CKD 5.During a review of the facility provided document titled, Chronic Kidney Disease 5 Diet, indicated, The Chronic Kidney Disease 5 (CKD 5) Diet provides high protein with limited . phosphorus .the foods that are typically restricted on the CKD 5 diet include high potassium foods and high sodium foods .High-Potassium .Vegetables: Potatoes; High-phosphorus Foods: Processed meatsOn May 11, 2026, at 3:23 p.m., a concurrent interview and the Therapeutic Diet Spreadsheet [the document used to guide dietary staff on food items, portions, and therapeutic diet (is a nutritionally planned diet that is ordered by a physician to meet a specific medical need. It modifies the type, nutrient content, or amount of food to support a patient's treatment plan)] review were conducted with the Registered Dietitian (RD). The RD stated Residents on CKD 5 diet not supposed to have potatoes due to high potassium and processed ham due to high sodium and phosphorus. Concurrent review the Therapeutic Diet Spreadsheet, there was no CKD 5. The RD stated the menu company missed including CKD 5 on the Therapeutic Diet Spreadsheet. When surveyor asked the RD several times did he reviewed the Therapeutic Diet Spreadsheet, since his signature on the Therapeutic Diet Spreadsheet. The RD kept avoiding answering the question. The RD stated Resident on CKD 5 diet was prescribed by the physician as part of the medical and nutrition treatment, since there was no CKD 5 in Therapeutic Diet Spreadsheet that mean the physician diet order was not being followed.On May 12, 2026, at 10:33 a.m., a concurrent interview and the Therapeutic Diet Spreadsheet review were conducted with CK 2. Concurrent review the Therapeutic Diet Spreadsheet, CK 2 stated, I followed the CKD 5 on the Therapeutic Diet Spreadsheet, but I do not know why there is no CKD 5 diet.On May 13, 2026, at 8:55 a.m., a concurrent interview and the Therapeutic Diet Spreadsheet review were conducted with CK 3. CK 3 stated he followed the CKD 5 on the Therapeutic Diet Spreadsheet when he served Resident on CKD 5 diet and he unable find the CKD 5 diet on the Therapeutic Diet Spreadsheet.During a review of the facility's provided Diet Type Report (same as physician diet order), dated May 12, 2026, the Diet Type Report indicated, five Residents (Resident 12, 30, 42,105, and 116) on CKD 5 diet.2. Review Therapeutic Diet Spreadsheet on 5/11/2026, indicated, House (Regular) diet: Ham 6 ounce (oz-unit for measurement); Potatoes: 1/2 cup; wheat roll 1 each; Margarine: 1 each. Large portion: Ham 8 oz; Potatoes 1 cup; wheat roll 2 each; Margarine: 2 eachOn May 11, 2026, at 12:13 p.m., a concurrent observation and meal ticket (contains Resident name, room number, physician diet order, Allergies, food like and dislike) review were conducted with Resident 104 at dining room. Review Resident 104's meal ticket indicated, large portion. Observed Resident 104 served food items and portion size, there was same food items and portion size as Regular diet being served to Resident 104 with 6 oz ham; 1/2 cup mashed Potatoes; wheat roll 1 each; and Margarine: 1 each.Review Therapeutic Diet Spreadsheet on 5/12/2026, indicated, Regular diet: Beef Stroganoff 6 oz; Noodle: 1/2 cup; wheat bread 1 slice; Margarine: 1 each. Large portion: Beef Stroganoff 8 oz; Noodle: 1 cup; wheat bread 2 slices; Margarine: 2 eachOn May 12, 2026, at 12:47 p.m., a concurrent observation and meal ticket review were conducted with Resident 104 at dining room. Review Resident 104's meal ticket indicated, large portion. Observed Resident 104 served food items, it was same serving size as Regular for Beef Stroganoff and Noodle ; 1 slice wheat bread and 1 Margarine.On May 13, 2026, at 9:31 a.m., a concurrent interview, the Therapeutic Diet Spreadsheet and Resident 104 Electronic Medical Record (EMR) review were conducted with the RD. After review EMR, the RD stated physician prescribed large portion for Resident 104. Concurrent review the Therapeutic Diet Spreadsheet and the served meals, the RD stated cooks missed to serve large portion for Resident 104. The RD stated therapeutic diet prescribed by the physician was part of nutrition and medical treatment. The RD stated his expectation was dietary staff should follow the meal ticket diet ordered (same as physician diet ordered) and the Therapeutic Diet Spreadsheet.During a review of the facility's Policy and Procedure (P&P) titled, NUTRITION CARE, dated 11/25/2025, the P&P indicated, SUBJECT: Diet orders . PROCEDURES: 1. All residents will have a written diet order . which has been prescribed by the physician.2. The facility will serve diets ordered by the physician and in accordance with the approved diet manual.3. Review the Therapeutic Diet Spreadsheet on 5/12/2026, indicated, No added Salt (NAS) diet: No salt packageOn May 12, 2026, at 12:47 p.m., a concurrent observation and meal ticket review were conducted with Resident 104 and Licensed Vocational Nurse (LVN) 1 in the dining room. Review Resident 104's meal ticket indicated, NAS diet. Observed Resident 104 served meal, there was a package of salt. LVN 1 reviewed Resident 104's meal ticket and stated Resident 104 not supposed to get the salt package.On May 13, 2026, at 9:31 a.m., a concurrent interview, the Therapeutic Diet Spreadsheets and Resident 104 EMR review were conducted with the RD. After review EMR, the RD stated physician prescribed NAS diet for Resident 104 as part of medical nutrition therapy. Concurrent review the Therapeutic Diet Spreadsheets and the meal served on 5/12/2026, the RD stated Resident 104 no supposed to get salt package. The RD stated his expectation was dietary staff should follow the meal ticket diet ordered (same as physician diet ordered) and the Therapeutic Diet Spreadsheet.During a review of the facility's Policy and Procedure (P&P) titled, NUTRITION CARE, dated 11/25/2025, the P&P indicated, SUBJECT: Diet orders . PROCEDURES: 1. All residents will have a written diet order .which has been prescribed by the physician.2. The facility will serve diets ordered by the physician and in accordance with the approved diet manual.4. On May 11, 2026, at 12:59 p.m., a concurrent observation and meal ticket review were conducted with Resident 55 in the dining room. Review Resident 55's meal ticket indicated, High fiber, high protein. Resident 55 was observed being served regular sandwich of the day as entree. There was no extra fiber food items, or large portion food items being served for Resident 55.On May 12, 2026, at 10:33 a.m., a concurrent interview and the Therapeutic Diet Spreadsheet review were conducted with CK 2. CK 2 stated he never came across Resident on high calories, high protein and high fiber diet.On May 13, 2026, at 8:55 a.m., a concurrent interview and the Therapeutic Diet Spreadsheet review were conducted with CK 3. CK 3 unable to demonstrate which diet on the Therapeutic Diet Spreadsheet he should follow for Resident on high calories, high protein and high fiber diet.On May 13, 2026, at 9:31 a.m., a concurrent interview, the Therapeutic Diet Spreadsheet and Resident 55 EMR review were conducted with the RD. After review EMR, the RD stated physician prescribed High calories, high protein, high fiber diet for Resident 55 as part of medical nutrition therapy. Concurrent review the Therapeutic Diet Spreadsheets and the served meal, the RD stated Cooks should follow large portion on the Therapeutic Diet Spreadsheet for high calories, high protein and high fiber diet. The RD unable provided in service documentation instructed dietary staff served large portion on the Therapeutic Diet Spreadsheets for High calories, high protein, high fiber diet.During a review of the facility's Policy and Procedure (P&P) titled, NUTRITION CARE, dated 11/25/2025, the P&P indicated, SUBJECT: Diet orders . PROCEDURES: 1. All residents will have a written diet order .which has been prescribed by the physician.2. The facility will serve diets ordered by the physician and in accordance with the approved diet manual.During a review of the facility provided document titled, High Fiber Diet, indicated, A high Fiber Diet is used in the prevention or treatment of several gastrointestinal, cardiovascular, and metabolic disease including diverticular disease, cancer of the colon, constipation, irritable bowel disease, hypercholesterolemia, diabetes, and obesity.During a review of the facility provided document titled, High Calories/High Protein Diet, indicated, High Calories/High Protein Diet is based on the Regular diet with additional protein sources.

Based on dietary observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when:1. Ice machine in kitchen found grime buildup on ice maker.2. Dust found on several pieces of equipment and area.3. Grime buildup found on several pieces of equipment.4. [NAME] 1 had exposed facial hair during meal preparation.These failures had the potential to result in cross contamination (bacteria are unintentionally transferred from one substance or object to another with harmful effect) and foodborne illnesses (are illnesses that results from ingesting contaminated foods) for 85 out of 85 sampled residents who received foods from the kitchen.1. On May 12, 2026, at 11:08 a.m., a concurrent observation and interview were conducted with the RD in the kitchen. Ice machine's ice maker was observed had black/ brown/yellowish grime buildup. The RD stated the ice maker needed to have deep clean. The RD stated inside ice machine should be free of grime buildup. The RD stated germ could grow on the grime buildup and cross contaminate the ice. The RD stated the facility only had one ice machine which located in the kitchen. The ice produced by the ice machine used for Residents consumption and also used for food production.During a review of the facility's policy and procedure (P&P) titled SANITATION AND INFECTION CONTROL, dated November 25, 2025, indicated, SUBJECT: Ice HANDLING POLICY: -Ice will be produced, stored and dispensed in a manner to avoid contamination. PROCEDURES: Ice will be dispensed through an ice machine, which has no contact with . contaminated source .2. According to the Federal Food and Drug Administration (FDA) 2022 Food Code, indicated, Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Also, The objective of cleaning focuses on the need to remove . soil from non-food contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted.On May 11, 2026, at 9:48 a.m., during a general kitchen tour was concurrent with the RD. Several pieces of kitchen equipment and areas found had brown debris. The RD referred the brown debris as dust. The equipment and areas were: a) door frame leading out of the kitchen; b) door frame leading to dining room; c) walk-in freezer fans' guard covers; d) walk-in refrigerator fans' guard covers; e) black pipe behind ventilator in the walk-in refrigerator. The RD confirmed above findings. The RD stated kitchen equipment and area should be kept clean, free of dust to prevent cross contamination and foodborne illness.3. According to the Federal Food and Drug Administration (FDA) 2022 Food Code, indicated, Cleanliness of the food establishment is important to minimize attractants for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions.On May 11, 2026, at 9:56 a.m., during a general kitchen tour was conducted with the RD. Several kitchen equipment found in kitchen not clean to sight and touch including grime buildup found in walk-in freezer green storage shelves; splash found inside top of microwave; grime buildup found on Microwave's door; black sticky grime found on can opener based.The RD confirmed above findings and stated kitchen equipment should be kept clean to prevent cross contamination and foodborne illness.4. According to the Federal Food and Drug Administration (FDA) 2022 Food Code, indicated, Food employees shall wear hair restraints such as, hair coverings, nets, or bears restraints to cover body hair to keep hair from contacting exposed food, clean equipment, and utensils.On May 11, 2026, at 10:01 a.m., an observation was conducted with [NAME] (CK) 1 in the kitchen. CK 1 had facial hair not covered was observed preparing foods in cook area.On May 11, 2026, at 10:34 a.m., an interview was conducted with the RD in the kitchen. The RD stated CK 1 should wear bear restraint to prevent hair fall into food.

Based on observation, interview and record review, the facility failed to ensure timely maintenance of equipment when:1. The walk-in freezer was maintained in good working condition with ice condensation buildup.2. Rust found on several shelves in kitchen.3. Two worn out cooking pans with missing nonstick coating found in kitchen.4. Chipped paint found in several pieces of equipment in kitchen.These failures had the potential to cause food borne illnesses and poor quality of food served to a population 85 out of 86 sample residents who received food from the kitchen.1. On May 11, 2026, at 10:10 a.m., a concurrent observation and interview were conducted with the Registered Dietitian (RD) in the walk-in freezer. Ice condensation was observed on the ceiling, on the black pipe behind ventilator, on storage shelves below ventilator. There was ice buildup observed on top of food boxes stored under the ventilator. The RD stated it was unacceptable to have ice condensation and ice buildup in the walk-in freezer. The RD explained ice buildup on food boxes could affect the quality of foods.During a review of the facility's policy and procedure (P&P) titled Cold Food Storage Areas, dated November 25, 2025, the P&P indicated, PURPOSE To safely and sanitarily store cold food. FUNDAMENTAL INFORMATION .Freezers are designed to keep food cold enough to .preserve the freshness and quality of foods. Units work effectively and efficiently when maintained .PROCEDURE: Inspect .freezers regularly .2. According to the Federal Food Code 2022, the Food Code indicates food-contact surfaces and utensils are to be clean to sight and touch. Utensils and food contact surfaces of equipment are to have a smooth, easily cleanable surface and resistant to pitting, chipping, crazing, scratching, scoring and decomposition.On May 11, 2026, at 10:41 a.m., during a general kitchen tour observation and interview were conducted with the RD. [NAME] grime was found on several pieces of equipment. The RD referred brown grime as rust. Example of those equipment were: a) Silver color storage shelves in walk-in freezer; b) Silver color storage shelves stored onion and potatoes; and c) drying board.The RD confirmed above findings. The RD stated rust could trap bacteria and cause cross contamination.3. According to the Federal Food Code 2022, the Food Code indicates food-contact surfaces and utensils are to be clean to sight and touch. Utensils and food contact surfaces of equipment are to have a smooth, easily cleanable surface and resistant to pitting, chipping, crazing, scratching, scoring and decomposition.On May 12, 2026, at 11:23 a.m., a concurrent observation and interview were conducted with the RD. Two worn out cooking pans with missing nonstick coating found in drying board. The RD stated for Residents safety, the two cooking pans were not appropriate to use.4. According to the Federal Food Code 2022, the Food Code indicates food-contact surfaces and utensils are to be clean to sight and touch. Utensils and food contact surfaces of equipment are to have a smooth, easily cleanable surface and resistant to pitting, chipping, crazing, scratching, scoring and decomposition.On May 12, 2026, at 11:23 a.m., a concurrent observation and interview were conducted with the RD. Several pieces of equipment found had chipped paint. Example of those equipment were: a) [NAME] storage shelves in walk-in freezer; b) drain in dish washing area. The RD stated those equipment needed to be painted or replaced otherwise unsmooth surface could trap bacteria.

Based on interview and record review, the facility failed to ensure there was documentation in the medical record the resident or the responsible party was fully informed with material information provided by the prescriber to be able to make informed decisions prior to starting a psychotropic medication for one of five residents reviewed (Resident 114). This failure had the potential for the residents to receive unnecessary medication.On May 12, 2026, the medical record of Resident 114 was reviewed and the following was noted: Resident 114 was [AGE] years old, admitted to the facility on [DATE], with diagnoses that included dementia with psychotic disturbance, major depressive disorder, and anxiety disorder; Resident 114 had a physician order on May 4, 2026, for ramelteon 8 mg by mouth daily 30 minutes prior to bedtime without an indication or diagnosis, which was discontinued on May 7, 2026; Resident 114 had a physician order on May 7, 2026, for ramelteon 8 mg by mouth daily at bedtime for supplement; Resident 114's care plan was reviewed and there was no indication the facility care planned for the resident's use of ramelteon for sleep; Resident 114's behavior monitoring record review did not indicate there was documentation of behavior monitoring for ramelteon; Resident 114's record review did not indicate there was an informed consent from the resident or the responsible party prior to use of ramelteon; and The electronic medication administration record (eMAR) in Resident 114's medical record indicated Resident 114 received one dose of ramelteon 8 mg daily from May 4, 2026 to May 12, 2026. The manufacturer's prescribing information for ramelteon indicated: Ramelteon tablets are indicated for the treatment of insomnia characterized by difficulty with sleep onset .Ramelteon Tablets are an orally active hypnotic .Ramelteon is a melatonin receptor agonist .Product Type .Human prescription drug . On May 13, 2026, at 11:38 a.m., during an interview, the Director of Nursing (DON) stated she thought it was a supplement because it was similar to melatonin and was not aware the medication was a prescription drug. The DON stated since it was for sleep, it would need informed consent and require monitoring of sleep. On May 14, 2026, at 9 a.m., during an interview, the Consultant Pharmacist (CP) stated ramelteon was a psychotropic medication and should not be given as a supplement, and because it was a psychotropic medication, there needed to be an informed consent for the medication and the monitoring of behavior for ramelteon. The facility's policy and procedure titled, Informed Consent, undated, was reviewed, and it indicated: It is the policy of this facility to ensure that all residents and/or their legally authorized representatives are fully informed and provide voluntary, written informed consent prior to initiation of any psychotropic medication .Psychotropic Medications: Any drug that affects brain activities associated with mental processes and behavior (e.g., antipsychotics, antidepressants, anxiolytics, hypnotics) .

Based on interview and record review, the facility failed to ensure there was a proper diagnosis and indication associated with the use of one psychotropic medication for one of five residents reviewed (Resident 114). This failure had the potential for the residents to receive unnecessary medication.On May 12, 2026, the medical record of Resident 114 was reviewed and the following was noted: Resident 114 was [AGE] years old, admitted to the facility on [DATE], with diagnoses that included dementia with psychotic disturbance, major depressive disorder, and anxiety disorder; Resident 114 had a physician order on May 4, 2026, for ramelteon 8 mg by mouth daily 30 minutes prior to bedtime without an indication or diagnosis, which was discontinued on May 7, 2026; Resident 114 had a physician order on May 7, 2026, for ramelteon 8 mg by mouth daily at bedtime for supplement; and The electronic medication administration record (eMAR) in Resident 114's medical record indicated Resident 114 received a dose of ramelteon 8 mg daily from May 4, 2026 to May 12, 2026. The manufacturer's prescribing information for ramelteon indicated: Ramelteon tablets are indicated for the treatment of insomnia characterized by difficulty with sleep onset .Ramelteon Tablets are an orally active hypnotic .Ramelteon is a melatonin receptor agonist .Product Type .Human prescription drug . On May 13, 2026, at 11:38 a.m., during an interview, the Director of Nursing (DON) stated she thought it was a supplement because it was similar to melatonin and was not aware the medication was a prescription drug. The DON stated since it was for sleep, it would need informed consent and require monitoring of sleep. On May 14, 2026, at 9 a.m., during an interview, the Consultant Pharmacist (CP) stated ramelteon was a psychotropic medication and should not be given as a supplement, and because it was a psychotropic medication, there needed to be an informed consent for the medication and the monitoring of behavior for ramelteon. The facility's policy and procedure titled, Physician Orders, undated, was reviewed, and it indicated: Physician orders are obtained to provide a clear direction in the care of the resident .The licensed nurse receiving the order must verify to ensure the order is complete and that it includes .other information as may be necessary to accurately and completely carry out the order .When receiving an order .ensure that the following necessary information is received .Diagnosis for medication .

Based on observation, interview, and record review, the facility failed to provide necessary care and treatment for an injury/wound to prevent decline in skin integrity for a right second toe injury for one of 21 residents reviewed (Resident 3).This failure resulted in the wound going unmonitored, placing the resident at risk for infection and skin breakdown.Findings:On May 11, 2026, at 11:16 a.m., an observation and a concurrent interview was conducted with Resident 3. Resident was observed resting in bed without socks on. The right second toe was observed with a discolored area below the nailbed with a wound/injury present. The area was open to air, and no wound dressing was visualized. Resident stated his foot hit the door in his room a few days ago, possibly a week ago. Resident stated that the injury occurred during transport to the emergency room (ER) by paramedics. Resident was alert, oriented and able to self-report the incident. Resident denied pain and stated he did not report the injury to nursing staff because the staff were already aware and he was not experiencing pain.On May 12, 2026, at 3p.m., an interview and a concurrent record review was conducted with the Minimum Data Set Nurse (MDS). The MDS nurse stated the most recent skin assessment for Resident 3 was dated April 9, 2026. The skin assessment indicated Resident 3 was free of any open skin areas. The MDS stated there were no other weekly skin assessments documented regarding Resident 3's skin assessment since April 9, 2026. She stated the requirement was that nurses document once a week on skin assessment and that was not done. The facility document titled, Shower Record, dated May 11, 2026, indicated the 2nd toe foot toe wound and was signed by Certified Nurse Assistant (CNA) and Licensed Vocational Nurse (LVN).On May 12, 2026, at 3:08 p.m., an interview was conducted with Resident 3. Resident 3 stated he hit his foot when the paramedics were transferring him out of his room. Resident 3 stated the staff at the facility were aware, the wound had been cleaned and looked at. Resident 3 stated he had no pain in the area.On May 12, 2026, at 3:13 p.m., an interview was conducted with LVN 3. LVN 3 stated Resident 3 was transported to the ER on [DATE]. LVN 3 stated there was no documentation regarding Resident 3's skin assessment by the accepting nurse when he was brought back to the facility. LVN 3 further stated that it was the standard of practice when a resident returns from transport, nurses document a skin assessment under the progress note section.On May 12, 2026, at 3:18 p.m., an interview and concurrent record review was conducted with LVN 1. LVN 1 stated she is the primary nurse for Resident 3. LVN 1 stated she was not aware of any skin issues/concerns/injuries/wounds on Resident 3. LVN 1 Stated the Wound Nurse completes weekly skin checks on Sundays. The last wound documentation was completed on May 10, 2026. A review of the May 10, 2026, skin check revealed no skin concerns or wounds documented for Resident 3. LVN 1 stated wound nurses conduct weekly skin checks on all residents every Sunday to identify any new skin concerns that need to be addressed.On May 13, 2026, at 8:24 a.m., a concurrent observation and interview was conducted with Resident 3. Resident 3 was observed to have a dressing to right foot second toe in place. Resident stated nursing staff cleaned and dressed the wound on May 12, 2026.On May 13, 2026, at 8:46 a.m., an interview and concurrent record review was conducted with Director of Staff Development (DSD). The DSD stated every Sunday the wound nurse would come and do weekly rounds, assess skin on every resident and assess any previous wounds. There was no documented evidence completed by the wound nurse regarding Resident 3 having any skin injuries. The DSD stated the first document for Resident 3 regarding the wound/injury was entered on May 12, 2026, at 9:58 p.m. The DSD stated if a wound was identified in the facility a notification to the Medical Doctor (MD) needs to occur immediately. The DSD stated if the MD was not notified immediately regarding a new wound/injury, Resident 3 could have a decline in his health.On May 13, 2026, at 9:11 a.m., an interview was conducted with LVN 4. LVN 4 stated she was the nurse for Resident 3 on May 2, 2026, when he was picked up by paramedics. LVN 4 stated Resident 3 must have hit his foot on the door during transport because there was blood on the floor. LVN 4 stated the paramedics said they would take care of Resident 3 at the hospital. LVN 4 stated she did not inform the next nurse what had occurred. LVN 4 did not document about the skin injury.On May 13, 2026, at 9:26 a.m., an interview and a concurrent record review was conducted with Director of Nurses (DON). The DON stated there is no documentation regarding Resident 3's wound/injury prior to May 12, 2026. The DON stated the failure to identify, assess, and treat Resident 3's wound/injury placed him at risk for possible infection.Resident 3's clinical record was reviewed. Resident 3 was admitted to the facility on [DATE], with a diagnosis which included infection and inflammatory reaction due to internal left knee prosthesis (an artificial device designed to replace a missing or non-functioning body part). The undated facility policy and procedure titled, Pressure Ulcer/Injury & Skin Care Management, indicated, A licensed nurse checks the resident's body for the presence of pressure ulcers/injuries, wounds and other skin conditions whenever the resident arrives by medical transport .weekly on all residents .the presence of any pressure ulcer/injury, wound, or other skin condition is documented weekly on pressure ulcer/injury or skin report forms .in progress notes .and in care plan.

Based on observation, interview, and record review, the facility failed to provide respiratory care and treatment for one resident (Resident 85) reviewed for oxygen (O2) use when the nasal cannula (NC - a tube used to deliver oxygen through the nose) was not dated when it was last replaced. This failure had the potential to result in deterioration of the nasal cannula, which would allow infectious organisms to grow, causing an infection. Findings: On May 11, 2026, at 12:05 p.m., Resident 85 was observed in bed, awake and alert. Resident 85 was using an NC for O2. The NC did not have a label to indicate the date when it was last changed. In a concurrent interview, Resident 85 stated she did not know when the NC was last changed. On May 11, 2026, at 12:09 p.m., a concurrent observation and interview was conducted with Licensed Vocational Nurse (LVN) 5. LVN 5 observed the NC for Resident 85 and confirmed the NC did not have a label with the date when it was last changed. LVN 5 stated without a date, there was no way to know when Resident 85's NC was last changed. LVN 5 stated Resident 85's NC should have had a label with a date when it was last changed. LVN 5 stated the NC should be changed every seven days, to prevent infection. On May 13, 2026, at 12:57 p.m., the Director of Nursing (DON) was interviewed. The DON stated the NC for Resident 85 should have been labeled with the date it was last changed. The DON stated the NC should be changed every seven days, as per facility policy. Resident 85's clinical record was reviewed. Resident 85 was admitted to the facility on [DATE], with diagnoses which included anemia (lack of red blood cells to carry enough oxygen in the blood). Resident 85's physician order was reviewed. The order, dated March 31, 2026, indicated, .Oxygen @ (at) 2 l (liters per minute - a unit of measurement) . The facility policy and procedure titled, Care and Handling of Respiratory Equipment, undated, was reviewed. The policy indicated, .Care should be exercised in handling respiratory equipment to prevent contamination.Change within every seven days.cannula .

Based on observation, interview, and record and document review, the facility failed to ensure accurate and complete record of controlled substances (CSs), free of discrepancies when the remaining volume in the one pharmacy-labeled bottle containing hydromorphone (a federally scheduled II CS which has the highest potential for addiction and abuse) 5 mg/5 ml (5 milligram per 5 milliliter, unit of concentration of a liquid) oral solution did match the corresponding CS dispense log. This failure could lead to potential diversion of CS and residents not receiving medications needed for pain relief.On May 13. 2026, at 1:49 p.m., during a controlled substance (CS) audit in E Court Medication Cart 1 with Licensed Vocational Nurse (LVN) 1, the following was noted: There was a pharmacy-dispensed bottle labeled, hydromorphone 5 mg/5 ml solution for Resident 10 with the dispensed date of April 1, 2026;The bottle had approximately 100 ml of the solution;The dispense log for Resident 10's hydromorphone solution indicated 2-ml doses were logged out from April 12, 2026, with the last 2-ml dose logged on May 13, 2026, at 5:13 a.m.; andThe dispense log indicated the volume remaining after the last dose on May 13, 2026, was 52 ml. During a concurrent interview, LVN 1 confirmed the remaining volume in the bottle was about 100 ml and was more than the volume last counted according to the dispense log for Resident 10's hydromorphone. On May 14, 2026, at 9 a.m., during an interview, the CP stated the CS count log and the actual volume of the bottle should match. The facility's policy and procedure titled, Controlled Medication Administration and Declining Sheet Verification, undated, was reviewed, and it indicated: .To ensure the safe, accurate, and accountable administration of controlled medications in the facility by requiring the use of a Controlled Medication Declining Sheet Binder in conjunction with the electronic Medication Administration Record (eMAR) or MAR paper form .This Process ensures .Accurate narcotic count verification .Prevention of medication diversion .Prevention of missed or duplicate doses .Immediate identification of discrepancies .Verification Before Administration .Verify that the remaining count matches the declining sheet balance .

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 57) was provided with special adaptive equipment as ordered by physician for eating with meals.This failure had the potential to result in a burn accident while Resident 57 drinking hot beverage.On May 11, 2026, at 12:28 p.m., a concurrent observation and meal ticket (contains Resident name, room number, physician diet order, allergies, adaptive equipment, food like and dislike) review were conducted with Resident 57 at Assisted Feeding dining room. Resident 57's meal ticket indicated, 2 Handled cup (sippy cup). Resident 57 was observed being used regular cup serving beverage.On May 12, 2026, at 12:42 p.m., an observation was conducted with Resident 57 at Assisted Feeding dining room. Resident 57 was observed both of her hands were shaking intensely.On May 12, 2026, at 1:01 p.m., a concurrent observation, interview and meal ticket review were conducted with Resident 57 and Certified Nursing Assistant (CNA) 2 at Assisted Feeding dining room. CNA 2 reviewed Resident 57's meal ticket and stated Resident 57 did not get sippy cup with her juice and coffee.On May 13, 2026, at 8:36 a.m., a concurrent interview and Electronic Medical Record (EMR) review were conducted with the Occupation Therapy (OT) and Rehabilitation Director (RHD). Concurrent review Resident 57's EMR, OT stated Resident 57 able eating independent with intense tremors hands. OT stated physician ordered sippy cup with each meal for Resident 57 to help her prevent spilled beverage. The RHD stated one time Resident 57 almost had an accident spilled hot beverage on herself. The RHD and OT stated for Resident 57's safety, it was important Resident 57 using sippy cup when she was drinking especially hot beverages. On May 13, 2026, at 9:01 a.m., an interview was conducted with Dietary Aide (DA) 2. DA 2 stated the facility only had 1 sippy cup and the sippy cup was missing for almost 3 weeks.On May 13, 2026, at 9:31 a.m., a concurrent interview and Electronic Medical Record (EMR) review were conducted with the Registered Dietitian (RD). The RD stated Dietary staff should follow the meal ticket providing sippy cup for Resident 57. The RD stated doctor ordered sippy cups as medical treatment for Resident 57 and he expected Dietary staff follow the doctor order. During a review of the Resident's 57 Physician Order Report, dated 5/01/2026 -05/12/2026, Physician's order indicated, Feeding/Mealtime order: For all meals, please providing the following equipment: .Closed cup (sippy cup)During a review of the facility's policy and procedure (P&P) titled MEAL SERVICE, dated November 25, 2025, indicated, RESTORATIVE DINING POLICY: The facility may establish a Restorative dining program to improve the resident's/patient's self-feeding skills, .foster independence and self-esteem by promoting safe swallowing, individualism, dignity, and socialism during dining. PROCEDURES: .Adaptive Equipment a. Recommended by OT, .other feeding equipment: order information can be obtained from your OT: .cups .

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly when trash were found outside surrounding the dumpsters. And the lids of the dumpsters did not close properly due to overflowing.This failure had the potential to attract pests and rodents.On May 11, 2026, at 9:39 a.m., a concurrent observation and interview were conducted with the Dietary Supervisor (DS) outside back kitchen at dumpster area. There was three dumpsters, one for recycle and another two for trash. The lids of the two trash dumpsters were unable to fully close due to overflowing with trash. Trash was found on floor surrounding the trash dumpster area. One of the recycled dumpster's lid was widely opened. The DS stated surrounding dumpsters should not have trash and dumpsters' lids should close properly to prevent attract pests.On May 11, 2026, at 9:45 a.m., an interview was conducted with the Registered Dietitian (RD). The RD stated it was infection control, and environment hazard issue with trash surrounding dumpsters and lids of the dumpsters not close properly which could attract pests.During a review of the facility's policy and procedure (P&P) titled Pest Control, dated November 25, 2025, indicated, .Keep facility grounds free of trash .Keep the dumpster area clean and the lids closed.

Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) was treated with dignity and respect when a staff member called the resident a liar after the resident alleged the staff member had purposely hit his elbow away while providing resident care.This failure resulted in Resident 1 becoming upset and angry. Findings:On January 29, 2026, at 4:20 p.m., an interview was conducted with Resident 1, who stated he could not remember the exact date, but Certified Nursing Assistant (CNA) 1 was providing perineal (area of skin between the anus and genitals) care for him when he asked CNA 1 if CNA 1 would hand him a wipe. When he (Resident 1) reached for the wipe CNA 1 Hit his elbow out of the way. Resident 1 stated it was more than a push. Resident 1 stated he told CNA 1, You hit my elbow, and CNA 1 responded by yelling You're a liar. Resident stated (CNA 1) Got mad at me, and it was upsetting, it made me mad. Resident 1 stated he was not sure of the exact date but he reported the incident to Registered Nurse (RN) 1, and the Administrator spoke to him regarding the incident soon after. A review of Resident 1's, Progress Notes, dated, January 15, 2026, at 10:57 a.m., indicated, . (Nurse) . FROM HOSPICE . REPORTED RESIDENT STATED (CNA 1) HIT HIS ELBOW WHILE PROVIDING . (RESIDENT 1) HAD NOT REPORTED TO ANY IN-HOUSE STAFF . (ADMINISTRATOR) NOTIFIED . On January 30, 2026, at 4:35 p.m., a telephone interview was conducted with CNA 1. CNA 1 stated on January 10 or 11, 2026, he was providing perineal care for Resident 1. CNA 1 stated Resident 1 was turned on his side, and CNA 1 put his hand on Resident 1's hip, at which time Resident 1 stated, Why did you hit me? CNA 1 stated he, Got a little angry, at Resident 1 and said to Resident 1, Your lying. CNA 1 further stated he told Resident 1, I go way out of my way for you, and you come out with this non-sense, lying that I hit you. A review of Resident 1's, Patient Information, indicated, resident was admitted to the facility on [DATE], with a diagnosis of Hemiplegia/Hemiparesis (One sided paralysis/weakness) following a stroke. A review of Resident 1's,Brief Interview for Mental Status (BIMS-a cognitive assessment), indicated a score of 12, moderate cognitive deficit. On February 9, 2026, at 11:07 a.m., a telephone interview was conducted with the Administrator (Admin), who stated he is the facility's abuse coordinator and he investigates allegations of abuse. The Admin stated staff receive abuse training upon hire, monthly and per episode of alleged abuse. The Admin further stated when a resident becomes angry or accusatory towards staff, the staff member should give the resident space by walking away, leaving the room, letting the resident calm down, and reporting right away to their charge nurse. The Admin stated on January 15, 2026, RN1 reported Resident 1's abuse allegations to him, at which time, he immediately reported these allegations to all required parties, started an investigation, and interviewed Resident 1 and CNA 1 the same day. The Admin further stated his investigation indicated the abuse allegations were unsubstantiated as CNA 1 denied hitting Resident 1's elbow during care. The Admin stated he was unaware CNA 1 called Resident 1 a liar, when Resident 1 accused CNA 1 of hitting his elbow, as CNA 1 did not report this information during the investigation. The Admin stated CNA 1 should have walked away from Resident 1 and should not have engaged in responding to Resident 1 by calling him a liar. The Administrator further stated CNA 1 did not make the right decision by engaging with Resident 1 instead of walking away, as CNA 1 should have given Resident 1 space and time to calm down. A facility Policy and Procedure titled, Mood and Behavior Management Techniques, undated, indicated .The unit staff will incorporate Behavior Management techniques to improve the patient's/resident's Quality of life .Procedure.If the patient/resident is escalating verbally and /or behaviorally, respond using a professional approach .Examples include.Employ a rational response; detach from patient/resident agitation .Stay focused on topic; redirect, ignore the challenge.Utilize examples below to address non-threatening behaviors .Do not argue.If you are not successful with the above approaches.walk away and wait 5-10 minutes .

Based on interview and record review, the facility failed to ensure pharmacy services were provided to meet the needs of residents when two of four sampled residents' (Resident 3 and Resident 7) medications were not administered in accordance with the physician orders. This failure has the potential to negatively impact the effectiveness of the medication which could lead to worsening of Residents 3 and 7's health condition. Findings: On April 29, 2025, at 1:20 p.m., Resident 3 was interviewed. Resident 3 was alert and oriented. Resident 3 stated he would at times receive his antibiotic late or early. A review of Resident 3's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included bacteremia (bacteria in blood), diabetes (high blood sugar), hypertension (high blood pressure). A review of the physician order dated April 11, 2025, indicated, cefazolin 2 (grams) gm/(milliliter) mL (gm/mL measure of metric) administer intravenous (in the vein) every 8 hours at 7:00 am, 3:00 pm, and 11:00 pm for bacteria in the blood. A review of the Medication Administration Record (MAR) for the month of April 2025, indicated the following: a. April 13, 2025, the 7 am dose of cefazolin was documented as administered late, charted at 9:16 a.m.; and b. April 13, 2025, the 11 pm dose of cefazolin was not documented as administered. A review of Resident 7's admission record was admitted to the facility on [DATE], with diagnoses which included pneumonia (infection in the lungs), congestive heart failure, cerebral vascular accident (stroke), and end stage renal disease (kidney failure). A review of the prescription order dated April 25, 2025, indicated a start date of April 28, 2025, and end date of May 4, 2025, for Vancomycin 500 mg. to be given intravenously once every Monday, Wednesday, and Friday, for hospital acquired pneumonia. A review of the MAR for the month of April 2025, indicated the 9 am dose of vancomycin was not administered on April 28 and April 29, 2025. The MAR indicated the medication was unavailable on April 28, 2025. On May 2, 2025, at 2:17 p.m., an interview and concurrent record review was conducted with the Registered Nurse (RN). The RN stated Residents 3's and Resident 7's MAR indicated late, missed, and early administration. The RN stated residents should not have missed or late medication doses. The RN stated if unable to administer a medication or a dose was missed the process is to call the physician, notify the physician of the issue and get orders to adjust the time. On May 2, 2025, at 4:04 p.m. an interview and concurrent record review was conducted with the Director of Nursing (DON). The DON stated there was no documented evidence that the antibiotics cefazolin and vancomycin were given on time. The DON stated the MAR should reflect the administered time of a medication not the charted time of a medication. The DON stated medication should be charted accurately and timely. The DON stated the physician, and the pharmacy should have been notified that a resident medication was not in the facility to administer. A review of the facility policy and procedure titled, Medication Administration General Guidelines, dated January 2021, indicated, .Medications are administered as prescribed .good nursing principles and practices .Medications are administered in accordance with written orders of the prescriber .if necessary the nurse contacts the prescriber for clarification .Medications are administered within 60 minutes of scheduled time .individuals who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given .

Based on interview and record review, the facility failed for one resident, Resident 1, to implement attending physician's orders to maintain the bed in the lowest position and place bilateral floor matts for fall precautions when Resident 1 had a fall and sustained a fractured right hip on February 28, 2020. This failure resulted in Resident 1 to be transported to an acute hospital for a partial hip replacement. Findings: On March 11, 2020, at 9:05 a.m., an unannounced visit was made to the facility. On March 11, 2020, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the History and Physical dated February 1, 2020, indicated Resident 1 did not have decision making capacity. The Physician Order dated January 1, 2020, indicated to .Adjust height of bed to low position Special Instructions: Fall Risk Every Shift .Bilateral floor matt when in bed Special Instructions: Fall Risk Every shift . The facility document titled, Fall Risk Data Collection dated February 2, 2020, indicated Resident 1 had a fall Risk of 18 (score above 10 is considered high risk for falls). A review of the facility document titled, Other Clinical Documentation- RISK MEETING INITIAL WEEK ONE dated February 3, 2020, indicated, Resident 1 had poor balance and coordination, poor safety awareness, with a history of falls with injury, and was at risk for repeated falls and potential injury. Resident 1's care plan dated February 1, 2020, confirmed Resident 1 was at high risk for falls due to neuromuscular dysfunction (nerve and muscle dysfunction) secondary to a stroke with paralysis and weakness, cerebral aneurysm, muscle wasting and atrophy.The care plan indicated to lower the bed and place bilateral floor matts while the resident was in bed with frequent visual checks. A review of the Nursing Progress Notes dated February 28, 2020, indicated Resident was found sitting on the floor of her room next to her bed with bed alarm beeping at 3:00 p.m. HX (history) of hematoma (an injury under the skin causing a bruise). On March 11, 2020, at 9:45 a.m., an interview was conducted with the Rehabilitation Nursing Assistant (RNA). The RNA stated on February 28, 2020, at approximately 2:50 p.m., she heard Licensed Vocational Nurse (LVN 1) yell for assistance in the room of Resident 1. The RNA entered the room of Resident 1 and found the resident sitting on the floor with her back to the bed. The RNA stated Resident 1's bed was not in the low position and the floor matts were not on the floor. The RNA stated the bed should have been in the low position and the floor matts should have been on the floor. The RNA was not assigned to Resident 1, but was covering the floor while other staff attended an inservice. On March 11, 2020, at 10:05 a.m., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated she was the CNA caring for Resident 1 during the day shift on February 28, 2020. CNA 1 stated she gave Resident 1 a shower at approximately at 2:10 to 2:30 p.m., then placed Resident 1 to bed for an afternoon nap. CNA 1 stated she left the room without putting the bed in the low position. CNA 1 stated she should have placed the bed in the lowest position and put the floor matts back in place, but was running late to attend an in-service. CNA 1 stated Resident 1 was a high risk for falls and she could not use the call light because of her dementia (memory disorder). On March 11, 2020, at 3:50 p.m., LVN 1 was interviewed. LVN 1 stated she arrived to the facility at approximately 2:55 p.m., and heard the pressure beep alarm coming from Resident 1's room. LVN 1 stated she found Resident 1 sitting on the floor of her room on the right side of the bed near the foot of the bed. LVN 1 stated the bed was not in the low position and matts were not on the floor. LVN 1 stated the bed should have been in the low position with floor matts on both sides of the bed. On March 17, 2020, at 11 a.m., an interview and record review was conducted with the Director of Nursing (DON). The DON stated LVN 1 reported Resident 1 was found on the floor. The bed was not in the low position and matts were not on the floor. The DON stated Resident 1's bed should have been in the lowest position with floor matts on both sides of the bed. A review of the facility's policy and procedure titled, Fall Prevention (Falling Star), dated December 2005, indicated, .Residents who are placed on Falling Star Program will be assessed by the IDT (Interdisciplinary team) for appropriateness of interventions for safety. Interventions may include, but not limited to .Use of low bed and/ ensure that the bed is in its lowest position .Use of matt in the floor-one on both sides .bed at its lowest position, especially after care is provided . A review of the acute hospital records indicated Resident 1 was transferred to the emergency department (ED) on February 29, 2020. The physical examination indicated Resident 1's right hip was tender with some deformity. An x ray of the hip and right pelvis, dated February 28, 2020, indicated a displaced, impacted trans-cervical neck fracture (a [MEDICAL CONDITION] bone in the leg, broken in 2 or more places near the hip, which moves the bone out of alignment and are jammed together). Resident 1 had surgery on February 29, 2020, for a partial right hip replacement.

Based on observation, interview, and record review, the facility failed to ensure 14 of 91 residents reviewed (Residents 44, 61, 74, 17, 76, 9, 28, 56, 57, 197, 90, 43, and 42) receive treatment and care in accordance with professional standards of practice and the comprehensive care plan when: 1. Resident 44 did not received her [MEDICATION NAME] (narcotic pain medication) from (MONTH) 10 to 15, (YEAR). This failure resulted for the resident to experienced increase pain. 2. Resident 44, who had unstable high blood sugar levels, did not received her prescribed Levimir insulin (medication to treat diabetes - a disease that result in too much sugar in the blood) on (MONTH) 22, (YEAR). In addition, Resident 44's blood sugar level were not checked on (MONTH) 25, (YEAR), at 11:30 a.m. and (MONTH) 22, (YEAR), at 6:30 a.m. to determine the resident's need to receive [MEDICATION NAME] R insulin (medication to treat diabetes). These failures could jeopardize Resident 44's health and safety for having unstable high blood sugar levels. 3. Residents 44, 61, and 74 received their prescribed antihypertensive medications (for treatment of [REDACTED]. [REDACTED].>This failure could jeopardize the residents' health and safety when putting the residents at risk for [MEDICAL CONDITION] (low blood pressure - less than 90/60). 4. Resident 44's endocrinology consult (a physician who has special training in diagnosing and treating disorders of the endocrine system) as ordered by the physician on (MONTH) 25, (YEAR), for uncontrolled blood sugar levels was not acted upon. This failure resulted for Resident 44's unstable blood sugar levels not assessed and evaluated by the specialize physician. 5. Resident 17 did not received his [MEDICATION NAME] (narcotic pain medication) on multiple occasions. This failure resulted for the resident to experienced increase pain. 6. Resident 76 did not received his [MEDICATION NAME] on multiple occasions. This failure resulted for the resident to experienced increase pain. 7. Resident 9 did not received her [MEDICATION NAME] (medication that treats nerve and muscle pain) on multiple occasions. This failure resulted for the resident to experienced increase [MEDICAL CONDITION] pain (nerve pain). 8. Resident 28 did not received her [MEDICATION NAME] (pain medication) on multiple occasions. This failure resulted for the resident to experienced increase pain. 9. Resident 56 did not received her [MEDICATION NAME] (narcotic pain medication) and [MEDICATION NAME] (narcotic pain medication) on multiple occasions. This failure resulted for the resident to experienced increase pain. 10. Resident 57 did not received his Bactrim (antibiotic for urinary tract infection [MEDICAL CONDITION]) as a [MEDICATION NAME] for UTI on multiple occasions. This failure could jeopardize Resident 57's health and safety for putting the resident at risk of developing UTI. 11. Resident 197 did not received his [MEDICATION NAME] eye drop (for treatment of [REDACTED]. This failure could jeopardize Resident 197's health and safety for not receiving the resident's prescribed medication for his [MEDICAL CONDITION]. 12. Resident 90 did not received her [MEDICATION NAME] (for [MEDICAL CONDITION]) on multiple occasions. This failure put the resident at risk to experience increase [MEDICAL CONDITION] pain. 13. Resident 43 did not received her [MEDICATION NAME] (narcotic pain medication) on multiple occasions. This failure resulted for the resident to experienced increase pain. 14. Resident 42's +3 [MEDICAL CONDITION] (swelling of a body part, when pressed creates an indentation - measured from +1 = slight indentation to +4 = deep indentation) that was identified on (MONTH) 4, (YEAR), had no documented evidence a care plan was developed. This failure resulted for the resident not receiving a comprehensive person-centered care plan that addressed and managed Resident 42's +3 [MEDICAL CONDITION]. 15. Resident 42's assessment for the used of device for appropriate positioning of resident's flaccid feet related to [MEDICAL CONDITION] (paralysis on half of the body) was not conducted. This failure put the resident at risk for skin breakdown and discomfort from the use of inappropriate positioning device. Findings: 1. On (MONTH) 25, (YEAR), Resident 44's record was reviewed. Resident 44 was readmitted to the facility on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. Resident 44 had cognitive decision-making. Resident 44 physician's orders [REDACTED].patch 72 hour; 12 mcg/hr (microgram/hour) .apply 1 patch [MEDICATION NAME] (application of a medication through the skin) .Every 72 Hours; 09:00 AM . date ordered (MONTH) 3, (YEAR). Resident 44's electronic Medication Administration Record [REDACTED]. Further review of Resident 44's eMAR for (MONTH) (YEAR), indicated the following: - .Monitor [MEDICATION NAME] placement Q-shift . - 09/10/2018 03:56 PM .waiting on pharmacy to deliver . - 09/12/2018 03:01 PM .PHARMACY WILL FAX (name of doctor) for continuous (sic) . - 09/12/2018 05:18 PM Not Administered: On Hold . - 09/13/2018 02:10 AM Not Administered: On Hold . - 09/13/2018 01:42 PM Not Administered: On Hold . - 09/13/2018 04:20 PM Not Administered: Drug/Item unavailable . - 09/14/2018 01:09 AM Not Administered: Drug/Item unavailable . - 09/15/2018 11:38 AM Not Administered .off . Resident 44's [MEDICATION NAME] narcotic count sheet with a delivery date of the medication on (MONTH) 10, (YEAR), containing 10 patch indicated the 10th patch was used on (MONTH) 7, (YEAR). Resident 44's [MEDICATION NAME] narcotic count sheet with a delivery date of the medication on (MONTH) 15, (YEAR), containing 5 patch indicated the first patch was used on (MONTH) 16, (YEAR). There was no documented evidence Resident 44's [MEDICATION NAME] was administered on (MONTH) 10 to 15, (YEAR). On (MONTH) 25, (YEAR), at 11:50 a.m., Resident 44 was interviewed. Resident 44 stated she was always in pain because of her myalgia. Resident 44 stated her [MEDICATION NAME] was important for her to have so she could manage her pain due to myalgia. Resident 44 stated the [MEDICATION NAME] would not completely remove her pain but the medication would helped to bring down her pain on a tolerable level. Resident 44 stated she had several days in the month of (MONTH) (YEAR) where she did not have the [MEDICATION NAME]. Resident 44 stated the nurses told her the [MEDICATION NAME] was not available because the pharmacy was waiting for the physician's authorization. Resident 44 stated her pain level on the days she did not have the [MEDICATION NAME] were 8 out of 10 (pain rating scale 0 to 10: 8-10 severe pain). Resident 44 stated because of severe pain she mostly stayed in bed. Resident 44 further stated, I sleep it off .so not to feel the pain. On (MONTH) 1, (YEAR), at 5:38 p.m., a concurrent record review and interview was conducted with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. MDS/LVN 2 verified [MEDICATION NAME] was not given to Resident 44 from (MONTH) 10 to (MONTH) 15, (YEAR), because it was not available. MDS/LVN 2 verified there was no documented evidence Resident 44's pain assessment was conducted on (MONTH) 10 to 15, (YEAR). MDS/LVN 2 verified there was no documented evidence MD was notified of the [MEDICATION NAME] not administered to Resident 44 when it was not available. On (MONTH) 28, (YEAR), at 1:05 p.m., LVN 5 was interviewed. LVN 5 stated she was the nurse assigned to Resident 44 on (MONTH) 13, (YEAR). LVN 5 stated Resident 44 was scheduled for a [MEDICATION NAME] on that day, but the medication was not available. LVN 5 stated Resident 44 needed her [MEDICATION NAME] for pain management. LVN 5 stated the [MEDICATION NAME] was not available because the pharmacy was waiting for the physician's authorization. LVN 5 stated she did not followed up with the pharmacy for the status of Resident 44's [MEDICATION NAME] refill. LVN 5 stated she should have coordinated with the pharmacy in obtaining the physician's authorization for [MEDICATION NAME] order. LVN 5 stated she did not notified the physician when Resident 44's [MEDICATION NAME] was not available. LVN 5 stated she should have notified the physician and asked for alternative pain medication when [MEDICATION NAME] was not available for Resident 44. LVN 5 stated she did not have documented evidence of Resident 44's pain assessment on (MONTH) 13, (YEAR), when she was the assigned nurse. On (MONTH) 25, (YEAR), at 3:15 p.m., the Director of Nursing (DON) was interviewed. The DON stated she was not aware the [MEDICATION NAME] for Resident 44 was not available because the pharmacy was waiting for the physician's authorization. The DON stated the nurses should have notified the physician when [MEDICATION NAME] was not available. The DON stated the nurses should have asked the physician for alternative pain medication while [MEDICATION NAME] was not available for Resident 44. The DON stated it is not acceptable for Resident 44 not to have the [MEDICATION NAME] nor an alternative pain medication for several days. On (MONTH) 1, (YEAR), Resident 44's care plan for pain with a reviewed and revised date of (MONTH) 24, (YEAR) was reviewed. The care plan for pain indicated, .Goal .Resident will be pain free or relieved from pain .Approach .Administer pain medication as ordered .Assess level of pain .Consult MD if above measures fail to provide adequate pain relief . 2. On (MONTH) 25, (YEAR), Resident 44's record was reviewed. Resident 44 was readmitted to the facility on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. Resident 44 physician's orders [REDACTED].>- .[MEDICATION NAME] .100 unit/mL (milliliter) .80 units .Once A Day; 06:30 AM . date ordered (MONTH) 25, (YEAR); and - .[MEDICATION NAME] R .per sliding scale (progressive increase on the insulin dose, based on pre-defined blood glucose ranges .Before Meals; 06:30 AM, 11:30 AM, 04:30 PM . date ordered (MONTH) 8, (YEAR). Resident 44's electronic Medication Administration Record [REDACTED] - Resident 44's blood sugar was not documented on (MONTH) 25, (YEAR), at 11:30 a.m.; - From (MONTH) 1 to 31, (YEAR), Resident 44's blood sugar level ranges from 230 mg/dl (milligram/deciliter) to 400 mg/dl (above 126 mg/dl was diabetic); and - Resident 44 was receiving [MEDICATION NAME] R every day from (MONTH) 1 to 31, (YEAR), at 6:30 a.m., 11:30 a.m., and 4:30 p.m., except on (MONTH) 25, (YEAR), at 11:30 a.m. Resident 44's eMAR for the month of (MONTH) (YEAR), indicated the following: - Resident 44's blood sugar was not documented on (MONTH) 22, (YEAR), at 6:30 a.m. - Resident 44's [MEDICATION NAME]was not administered on (MONTH) 22, (YEAR), at 6:30 a.m. - From (MONTH) 1 to 25, (YEAR), Resident 44's blood sugar level ranges from 262 mg/dl to 461 mg/dl; and - Resident 44 was receiving [MEDICATION NAME] R every day from (MONTH) 1 to 25, (YEAR), at 6:30 a.m., 11:30 a.m., and 4:30 p.m., except on (MONTH) 22, (YEAR), at 6:30 a.m. On (MONTH) 1, (YEAR), at 2:37 p.m., a concurrent record review and interview was conducted with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. MDS/LVN 2 verified: - Resident 44's eMAR for the month of (MONTH) (YEAR), had no documented evidence Resident 44's blood sugar level was documented on (MONTH) 25, (YEAR), at 11:30 a.m.; and - Resident 44's eMAR for the month of (MONTH) (YEAR), had no documented evidence Resident 44's blood sugar level was documented on (MONTH) 22, (YEAR) and the [MEDICATION NAME]was not administered to the resident on (MONTH) 22, (YEAR). MDS/LVN 2 stated if there was no documentation on the eMAR it means the blood sugar was not checked and the insulin was not given. MDS/LVN 2 stated it was important for Resident 44's blood sugar to be checked before each meal, and insulin to be administered as indicated on the physician's orders [REDACTED].>MDS/LVN 2 further stated monitoring of blood sugar level and administering the prescribed insulin to Resident 44 should be done to help manage the resident's diabetes and to prevent adverse consequences of having a high blood sugar level. On (MONTH) 1, (YEAR), Resident 44's care plan for diabetes with a reviewed and revised date of (MONTH) 27, (YEAR) was reviewed. The care plan for diabetes indicated, .Goal .Resident's blood sugar level will remain stable .Resident's sign and symptoms of hypo/[MEDICAL CONDITION] will improve with interventions .Approach .Blood sugar checked as ordered .Follow sliding scale if applicable .Insulin as ordered . The facility's policy and procedure titled, Medication Administration Times, dated (MONTH) 6, (YEAR), indicated, .Facility should ensure that authorized personnel .administer medications according to times of administration as determined by .physician . 3a. On (MONTH) 25, (YEAR), Resident 44's record was reviewed. Resident 44 was readmitted to the facility on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. Resident 44 had cognitive decision-making. Resident 44 physician's orders [REDACTED].>- .[MEDICATION NAME] (antihypertensive medication) tablet; 5 mg (milligram) .1 tablet; oral .hold for sbp (systolic blood pressure - the first number on the blood pressure (BP) reading) less than 100 .Once A Day; 09:00 AM . date ordered (MONTH) 8, (YEAR); - .[MEDICATION NAME] (antihypertensive medication) tablet; 100 mg .1 tablet; oral .hold for sbp less than 100 .Twice A Day; 09:00 AM, 05:00 PM . date ordered (MONTH) 8, (YEAR); - .[MEDICATION NAME] (medication for [MEDICAL CONDITION]) tablet; 25 mg .0.5 tablet; oral .hold for sbp less than 100 .Once A Day; 09:00 AM . date ordered (MONTH) 8, (YEAR); Resident 44's physician's orders [REDACTED]. Resident 44's electronic Medication Administration Record [REDACTED] - Resident 44's BP was 98/68 on (MONTH) 15, (YEAR) at 5 p.m., the resident was given [MEDICATION NAME] 100 mg (1 tablet); - Resident 44's BP was 98/62 on (MONTH) 21, (YEAR) at 5 p.m., the resident was given [MEDICATION NAME] 100 mg (1 tablet); and - Resident 44's BP was 92/68 on (MONTH) 28, (YEAR) at 9 a.m., the resident was given [MEDICATION NAME] 5 mg (1 tablet), [MEDICATION NAME] 100 mg (1 tablet), and [MEDICATION NAME] 25 mg (1/2 tablet). Resident 44's electronic Medication Administration Record [REDACTED] - Resident 44's BP was 98/62 on (MONTH) 5, (YEAR) at 5 p.m., the resident was given [MEDICATION NAME] 100 mg (1 tablet); - Resident 44's BP was 93/60 on (MONTH) 7, (YEAR) at 9 a.m., the resident was given [MEDICATION NAME] 5 mg (1 tablet); - Resident 44's BP was 98/56 on (MONTH) 12, (YEAR) at 5 p.m., the resident was given [MEDICATION NAME] 100 mg (1 tablet); - Resident 44's BP was 98/72 on (MONTH) 17, (YEAR) at 5 p.m., the resident was given [MEDICATION NAME] 100 mg (1 tablet); and - Resident 44's BP was 98/66 on (MONTH) 22, (YEAR) at 9:00 a.m., the resident was given [MEDICATION NAME] 5 mg (1 tablet), [MEDICATION NAME] 100 mg (1 tablet), and [MEDICATION NAME] 25 mg (1/2 tablet). On (MONTH) 1, (YEAR), at 9:31 a.m., a concurrent record review and interview was conducted with Registered Nurse (RN) 2. RN 2 verified Resident 44 had the following medications: [REDACTED] RN 2 stated Resident 44's antihypertensive medications were not change nor discontinued since the order date of (MONTH) 8, (YEAR). RN 2 verified Resident 44's antihypertensive medications were administered on multiple occasions to the resident when Resident 44's BP was below the indicated sbp parameter. RN 2 stated Resident 44 should have not given the antihypertensive medications when her sbp was below indicated parameter. RN 2 stated the resident would be at risk for [MEDICAL CONDITION]. 3b. On (MONTH) 25, (YEAR), Resident 61's record was reviewed. Resident 61 was readmitted to the facility on (MONTH) 21, (YEAR). Resident 61 was self-responsible. Resident 61 physician's orders [REDACTED].[MEDICAL CONDITION](hypertension - high blood pressure). Hold for sbp (systolic blood pressure - the first number on the blood pressure (BP) reading) < (less than) 120 .Twice A Day; 09:00 AM, 05:00 PM . date ordered (MONTH) 25, (YEAR). Resident 61's physician's orders [REDACTED]. Resident 61's electronic Medication Administration Record [REDACTED] - Resident 61's BP was 110/70 on (MONTH) 14, (YEAR) at 9 a.m., the resident was given Carvedilol 6.25 mg; - Resident 61's BP was 108/70 on (MONTH) 16, (YEAR) at 9 a.m., the resident was given Carvedilol 6.25 mg; - Resident 61's BP was 110/70 on (MONTH) 21, (YEAR) at 9 a.m., the resident was given Carvedilol 6.25 mg; - Resident 61's BP was 107/72 on (MONTH) 23, (YEAR) at 5 p.m., the resident was given Carvedilol 6.25 mg; and - Resident 61's BP was 116/69 on (MONTH) 30, (YEAR) at 9 a.m., the resident was given Carvedilol 6.25 mg; Resident 61's electronic Medication Administration Record [REDACTED] - Resident 61's BP was 110/70 on (MONTH) 4, (YEAR) at 9 a.m., the resident was given Carvedilol 6.25 mg; - Resident 61's BP was 112/68 on (MONTH) 8, (YEAR) at 9 a.m., the resident was given Carvedilol 6.25 mg; - Resident 61's BP was 117/62 on (MONTH) 9, (YEAR) at 9 a.m., the resident was given Carvedilol 6.25 mg; - Resident 61's BP was 109/58 on (MONTH) 12, (YEAR) at 9 a.m., the resident was given Carvedilol 6.25 mg; and - Resident 61's BP was 117/57 on (MONTH) 14, (YEAR) at 5 p.m., the resident was given Carvedilol 6.25 mg; On (MONTH) 28, (YEAR), at 9:55 a.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 4. LVN 4 stated when the resident have antihypertensive medication, the blood pressure (BP) should be checked first. LVN 4 stated if the blood pressure reading was below the indicated parameters, the antihypertensive medication should not be given. LVN 4 stated when antihypertensive medication was given to the resident with the blood pressure below indicated parameter, there could be a risk for the resident to have [MEDICAL CONDITION]. LVN 4 verified Resident 61 received Carvedilol on multiple occasions on the month of (MONTH) and (MONTH) (YEAR), when the resident's BP was below indicated parameter. LVN 4 verified she was the nurse, as documented in the eMAR, who administered the Carvedilol to Resident 61 below indicated parameter on the following dates: - (MONTH) 14, 16, 21, and 30, (YEAR); and - (MONTH) 4, 8, and 12, (YEAR). LVN 4 stated she should have not administered the Carvedilol to Resident 61 when the resident's BP was below indicated parameter. 3c. On (MONTH) 25, (YEAR), Resident 74's record was reviewed. Resident 74 was admitted to the facility on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. Resident 74 was self-responsible. Resident 74 physician's orders [REDACTED].>- .[MEDICATION NAME] (antihypertensive medication) tablet; 50 mg (milligram) .1 tablet; oral .hold for SBP (systolic blood pressure - the first number on the blood pressure (BP) reading) less than 100 .Once A Day; 09:00 AM . date ordered (MONTH) 31, (YEAR); - .[MEDICATION NAME] (antihypertensive medication) tablet; 20 mg .1 tablet; oral .hold for systolic B/P (blood pressure) < 100 Once A Day; 09:00 AM . date ordered (MONTH) 31, (YEAR); and - .[MEDICATION NAME] (antihypertensive medication) tablet; 60 mg; oral .hold for SBP less (sic)110 Once A Day; 09:00 AM . date ordered (MONTH) 23, (YEAR). Resident 74 physician's orders [REDACTED]. Resident 74's electronic Medication Administration Record [REDACTED] - Resident 74's BP was 108/60 on (MONTH) 7, (YEAR) at 9 a.m., the resident was given [MEDICATION NAME] 60 mg; - Resident 74's BP was 104/60 on (MONTH) 10, (YEAR) at 9 a.m., the resident was given [MEDICATION NAME] 60 mg; and - Resident 74's BP was 99/77 on (MONTH) 16, (YEAR) at 9 a.m., the resident was given [MEDICATION NAME] 50 mg, [MEDICATION NAME] 60 mg, and [MEDICATION NAME] 20mg. On (MONTH) 28, (YEAR), at 10 a.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 4. LVN 4 stated when the resident have antihypertensive medication, the blood pressure (BP) should be checked first. LVN 4 stated if the blood pressure reading was below the indicated parameters, the antihypertensive medication should not be given. LVN 4 stated when antihypertensive medication was given to the resident with the blood pressure below indicated parameter, there could be a risk for the resident to have [MEDICAL CONDITION]. LVN 4 verified Resident 74 received antihypertensive medications on multiple occasions on the month of (MONTH) (YEAR), when the resident's BP was below indicated parameter. LVN 4 verified she was the nurse, as documented in the eMAR, who administered the [MEDICATION NAME], and [MEDICATION NAME] to Resident 61 below indicated parameter on (MONTH) 16, (YEAR). LVN 4 stated she should have not administered Resident 61's antihypertensive medications when the resident's BP was below indicated parameter. The facility's policy and procedure titled, Administering Medications, dated (MONTH) 6, (YEAR), indicated, .Medications shall be administered in a safe and timely manner, and as prescribed .The following information must be checked/verified for each resident prior to administering medications .Vital signs, if necessary . 4. On (MONTH) 25, (YEAR), Resident 44's record was reviewed. Resident 44 was readmitted to the facility on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. Resident 44 physician's orders [REDACTED].PLS (please) CALL MAKE APPT (appointment) . date ordered (MONTH) 25, (YEAR). Resident 44's electronic Medication Administration Record [REDACTED] - From (MONTH) 1 to 31, (YEAR), Resident 44's blood sugar level ranges from 230 mg/dl (milligram/deciliter) to 400 mg/dl (above 126 mg/dl was diabetic); - Resident 44 was receiving [MEDICATION NAME]80 units at 6:30 a.m. and 40 units at bedtime; and - Resident 44 was receiving [MEDICATION NAME] R every day from (MONTH) 1 to 31, (YEAR), three times a day before meals. Resident 44's eMAR for (MONTH) 1 to 25, (YEAR), indicated the following: - Resident 44's blood sugar level ranges from 262 mg/dl to 461 mg/dl; - Resident 44 was receiving [MEDICATION NAME]80 units at 6:30 a.m. and 40 units at bedtime; and - Resident 44 was receiving [MEDICATION NAME] R every day from (MONTH) 1 to 25, (YEAR), three times a day before meals. On (MONTH) 1, (YEAR), at 10:35 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated if there were an order for [REDACTED]. LVN 1 stated if there would be a need for insurance approval before making the consult appointment, the charge nurse would refer it to the social services. LVN 1 stated there was no documented evidence an appointment was made for Resident 44's endocrinology consult that was ordered on (MONTH) 25, (YEAR) nor a reason for not obtaining the consult appointment. LVN 1 stated the charge nurse who received the endocrinology consult should have made an appointment. LVN 1 stated it was important to schedule Resident 44's endocrinology consult because of the resident's uncontrolled high blood sugar levels. The facility's policy and procedure titled, Referral to Outside Agencies, dated (MONTH) 6, (YEAR), indicated, .Referrals can be made by the Social Services Director, licensed nurse, or a member of the IDT based on a resident's individualized, specific needs identified through interviews, evaluations, and assessments . 5. On (MONTH) 27, (YEAR), Resident 17's record was reviewed. Resident 17 was admitted to the facility on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. Resident 17's electronic Medication Administration Record [REDACTED]. The physician's orders [REDACTED]. Further review of Resident 17's eMAR indicated, the resident did not receive his [MEDICATION NAME] dose on the following dates: - (MONTH) 15, 16, and 18, (YEAR) at 9 a.m. and 9 p.m. - (MONTH) 19, (YEAR) the dose at 9 a.m. On (MONTH) 27, (YEAR) at 10 a.m., an interview was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 stated when medications are not available, the licensed nurse should call the pharmacy and asks when the facility is going to receive the medication. LVN 2 further stated she follows up with pharmacy usually after rounds and calls the pharmacy again at the end of the shift. On (MONTH) 28, (YEAR), at 11:20 a.m., a concurrent interview and record review was conducted with LVN 3. LVN 3 verified the [MEDICATION NAME] doses were not administered to Resident 17 on (MONTH) 15, 16, 18, and 19, (YEAR). LVN 3 stated there was no assessment for pain conducted on (MONTH) 15, 16, 18, and 19, (YEAR) for Resident 17. On (MONTH) 1, (YEAR) at 10:35 a.m., an interview was conducted with Resident 17. Resident 17 stated he was aware and was notified [MEDICATION NAME] was not available by the licensed nurses. Resident 17 stated when he did not received his [MEDICATION NAME], his pain scale was 8 out of 10. Resident 17 further stated it was generalized pain and It was very bad pain for several days. 6. On (MONTH) 28, (YEAR), at 10:33 a.m., Resident 76's record was reviewed with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. Resident 76 was admitted to the facility on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. Resident 76's history and physical indicated the resident had the capacity to make health care decisions. Resident 76's electronic Medication Administration Record [REDACTED] - .[MEDICATION NAME] .10 mg (milligram - a unit of measurement) .1 tablet; oral .Twice A Day .chronic pain management . Reasons/Comments: Not Administered: Drug/Item unavailable: 08/09/2018, 9:00 AM .08/15/2018, 5:00 PM .08/17/2018, 9:00 AM . 8/17/2018, 5:00 PM . Resident 76's eMAR for the month of (MONTH) (YEAR), indicated: - .[MEDICATION NAME] tablet; 10 mg .0.5 tablet; oral .At Bedtime .for pain management . Reasons/Comments: Not Administered: Drug/Item unavailable: 09/07/2018, 9:00 PM .09/08/2018, 9:00 PM .09/09/2018, 9:00 PM .and 09/10/2018, 9:00 PM . In a concurrent interview MDS/LVN 2 acknowledged [MEDICATION NAME] was not administered to Resident 76 on multiple occasions because the drug was unavailable. MDS/LVN 2 stated there was no documented evidence Resident 76's pain assessments were conducted when the [MEDICATION NAME] was not administered to the resident on those dates. MDS/LVN 2 stated there was no documented evidence the physician was informed of the missed doses of [MEDICATION NAME] for Resident 76. On (MONTH) 1, (YEAR), at 10:46 a.m., Resident 76 was observed awake, alert, and lying in bed. In a concurrent interview, Resident 76 stated, he was told by the nurses when his [MEDICATION NAME] was unavailable but he could not recall the exact dates when it was. Resident 76 stated he needed the [MEDICATION NAME] to control his chronic pain. Resident 76 further stated he felt terrible pain whenever [MEDICATION NAME] was not administered to him. 7. On (MONTH) 28, (YEAR), at 11:03 a.m., Resident 9's record was reviewed with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. Resident 9 was admitted to the facility on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. Resident 9's history and physical indicated she had the capacity to understand and make health care decisions. Resident 9's electronic Medication Administration Record [REDACTED] - .[MEDICATION NAME] (pregabalin) capsule; 75 mg .1 capsule; oral .Twice A Day .[MEDICAL CONDITION] . Reasons/Comments: Not Administered: Drug/Item Unavailable: 09/13/2018, 9:00 AM .09/13/2018, 5:00 PM .09/14/2018, 9:00 AM . In a concurrent interview MDS/LVN 2 acknowledged [MEDICATION NAME] was not administered to Resident 9 on multiple occasions because the drug was unavailable. MDS/LVN 2 stated there was no documented evidence Resident 9's pain assessments were conducted when the [MEDICATION NAME] was not administered to the resident on those dates. MDS/LVN 2 stated there was no documented evidence the physician was informed of the missed doses of [MEDICATION NAME] for Resident 9. On (MONTH) 1, (YEAR), at 10:52 a.m., Resident 9 was observed sitting on her wheelchair inside her room. In a concurrent interview, Resident 9 stated she was made aware by the nurse on multiple occasions that [MEDICATION NAME] was unavailable, but could not recall the exact dates when it was. Resident 9 stated she felt terrible when she missed her [MEDICATION NAME] medication. Resident 9 further stated she felt as if there was a tight band-aid around her fingers, and her fingers were numb, and felt like more than a tingling sensation. 8. On (MONTH) 28, (YEAR), at 10:41 a.m., Resident 28's record was reviewed with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. Resident 28 was admitted to the facility on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. Resident 28's history and physical indicated he had the capacity to understand and make medical decisions. Resident 28's electronic medicaion administration record (eMAR) for the month of (MONTH) (YEAR), indicated: - .[MEDICATION NAME] .tablet; 50 mg .50 MG; oral .Every 4 Hours .PAIN MANAGEMENT . Reasons/Comments: Not Administered: Drug/Item unavailable: 08/04/2018, 6:00 AM .08/04/2018, 10:00 AM .and 08/04/2018, 2:00 PM . Resident 28's eMAR for the month of (MONTH) (YEAR), indicated: - .[MEDICATION NAME] .tablet; 50 mg .50 MG; oral .Every 4 Hours .PAIN MANAGEMENT . Reasons/Comments: Not Administered: Drug/Item unavailable: 09/04/2018, 10:00 AM . In a concurrent intervie(TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure 25 of 91 residents reviewed (Residents 44, 74, 61, 17, 9, 56, 28, 76, 77, 395, 47, 90, 43, 57, 197, 192, 25, 199, 69, 53, 194, 196, 198, 195, and 36) prescribed medications were provided and available for timely administration from the period of (MONTH) to (MONTH) (YEAR). This failure resulted for the residents not receiving the medications as ordered by the physician to manage and treat medical conditions, and overall long-term health and well-being of the residents. Findings: 1. On (MONTH) 25, (YEAR), Resident 44's record was reviewed. Resident 44 was readmitted to the facility on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. Resident 44 had cognitive decision-making. Resident 44 physician's orders [REDACTED].patch 72 hour; 12 mcg/hr (microgram/hour) .apply 1 patch [MEDICATION NAME] (application of a medication through the skin) .Every 72 Hours; 09:00 AM . date ordered (MONTH) 3, (YEAR). Resident 44's electronic Medication Administration Record [REDACTED]. Further review of Resident 44's eMAR for (MONTH) (YEAR), indicated the following: - .Monitor [MEDICATION NAME] placement Q-shift . - 09/10/2018 03:56 PM .waiting on pharmacy to deliver . - 09/12/2018 03:01 PM .PHARMACY WILL FAX (name of doctor) for continuous (sic) . - 09/12/2018 05:18 PM Not Administered: On Hold - 09/13/2018 02:10 AM Not Administered: On Hold - 09/13/2018 01:42 PM Not Administered: On Hold - 09/13/2018 04:20 PM Not Administered: Drug/Item unavailable - 09/14/2018 01:09 AM Not Administered: Drug/Item unavailable - 09/15/2018 11:38 AM Not Administered .off . Resident 44's [MEDICATION NAME] narcotic count sheet, with a delivery date of the medication on (MONTH) 10, (YEAR), indicated 10 patch was delivered. The fenatanyl narcotic count sheet indicated the 10th patch was used on (MONTH) 7, (YEAR). Resident 44's [MEDICATION NAME] narcotic count sheet, with a delivery date of the medication on (MONTH) 15, (YEAR), indicated 5 patch was delivered. The [MEDICATION NAME] narcotic count sheet indicated the first patch was used on (MONTH) 16, (YEAR). On (MONTH) 25, (YEAR), at 11:50 a.m., Resident 44 was interviewed. Resident 44 stated she was always in pain because of her myalgia. Resident 44 stated her pain medication was important for her to have so she could manage her pain. Resident 44 stated she used the [MEDICATION NAME] for her myalgia pain. Resident 44 stated the [MEDICATION NAME] would not completely remove her pain but the medication helped bring down her pain on a tolerable level. Resident 44 stated she had several days in the month of (MONTH) (YEAR) where she did not have the [MEDICATION NAME]. Resident 44 stated the nurses told her the [MEDICATION NAME] was not available because the pharmacy was waiting for the physician's authorization. Resident 44 stated her pain level on the days she did not have the [MEDICATION NAME] were 8/10 (pain rating scale 0 to 10: 8-10 severe pain). Resident 44 stated because of severe pain she mostly stayed in bed. Resident 44 further stated, I sleep it off .so not to feel the pain. On (MONTH) 28, (YEAR), at 1:05 p.m., Licensed Vocational Nurse (LVN) 5 was interviewed. LVN 5 stated she was the nurse assigned to Resident 44 on (MONTH) 13, (YEAR). LVN 5 stated Resident 44 was scheduled to receive a [MEDICATION NAME] on that day, but the medication was not available. LVN 5 stated Resident 44 needed her [MEDICATION NAME] for pain management. LVN 5 stated the [MEDICATION NAME] was not available because the pharmacy was waiting for the physician's authorization. LVN 5 stated she did not followed up with the pharmacy for the status of [MEDICATION NAME] refill. LVN 5 stated she did not notified the physician when Resident 44's [MEDICATION NAME] was not available. LVN 5 stated she did not have documented evidence of Resident 44's pain assessment on (MONTH) 13, (YEAR), when she was the assigned nurse. LVN 5 stated she should have coordinated with the pharmacy in obtaining the physician's authorization for [MEDICATION NAME] order. LVN 5 stated she should have notified the physician when Resident 44's [MEDICATION NAME] was not available. LVN 5 stated she should have asked the physician for alternative pain medication for Resident 44 when [MEDICATION NAME] was not available. On (MONTH) 1, (YEAR), at 5:38 p.m., a concurrent record review and interview was conducted with the Minimum Data Set (MDS- an assessment tool)/ Licensed Vocational Nurse (LVN) 2. MDS/LVN 2 verified the [MEDICATION NAME] was not given to Resident 44 from (MONTH) 10 to (MONTH) 15, (YEAR), because it was not available. MDS/LVN 2 verified there was no documented evidence Resident 44's pain assessment was conducted on (MONTH) 10 to 15, (YEAR). MDS/LVN 2 verified there was no documented evidence the physician was notified of the [MEDICATION NAME] not administered to Resident 44 because it was not available. MDS/LVN 2 further stated residents' medication refills should be requested five days before the last dose to ensure pharmacy would deliver it before the medication run out. MDS/LVN 2 stated for controlled medication refill (such as [MEDICATION NAME]) the nurses should have communicated with the pharmacy for the status of the request. The nurses should have informed the DON or the Administrator if there was a delay with the physician authorization to help expedite in obtaining authorization for the controlled medication. On (MONTH) 25, (YEAR), at 3:15 p.m., the Director of Nursing (DON) was interviewed. The DON stated she was not aware the [MEDICATION NAME] for Resident 44 was not available because the pharmacy was waiting for the physician's authorization. The DON stated the nurses should have notified the physician when [MEDICATION NAME] was not available. The DON stated the nurses should have asked the physician for alternative pain medication while [MEDICATION NAME] was not available for Resident 44. The DON stated it is not acceptable for Resident 44 not to have the [MEDICATION NAME] nor an alternative pain medication for several days. 2. On (MONTH) 24, (YEAR), at 9:35 a.m. a medication pass observation on Resident 74 was conducted with Licensed Vocational Nurse (LVN) 4. LVN 4 was observed verifying medications with the physician's orders [REDACTED]. - One tablet of aspirin ([MEDICATION NAME] for stroke); - One tablet of [MEDICATION NAME] (medication used for high blood pressure - that is 140/90 or higher); and - One tablet of [MEDICATION NAME] (medication used for high blood pressure). On (MONTH) 24, (YEAR), at 9:50 a.m., LVN 4 administered these medications to Resident 74 then subsequently signed the eMAR. On (MONTH) 24, (YEAR), at 12:30 p.m., Resident 74's record was reviewed. Resident 74 was admitted to the facility on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. Resident 74's physician's orders [REDACTED]. - .aspirin .81 mg (milligram) .1 tablet; oral .Once A day; 09:00 AM . date ordered (MONTH) 29, (YEAR); - .[MEDICATION NAME] .50 mg .1 tablet; oral .Once A Day; 09:00 AM . date ordered (MONTH) 31, (YEAR); - .[MEDICATION NAME] (diuretic medication) .20 mg .1 tablet; oral .[MEDICAL CONDITION](hypertension) .Once A Day; 09:00 AM . date ordered (MONTH) 31, (YEAR); and - .[MEDICATION NAME] .60 mg .oral .Once A day; 09:00 AM . date ordered (MONTH) 23, (YEAR). On (MONTH) 24, (YEAR), at 4:10 p.m., a concurrent record review and interview was conducted with LVN 4. LVN 4 verified Resident 74's [MEDICATION NAME] was administered to the resident at 9 a.m. LVN 4 was made aware the [MEDICATION NAME] medication was not observed to have prepared and administered to Resident 74. LVN 4 stated she will check the [MEDICATION NAME] medication pack to verify the medication was administered today. After checking her medication cart, LVN 4 stated Resident 74 did not have a medication pack for [MEDICATION NAME]. LVN 4 stated Resident 74's [MEDICATION NAME] was not available to be administered. LVN 4 stated she made a mistake in signing the eMAR for 9 a.m. dose today as administered. LVN 4 stated she did not give Resident 74's [MEDICATION NAME] today because it was not available. 3. On (MONTH) 24, (YEAR), at 9:19 a.m. a medication pass observation on Resident 61 was conducted with Licensed Vocational Nurse (LVN) 4. LVN 4 was observed verifying medications with the physician's orders [REDACTED]. - One tablet of vitamin C (supplement); - One capsule of cranberry extract (supplement used to prevent urinary tract infection); - One tablet of [MEDICATION NAME] (a diuretic medication); - Two capsule of milk thistle (supplement used to treat liver problem); - One tablet of [MEDICATION NAME] (potassium chloride - an electrolyte supplement) - One tablet of sodium chloride (an electrolyte supplement); and - One capsule of zinc sulfate (supplement). LVN 4 stated Resident 61 refused the 9 a.m. dose of his antihypertensive medication (for high blood pressure - that is 140/90 or higher). On (MONTH) 24, (YEAR), at 9:30 a.m., LVN 4 administered these medications to Resident 61 then subsequently signed the eMAR. On (MONTH) 24, (YEAR), at 12 p.m., Resident 61's record was reviewed. Resident 61 was readmitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. Resident 61's physician's orders [REDACTED]. - .vitamin C .tablet; 500 mg (milligram) .1 tab (tablet); oral .Once A day; 09:00 AM . date ordered (MONTH) 21, (YEAR); - .cranberry .400 mg .1 capsule; oral .Once A Day; 09:00 AM . date ordered (MONTH) 21, (YEAR); - .sodium chloride .1 gram .1 tab; oral .Twice A Day; 09:00 AM . date ordered (MONTH) 21, (YEAR); - .[MEDICATION NAME] .20 mg .1 tab; oral .scrotal swelling Once A Day; 09:00 AM . date ordered (MONTH) 22, (YEAR); - .potassium chloride .10 mEq (milliequivalent) .1 tab; oral .supplement Once A Day; 09:00 AM . date ordered (MONTH) 22, (YEAR); - .[MEDICATION NAME] ([MEDICAL CONDITION] medication) .500 mg; 1 tab; oral .PPx ([MEDICATION NAME]) for [MEDICAL CONDITION] Rash Once A Day; 09:00 AM . date ordered (MONTH) 20, (YEAR); - .zinc sulfate .220 (50) mg .1 capsule; oral .Once A Day; 09:00 AM . dated (MONTH) 22, (YEAR); - .[MEDICATION NAME] solution (medication for treating liver disease); 20 gram/30 ml (milliliter) .45ml (30g total); oral .[MEDICAL CONDITION] Twice A Day; 09:00 AM . dated (MONTH) 23, (YEAR); - .carvedilol tablet (medication used for high blood pressure); 6.25 mg .oral .[MEDICAL CONDITION](hypertension - high blood pressure) .Twice A Day; 09:00 AM . dated (MONTH) 25, (YEAR); and - .tamsulosin (medication for [MEDICAL CONDITION]) .0.4 mg .1 tab; oral .Once A Day; 09:00 AM . dated (MONTH) 31, (YEAR). On (MONTH) 24, (YEAR), at 4:04 p.m., a concurrent record review and interview was conducted with LVN 4. LVN 4 verified Resident 61's medications: [REDACTED] LVN 4 was made aware on the following medications not observed to have prepared and administered to Resident 61: - [MEDICATION NAME]; - Tamsulosin; and - [MEDICATION NAME]. LVN 4 stated the [MEDICATION NAME] was given to Resident 61 at 8:00 a.m., as requested by the resident. LVN 4 stated the Tamsulosin and [MEDICATION NAME] were not administered to Resident 61 because it was not available. LVN 4 stated when medications were not available, medication refill should have been requested and a follow up call should be have been made to the pharmacy for the time of delivery. LVN 4 stated the physician should have been notified of medications not administered to the residents. LVN 4 stated the residents' medication refill should be requested from the pharmacy five days before the last dose. LVN 4 stated it is important for the refill request submitted ahead of time to ensure the resident's medication would be available for administration. LVN 4 stated the refill of the missing medications were not yet delivered. LVN 1 stated she did not follow up with the pharmacy for the status of the refill requests. LVN 4 further stated she did not notify the physician on Resident 61's medications: [REDACTED]. 4. On (MONTH) 27, (YEAR), Resident 17's record was reviewed. Resident 17 was admitted to the facility on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. Resident 17's electronic Medication Administration Record [REDACTED]. The physician's orders [REDACTED]. Further review of Resident 17's eMAR indicated, the resident did not receive his [MEDICATION NAME] dose on the following dates: - (MONTH) 15, 16, and 18, (YEAR) at 9 a.m. and 9 p.m. ; and - (MONTH) 19, (YEAR) the dose at 9 a.m. On (MONTH) 27, (YEAR) at 10 a.m., an interview was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 stated when medications are not available, the licensed nurse should call the pharmacy and asks when the facility is going to receive the medication. LVN 2 further stated she follows up with pharmacy usually after rounds and calls the pharmacy again at the end of the shift. On (MONTH) 28, (YEAR), at 11:20 a.m., a concurrent interview and record review was conducted with LVN 3. LVN 3 verified the [MEDICATION NAME] doses were not administered to Resident 17 on (MONTH) 15, 16, 18, and 19, (YEAR). 5. On (MONTH) 28, (YEAR), at 11:03 a.m., Resident 9's record was reviewed with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. Resident 9 was admitted to the facility on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. Resident 9's electronic Medication Administration Record [REDACTED] - .[MEDICATION NAME] (pregabalin) capsule; 75 mg .1 capsule; oral .Twice A Day .[MEDICAL CONDITION] . Reasons/Comments: Not Administered: Drug/Item Unavailable: 09/13/2018, 9:00 AM .09/13/2018, 5:00 PM .09/14/2018, 9:00 AM . In a concurrent interview MDS/LVN 2 acknowledged [MEDICATION NAME] was not administered to Resident 9 on multiple occasions because the drug was unavailable. MDS/LVN 2 stated there was no documented evidence the physician was informed of the missed doses of [MEDICATION NAME] for Resident 9. On (MONTH) 1, (YEAR), at 10:52 a.m., Resident 9 was observed sitting on her wheelchair inside her room. In a concurrent interview, Resident 9 stated she was made aware by the nurse on multiple occasions that [MEDICATION NAME] was unavailable, but could not recall the exact dates when it was. 6. On (MONTH) 28, (YEAR), at 10:58 a.m., Resident 56's record was reviewed with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. Resident 56 was admitted to the facility on (MONTH) 17, (YEAR), with [DIAGNOSES REDACTED]. Resdient 56's electronic Medication Administration Record [REDACTED] - .[MEDICATION NAME] .patch 72 hour; 12 mcg/hr (microgram per hour- a unit of measurement) .1 patch; [MEDICATION NAME] .Every 72 Hours .for pain control . Reasons/Comments: Not Administered: Drug/Item Unavailable: (MONTH) 4, (YEAR), 9:00 AM .and 8/16/2018, 9:00 AM . In a concurrent interview, MDS/LVN 2 acknowledged [MEDICATION NAME] was not administered on multiple occasions because the drug was unavailable. LVN/MDSN 2 stated there was no documented evidence the physician was informed of the missed doses of fentanly patch for Resident 56. On (MONTH) 1, (YEAR), at 10:41 a.m., Resident 56 was observed awake and alert, while sitting at the side of her bed, rubbing her legs with her hands. In a concurrent interview, Resident 56 stated she currently had severe pain on both lower legs and she just took her pain medication. Resident 56 stated the nurse had informed her on multiple occasions when her [MEDICATION NAME] was unavailable. Resident 56 further stated she felt terrible pain' when [MEDICATION NAME] was not given to her. 7. On (MONTH) 28, (YEAR), at 10:41 a.m., Resident 28's record was reviewed with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. Resident 28 was admitted to the facility on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. Resident 28's electronic Medication Administration Record [REDACTED] - .[MEDICATION NAME] .tablet; 50 mg .50 MG; oral .Every 4 Hours .PAIN MANAGEMENT . Reasons/Comments: Not Administered: Drug/Item unavailable: 08/04/2018, 6:00 AM .08/04/2018, 10:00 AM .and 08/04/2018, 2:00 PM . Resident 28's eMAR for the month of (MONTH) (YEAR), indicated: - .[MEDICATION NAME] .tablet; 50 mg .50 MG; oral .Every 4 Hours .PAIN MANAGEMENT . Reasons/Comments: Not Administered: Drug/Item unavailable: 09/04/2018, 10:00 AM . In a concurrent interview, MDS/LVN 2 acknowledged [MEDICATION NAME] was not administered on multiple occasions because the drug was unavailable. LVN/MDSN 2 stated there was no documented evidence the physician was informed of the missed doses of [MEDICATION NAME] for Resident 28. On (MONTH) 1, (YEAR), at 10:39 a.m., Resident 28 was observed awake and alert, and lying in bed. In a concurrent interview, Resident 28 stated he was made aware by the nurse on multiple occasions that [MEDICATION NAME] was unavailable, but could not recall the exact dates when it was. Resident 28 further stated when he missed his [MEDICATION NAME] medication, he felt terrible pain from his legs all the way up to his body. 8. On (MONTH) 28, (YEAR), at 10:33 a.m., Resident 76's record was reviewed with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. Resident 76 was admitted to the facility on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. Resident 76's electronic Medication Administration Record [REDACTED] - .[MEDICATION NAME] .10 mg (milligram - a unit of measurement) .1 tablet; oral .Twice A Day .chronic pain management . Reasons/Comments: Not Administered: Drug/Item unavailable: 08/09/2018, 9:00 AM .08/15/2018, 5:00 PM .08/17/2018, 9:00 AM . 8/17/2018, 5:00 PM .; .Eliquis (apixaban) tablet .5 mg .2 tablets; oral .Every 12 Hours .MI ([MEDICAL CONDITION] infarction- [MEDICAL CONDITION]) prevention; Start/End Date: 08/26/2018 - 08/30/2018; Reasons/Comments: Not Administered: Drug unavailable: 08/26/2018, 9:00 PM; and - .[MEDICATION NAME] (medication used for anxiety) .2 mg; oral .Every 8 Hours .FOR ANXIETY M/B/ CONSTANTLY CALLING/YELLING FOR HELP . Reasons/Comments: Not Administered: Drug/Item unavailable; 08/09/2018, 2:00 PM; and 08/09/2018, 10:00 PM. Resident 76's eMAR for the month of (MONTH) (YEAR), indicated: - .[MEDICATION NAME] tablet; 10 mg .0.5 tablet; oral .At Bedtime .for pain management . Reasons/Comments: Not Administered: Drug/Item unavailable: 09/07/2018, 9:00 PM .09/08/2018, 9:00 PM .09/09/2018, 9:00 PM .and 09/10/2018, 9:00 PM . In a concurrent interview MDS/LVN 2 acknowledged [MEDICATION NAME] was not administered to Resident 76 on multiple occasions because the drug was unavailable. MDS/LVN 2 stated there was no documented evidence the physician was informed of the missed doses of [MEDICATION NAME] for Resident 76. MDS/LVN 2 stated multiple medications were not administered on several occasions because the drugs were unavailable for the resident. MDS/LVN 2 stated there was no documented evidence the physician was informed of the missed medication administration. LVN/MDSN further stated medications should have been reordered on a timely manner, especially for pain medications. 9. On (MONTH) 28, (YEAR), at 10:47 a.m., Resident 77's record was reviewed with Mimimun Data Set (MDS- an assessment tool)/ Licensed Vocational Nurse (LVN) 2. Resident 77 was admitted on (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. Resident 77's electronic Medication Administration Record [REDACTED] - .lanthanum tablet .1,000 mg .1 TAB (tablet); oral .Three Times A Day .[MEDICAL CONDITION] ([MEDICAL CONDITION]- kidney failure) . Reasons/Comments: Not Administered: Drug/Item Unavailable: 08/31/2018, 9:00 AM; and 08/31/2018, 5:00 PM . In a concurrent interview, MDS/LVN 2 stated the medication were not administered on several occasions because the drug was unavailable for the resident. MDS/LVN 2 stated there was no documented evidence the physician was informed of the missed medication administration. MDS/LVN 2 further stated medications should have been reordered on a timely manner. 10. On (MONTH) 28, (YEAR), at 11:07 a.m., Resident 395's record was reviewed with Mimimun Data Set (MDS- an assessment tool)/ Licensed Vocational Nurse (LVN) 2. Resident 395 was admitted on (MONTH) 1, (YEAR). Resident 395's eMAR for the month of (MONTH) (YEAR), indicated: - .[MEDICATION NAME] .tablet; 10 mg; Amount to Administer: 1 TAB; oral; Frequency: Once A Day; Special Instructions: FOR: ALLERGY RELIEF; Start/End Date: 09/01/2018 - Open Ended; Reasons/Comments: Not Administered: Drug/Item unavailable: 09/09/2018, 9:00 AM; 09/11/2018, 9:00 AM; and 09/12/2018, 9:00 AM. During a concurrent interview; LVN/MDSN acknowledged the medication was not administered on several occasions because the drug was unavailable for the resident. LVN/MDSN stated there was no documented evidence the physician was informed of the missed medication administration. LVN/MDSN further stated medications should have been reordered on a timely manner. 11. On (MONTH) 28, (YEAR), at 11:12 a.m., Resident 47's record was reviewed with Mimimun Data Set (MDS- an assessment tool)/ Licensed Vocational Nurse (LVN) 2. Resident 47 was admitted on (MONTH) 9, (YEAR). Resident 47's electronic Medication Administration Record [REDACTED] - .pantoprazole tablet .40 mg .oral .Once A Day .GERD (gastro-[MEDICAL CONDITION] reflux disease- acid reflux) . Reasons/Comments: Not Administered: Drug/Item unavailable: 08/24/2018, 6:30 AM; and 08/25/2018, 6:30 AM . In a concurrent interview, MDS/LVN 2 stated the medication were not administered on several occasions because the drug was unavailable for the resident. MDS/LVN 2 stated there was no documented evidence the physician was informed of the missed medication administration. MDS/LVN 2 further stated medications should have been reordered on a timely manner. 12. On (MONTH) 17, (YEAR), Resident 90's record was reviewed. Resident 90 was admitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. The (MONTH) (YEAR) electronic Administration Record (eMAR) indicated Resident 90 had a physician's orders [REDACTED]. The (MONTH) (YEAR) eMAR also indicated, the [MEDICATION NAME] 400 mg was not administered to Resident 90 due to medication unavailability on the following dates: - (MONTH) 1, (YEAR), at 6 a.m.; - (MONTH) 2, (YEAR), at 6 a.m.; - (MONTH) 3, (YEAR), at 6 a.m.; - (MONTH) 5, (YEAR), at 6 a.m.; - (MONTH) 6, (YEAR), at 6 a.m.; and - (MONTH) 9, (YEAR) at 6 a.m. On (MONTH) 1, (YEAR), at 8:47 a.m., Resident 90's record was reviewed with Licensed Vocational Nurse (LVN) 5. LVN 5 verified her electronic signatures for the missed doses of [MEDICATION NAME]. LVN 5 stated she was not able to administer the [MEDICATION NAME] because the medication was not available on (MONTH) 1, 2, 3, 5, 6, and 9, (YEAR). LVN 5 stated the medication was not in the cart. LVN 1 stated she did not notify the pharmacy on the medication unavailability. 13. On (MONTH) 26, (YEAR), Resident 43's record was reviewed. Resident 46 was admitted to the facility on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].tablet extended release .15 mg (milligrams) .1 tablet oral .every 12 hours .for pain management . The (MONTH) (YEAR) electronic Medication Administration Record [REDACTED] - (MONTH) 6, (YEAR), at 9 p.m.; - (MONTH) 7, (YEAR), at 9 a.m. and 9 p.m.; - (MONTH) 8, (YEAR), at 9 a.m. and 9 p.m.; - (MONTH) 8, (YEAR), at 9 p.m.; and - (MONTH) 23, (YEAR) at 9 p.m. The (MONTH) (YEAR) eMAR indicated the licensed nurse was not able to give the [MEDICATION NAME] 15 mg tablet for pain due to medication unavailability on the following dates: - (MONTH) 8, (YEAR), at 9 a.m.; - (MONTH) 14, (YEAR), at 9 a.m. and 9 p.m.; - (MONTH) 15, (YEAR), at 9 a.m.; - (MONTH) 16, (YEAR), at 9 a.m. and 9 p.m.; - (MONTH) 17, (YEAR), at 9 a.m.; - (MONTH) 18, (YEAR), at 9 a.m.; - (MONTH) 19, (YEAR), at 9 a.m.; - (MONTH) 20, (YEAR), at 9 a.m. and 9 p.m.; and - (MONTH) 21, (YEAR), at 9 a.m. and 9 p.m. On (MONTH) 1, (YEAR), at 10:36 a.m., Resident 43's record was reviewed with Licensed Vocational Nurse (LVN) 3. LVN 3 stated he was not able to administer the 9 a.m. dose of the [MEDICATION NAME] tablet to Resident 43 because it was unavailable on (MONTH) 8, 14, 15, 16, 17, 18, and 21. LVN 3 stated he should have called the pharmacy to follow up on the refill of the [MEDICATION NAME] 15 mg. LVN 2 further stated the facility had always encountered issues with the availability of the medications. 14. On (MONTH) 28, (YEAR), Resident 57's record was reviewed. Resident 57 was admitted to the facility on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED].cause bladder, urinary tract or kidney problems with lower urinary tract infection [MEDICAL CONDITION]). The physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. On (MONTH) 28, (YEAR), at 9:33 a.m., Registered Nurse (RN) 1 was interviewed. RN 1 stated Bactrim was not administered to Resident 57 on (MONTH) 2, 4, 10, and 12, (YEAR), because it was not available. In addition, RN 1 stated the physician should have been called and informed the Bactrim was not administered as ordered on (MONTH) 2, 4, 10, and 12, (YEAR). 15. On (MONTH) 28, (YEAR), Resident 197's record was reviewed. Resident 197 was admitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. - [MEDICATION NAME] Z .drops; 0.04 % (percent); amt (amount): 1 drop per eye .At Bedtime .; and - [MEDICATION NAME] .drops; 0.005 %; amt: 1 drop per eye .At Bedtime . Resident 197's electronic Medication Administration Record [REDACTED]. On (MONTH) 28, (YEAR), at 10:22 a.m., the Registered Nurse (RN) 1 and Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2 were interviewed. RN 1 stated medications for newly admitted residents were usually available on the same day or the next day for the first dose administration. RN 1 stated the physician should have been informed the eyedrop medications fro Resident 197 were not available and not administered as ordered on (MONTH) 22, (YEAR). MDS/LVN 2 stated, Resident 197 was up and about and need his eye medication to maintain adequate vision and function especially when performing activities of daily living (ADL). 16. On (MONTH) 28, (YEAR), Resident 192's record was reviewed. Resident 192 was admitted to the facility on (MONTH) 15, (YEAR). The physician's orders [REDACTED].>- carvedilol tablet; 3.125 mg .Twice A Day .Start .09/15/2018 .; - [MEDICATION NAME] capsule; 100 mg .Three Times A Day .Start .09/15/2018 . and - donepezil tablet .5mg .At Bedtime .Start 09/15/2018 . The electronic Medication Administration Record [REDACTED] - Carvedilol 3.125 mg on (MONTH) 15, (YEAR), at 5:00 p.m.; - [MEDICATION NAME] 100 mg on (MONTH) 15, (YEAR), at 5:00 p.m.; and - Donezepil 15 mg on (MONTH) 15, (YEAR), at 9:00 p.m. On (MONTH) 28, (YEAR) at 11:00 a.m., the Mimimum Data Set (MDS - resident assessment tool) /Licensed Vocational Nurse (LVN) 2was interviewed. MDS/LVN 2 stated the medications were not administered as ordered. MDS/LVN 2 stated new admission medications should have been ordered, made available, and administered as ordered. 17. On (MONTH) 28, (YEAR),Resident 25's record was reviewed. Resident 25 was admitted to the facility on (MONTH) 24, (YEAR). The physician's orders [REDACTED].>- [MEDICATION NAME]-[MEDICATION NAME] .tablet; 5-325 mg (milligram) .1 TAB (tablet) .Every 12 Hours For Pain .Start .9/16/2017 .; - Aspir-81 (aspirin) (OTC) (over-the-counter); 81 mg .1tab .Once a Day .Start .6/24/2017 .; - [MEDICATION NAME] sulfate (OTC) .325 mg .Once a Day .Start .9/16/2017 .; and - Vitamin D3 .(OTC) tablet .1000 unit .1 tab .Once a Day .Start .9/16/2017 . The Medication Administration Record [REDACTED] - [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg tab on (MONTH) 4, (YEAR), at 6:00 a.m.; - Aspir-81 1 tab on (MONTH) 8, 9, and 10, (YEAR), at 9:00 a.m.; - [MEDICATION NAME] sulfate 325 mg on (MONTH) 18, (YEAR), at 9:00 a.m.; and - Vitamin D3 1 tab on (MONTH) 9 and 10, (YEAR), at 9:00 a.m. On (MONTH) 28, (YEAR) at 11:00 a.m., the Minimum Data Set (MDS - resident assessment tool)/Licensed Vocational Nurse (LVN) 2 was inte(TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure 12 of 91 residents reviewed (Residents 44, 61, 74, 17, 9, 56, 28, 76, 90, 43, 57, and 197) were free of significant error when: 1. Resident 44 did not received her [MEDICATION NAME] (narcotic pain medication) from (MONTH) 10 to 15, (YEAR). This failure resulted for the resident to experienced increase pain. 2. Resident 44, who had unstable high blood sugar levels, did not received her prescribed Levimir insulin (medication to treat diabetes - a disease that result in too much sugar in the blood) on (MONTH) 22, (YEAR). In addition, Resident 44's blood sugar level were not checked on (MONTH) 25, (YEAR), at 11:30 a.m. and (MONTH) 22, (YEAR), at 6:30 a.m. to determine the resident's need to receive [MEDICATION NAME] R insulin (medication to treat diabetes). These failures could jeopardize Resident 44's health and safety for having unstable high blood sugar levels. 3. Residents 44, 61, and 74 received their prescribed antihypertensive medications (for treatment of [REDACTED]. [REDACTED].>This failure could jeopardize the residents' health and safety when putting the residents at risk for [MEDICAL CONDITION] (low blood pressure - less than 90/60). 4. Resident 17 did not received his [MEDICATION NAME] (narcotic pain medication) on multiple occasions. This failure resulted for the resident to experienced increase pain. 5. Resident 9 did not received her [MEDICATION NAME] (medication that treats nerve and muscle pain) on multiple occasions. This failure resulted for the resident to experienced increase [MEDICAL CONDITION] pain (nerve pain). 6. Resident 56 did not received her [MEDICATION NAME] (narcotic pain medication) and [MEDICATION NAME] (narcotic pain medication) on multiple occasions. This failure resulted for the resident to experienced increase pain. 7. Resident 28 did not received her [MEDICATION NAME] (pain medication) on multiple occasions. This failure resulted for the resident to experienced increase pain. 8. Resident 76 did not received his [MEDICATION NAME] on multiple occasions. This failure resulted for the resident to experienced increase pain. 9. Resident 90 did not received her [MEDICATION NAME] (for [MEDICAL CONDITION]) on multiple occasions. This failure put the resident at risk to experience increase [MEDICAL CONDITION] pain. 10. Resident 43 did not received her [MEDICATION NAME] (narcotic pain medication) on multiple occasions. This failure put the resident at risk to experience increase pain. 11. Resident 57 did not received his Bactrim (antibiotic for urinary tract infection [MEDICAL CONDITION]) as a [MEDICATION NAME] for UTI on multiple occasions. This failure could jeopardize Resident 57's health and safety for putting the resident at risk of developing UTI. 12. Resident 197 did not received his [MEDICATION NAME] eye drop (for treatment of [REDACTED]. This failure could jeopardize Resident 197's health and safety for not receiving the resident's prescribed medication for his [MEDICAL CONDITION]. Findings: 1. On (MONTH) 25, (YEAR), Resident 44's record was reviewed. Resident 44 was readmitted to the facility on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. Resident 44 had cognitive decision-making. Resident 44 physician's orders [REDACTED].patch 72 hour; 12 mcg/hr (microgram/hour) .apply 1 patch [MEDICATION NAME] (application of a medication through the skin) .Every 72 Hours; 09:00 AM . date ordered (MONTH) 3, (YEAR). Resident 44's electronic Medication Administration Record [REDACTED]. Further review of Resident 44's eMAR for (MONTH) (YEAR), indicated the following: - .Monitor [MEDICATION NAME] placement Q-shift . - 09/10/2018 03:56 PM .waiting on pharmacy to deliver . - 09/12/2018 03:01 PM .PHARMACY WILL FAX (name of doctor) for continuous (sic) . - 09/12/2018 05:18 PM Not Administered: On Hold . - 09/13/2018 02:10 AM Not Administered: On Hold . - 09/13/2018 01:42 PM Not Administered: On Hold . - 09/13/2018 04:20 PM Not Administered: Drug/Item unavailable . - 09/14/2018 01:09 AM Not Administered: Drug/Item unavailable . - 09/15/2018 11:38 AM Not Administered .off . Resident 44's [MEDICATION NAME] narcotic count sheet with a delivery date of the medication on (MONTH) 10, (YEAR), containing 10 patch indicated the 10th patch was used on (MONTH) 7, (YEAR). Resident 44's [MEDICATION NAME] narcotic count sheet with a delivery date of the medication on (MONTH) 15, (YEAR), containing 5 patch indicated the first patch was used on (MONTH) 16, (YEAR). There was no documented evidence Resident 44's [MEDICATION NAME] was administered on (MONTH) 10 to 15, (YEAR). On (MONTH) 25, (YEAR), at 11:50 a.m., Resident 44 was interviewed. Resident 44 stated she was always in pain because of her myalgia. Resident 44 stated her [MEDICATION NAME] was important for her to have so she could manage her pain due to myalgia. Resident 44 stated the [MEDICATION NAME] would not completely remove her pain but the medication would helped to bring down her pain on a tolerable level. Resident 44 stated she had several days in the month of (MONTH) (YEAR) where she did not have the [MEDICATION NAME]. Resident 44 stated the nurses told her the [MEDICATION NAME] was not available because the pharmacy was waiting for the physician's authorization. Resident 44 stated her pain level on the days she did not have the [MEDICATION NAME] were 8 out of 10 (pain rating scale 0 to 10: 8-10 severe pain). Resident 44 stated because of severe pain she mostly stayed in bed. Resident 44 further stated, I sleep it off .so not to feel the pain. On (MONTH) 1, (YEAR), at 5:38 p.m., a concurrent record review and interview was conducted with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. MDS/LVN 2 verified [MEDICATION NAME] was not given to Resident 44 from (MONTH) 10 to (MONTH) 15, (YEAR), because it was not available. MDS/LVN 2 verified there was no documented evidence Resident 44's pain assessment was conducted on (MONTH) 10 to 15, (YEAR). MDS/LVN 2 verified there was no documented evidence MD was notified of the [MEDICATION NAME] not administered to Resident 44 when it was not available. On (MONTH) 28, (YEAR), at 1:05 p.m., LVN 5 was interviewed. LVN 5 stated she was the nurse assigned to Resident 44 on (MONTH) 13, (YEAR). LVN 5 stated Resident 44 was scheduled for a [MEDICATION NAME] on that day, but the medication was not available. LVN 5 stated Resident 44 needed her [MEDICATION NAME] for pain management. LVN 5 stated the [MEDICATION NAME] was not available because the pharmacy was waiting for the physician's authorization. LVN 5 stated she did not followed up with the pharmacy for the status of Resident 44's [MEDICATION NAME] refill. LVN 5 stated she should have coordinated with the pharmacy in obtaining the physician's authorization for [MEDICATION NAME] order. LVN 5 stated she did not notified the physician when Resident 44's [MEDICATION NAME] was not available. LVN 5 stated she should have notified the physician and asked for alternative pain medication Resident 44 when [MEDICATION NAME] was not available for Resident 44. LVN 5 stated she did not have documented evidence of Resident 44's pain assessment on (MONTH) 13, (YEAR), when she was the assigned nurse. On (MONTH) 25, (YEAR), at 3:15 p.m., the Director of Nursing (DON) was interviewed. The DON stated she was not aware the [MEDICATION NAME] for Resident 44 was not available because the pharmacy was waiting for the physician's authorization. The DON stated the nurses should have notified the physician when [MEDICATION NAME] was not available. The DON stated the nurses should have asked the physician for alternative pain medication while [MEDICATION NAME] was not available for Resident 44. The DON stated it is not acceptable for Resident 44 not to have the [MEDICATION NAME] nor an alternative pain medication for several days. On (MONTH) 1, (YEAR), Resident 44's care plan for pain with a reviewed and revised date of (MONTH) 24, (YEAR) was reviewed. The care plan for pain indicated, .Goal .Resident will be pain free or relieved from pain .Approach .Administer pain medication as ordered .Assess level of pain .Consult MD if above measures fail to provide adequate pain relief . 2. On (MONTH) 25, (YEAR), Resident 44's record was reviewed. Resident 44 was readmitted to the facility on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. Resident 44 physician's orders [REDACTED].>- .[MEDICATION NAME] .100 unit/mL (milliliter) .80 units .Once A Day; 06:30 AM . date ordered (MONTH) 25, (YEAR); and - .[MEDICATION NAME] R .per sliding scale (progressive increase on the insulin dose, based on pre-defined blood glucose ranges .Before Meals; 06:30 AM, 11:30 AM, 04:30 PM . date ordered (MONTH) 8, (YEAR). Resident 44's electronic Medication Administration Record [REDACTED] - Resident 44's blood sugar was not documented on (MONTH) 25, (YEAR), at 11:30 a.m.; - From (MONTH) 1 to 31, (YEAR), Resident 44's blood sugar level ranges from 230 mg/dl (milligram/deciliter) to 400 mg/dl (above 126 mg/dl was diabetic); and - Resident 44 was receiving [MEDICATION NAME] R every day from (MONTH) 1 to 31, (YEAR), at 6:30 a.m., 11:30 a.m., and 4:30 p.m., except on (MONTH) 25, (YEAR), at 11:30 a.m. Resident 44's eMAR for the month of (MONTH) (YEAR), indicated the following: - Resident 44's blood sugar was not documented on (MONTH) 22, (YEAR), at 6:30 a.m. - Resident 44's [MEDICATION NAME]was not administered on (MONTH) 22, (YEAR), at 6:30 a.m. - From (MONTH) 1 to 25, (YEAR), Resident 44's blood sugar level ranges from 262 mg/dl to 461 mg/dl; and - Resident 44 was receiving [MEDICATION NAME] R every day from (MONTH) 1 to 25, (YEAR), at 6:30 a.m., 11:30 a.m., and 4:30 p.m., except on (MONTH) 22, (YEAR), at 6:30 a.m. On (MONTH) 1, (YEAR), at 2:37 p.m., a concurrent record review and interview was conducted with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. MDS/LVN 2 verified: - Resident 44's eMAR for the month of (MONTH) (YEAR), had no documented evidence Resident 44's blood sugar level was documented on (MONTH) 25, (YEAR), at 11:30 a.m.; and - Resident 44's eMAR for the month of (MONTH) (YEAR), had no documented evidence Resident 44's blood sugar level was documented on (MONTH) 22, (YEAR) and the [MEDICATION NAME]was not administered to the resident on (MONTH) 22, (YEAR). MDS/LVN 2 stated if there was no documentation on the eMAR it means the blood sugar was not checked and the insulin was not given. MDS/LVN 2 stated it was important for Resident 44's blood sugar to be checked before each meal, and insulin to be administered as indicated on the physician's orders [REDACTED].>MDS/LVN 2 further stated monitoring of blood sugar level and administering the prescribed insulin to Resident 44 should be done to help manage the resident's diabetes and to prevent adverse consequences of having a high blood sugar level. On (MONTH) 1, (YEAR), Resident 44's care plan for diabetes with a reviewed and revised date of (MONTH) 27, (YEAR) was reviewed. The care plan for diabetes indicated, .Goal .Resident's blood sugar level will remain stable .Resident's sign and symptoms of hypo/[MEDICAL CONDITION] will improve with interventions .Approach .Blood sugar checked as ordered .Follow sliding scale if applicable .Insulin as ordered . The facility's policy and procedure titled, Medication Administration Times, dated (MONTH) 6, (YEAR), indicated, .Facility should ensure that authorized personnel .administer medications according to times of administration as determined by .physician . 3a. On (MONTH) 25, (YEAR), Resident 44's record was reviewed. Resident 44 was readmitted to the facility on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. Resident 44 had cognitive decision-making. Resident 44 physician's orders [REDACTED].>- .[MEDICATION NAME] (antihypertensive medication) tablet; 5 mg (milligram) .1 tablet; oral .hold for sbp (systolic blood pressure - the first number on the blood pressure (BP) reading) less than 100 .Once A Day; 09:00 AM . date ordered (MONTH) 8, (YEAR); - .[MEDICATION NAME] (antihypertensive medication) tablet; 100 mg .1 tablet; oral .hold for sbp less than 100 .Twice A Day; 09:00 AM, 05:00 PM . date ordered (MONTH) 8, (YEAR); - .[MEDICATION NAME] (medication for [MEDICAL CONDITION]) tablet; 25 mg .0.5 tablet; oral .hold for sbp less than 100 .Once A Day; 09:00 AM . date ordered (MONTH) 8, (YEAR); Resident 44's physician's orders [REDACTED]. Resident 44's electronic Medication Administration Record [REDACTED] - Resident 44's BP was 98/68 on (MONTH) 15, (YEAR) at 5 p.m., the resident was given [MEDICATION NAME] 100 mg (1 tablet); - Resident 44's BP was 98/62 on (MONTH) 21, (YEAR) at 5 p.m., the resident was given [MEDICATION NAME] 100 mg (1 tablet); and - Resident 44's BP was 92/68 on (MONTH) 28, (YEAR) at 9 a.m., the resident was given [MEDICATION NAME] 5 mg (1 tablet), [MEDICATION NAME] 100 mg (1 tablet), and [MEDICATION NAME] 25 mg (1/2 tablet). Resident 44's electronic Medication Administration Record [REDACTED] - Resident 44's BP was 98/62 on (MONTH) 5, (YEAR) at 5 p.m., the resident was given [MEDICATION NAME] 100 mg (1 tablet); - Resident 44's BP was 93/60 on (MONTH) 7, (YEAR) at 9 a.m., the resident was given [MEDICATION NAME] 5 mg (1 tablet); - Resident 44's BP was 98/56 on (MONTH) 12, (YEAR) at 5 p.m., the resident was given [MEDICATION NAME] 100 mg (1 tablet); - Resident 44's BP was 98/72 on (MONTH) 17, (YEAR) at 5 p.m., the resident was given [MEDICATION NAME] 100 mg (1 tablet); and - Resident 44's BP was 98/66 on (MONTH) 22, (YEAR) at 9:00 a.m., the resident was given [MEDICATION NAME] 5 mg (1 tablet), [MEDICATION NAME] 100 mg (1 tablet), and [MEDICATION NAME] 25 mg (1/2 tablet). On (MONTH) 1, (YEAR), at 9:31 a.m., a concurrent record review and interview was conducted with Registered Nurse (RN) 2. RN 2 verified Resident 44 had the following medications: [REDACTED] RN 2 stated Resident 44's antihypertensive medications were not change nor discontinued since the order date of (MONTH) 8, (YEAR). RN 2 verified Resident 44's antihypertensive medications were administered on multiple occasions to the resident when Resident 44's BP was below the indicated sbp parameter. RN 2 stated Resident 44 should have not given the antihypertensive medications when her sbp was below indicated parameter. RN 2 stated the resident would be at risk for [MEDICAL CONDITION]. 3b. On (MONTH) 25, (YEAR), Resident 61's record was reviewed. Resident 61 was readmitted to the facility on (MONTH) 21, (YEAR). Resident 61 was self-responsible. Resident 61 physician's orders [REDACTED].[MEDICAL CONDITION](hypertension - high blood pressure). Hold for sbp (systolic blood pressure - the first number on the blood pressure (BP) reading) < (less than) 120 .Twice A Day; 09:00 AM, 05:00 PM . date ordered (MONTH) 25, (YEAR). Resident 61's physician's orders [REDACTED]. Resident 61's electronic Medication Administration Record [REDACTED] - Resident 61's BP was 110/70 on (MONTH) 14, (YEAR) at 9 a.m., the resident was given Carvedilol 6.25 mg; - Resident 61's BP was 108/70 on (MONTH) 16, (YEAR) at 9 a.m., the resident was given Carvedilol 6.25 mg; - Resident 61's BP was 110/70 on (MONTH) 21, (YEAR) at 9 a.m., the resident was given Carvedilol 6.25 mg; - Resident 61's BP was 107/72 on (MONTH) 23, (YEAR) at 5 p.m., the resident was given Carvedilol 6.25 mg; and - Resident 61's BP was 116/69 on (MONTH) 30, (YEAR) at 9 a.m., the resident was given Carvedilol 6.25 mg; Resident 61's electronic Medication Administration Record [REDACTED] - Resident 61's BP was 110/70 on (MONTH) 4, (YEAR) at 9 a.m., the resident was given Carvedilol 6.25 mg; - Resident 61's BP was 112/68 on (MONTH) 8, (YEAR) at 9 a.m., the resident was given Carvedilol 6.25 mg; - Resident 61's BP was 117/62 on (MONTH) 9, (YEAR) at 9 a.m., the resident was given Carvedilol 6.25 mg; - Resident 61's BP was 109/58 on (MONTH) 12, (YEAR) at 9 a.m., the resident was given Carvedilol 6.25 mg; and - Resident 61's BP was 117/57 on (MONTH) 14, (YEAR) at 5 p.m., the resident was given Carvedilol 6.25 mg; On (MONTH) 28, (YEAR), at 9:55 a.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 4. LVN 4 stated when the resident have antihypertensive medication, the blood pressure (BP) should be checked first. LVN 4 stated if the blood pressure reading was below the indicated parameters, the antihypertensive medication should not be given. LVN 4 stated when antihypertensive medication was given to the resident with the blood pressure below indicated parameter, there could be a risk for the resident to have [MEDICAL CONDITION]. LVN 4 verified Resident 61 received Carvedilol on multiple occasions on the month of (MONTH) and (MONTH) (YEAR), when the resident's BP was below indicated parameter. LVN 4 verified she was the nurse, as documented in the eMAR, who administered the Carvedilol to Resident 61 below indicated parameter on the following dates: - (MONTH) 14, 16, 21, and 30, (YEAR); and - (MONTH) 4, 8, and 12, (YEAR). LVN 4 stated she should have not administered the Carvedilol to Resident 61 when the resident's BP was below indicated parameter. 3c. On (MONTH) 25, (YEAR), Resident 74's record was reviewed. Resident 74 was admitted to the facility on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. Resident 74 was self-responsible. Resident 74 physician's orders [REDACTED].>- .[MEDICATION NAME] (antihypertensive medication) tablet; 50 mg (milligram) .1 tablet; oral .hold for SBP (systolic blood pressure - the first number on the blood pressure (BP) reading) less than 100 .Once A Day; 09:00 AM . date ordered (MONTH) 31, (YEAR); - .[MEDICATION NAME] (antihypertensive medication) tablet; 20 mg .1 tablet; oral .hold for systolic B/P (blood pressure) < 100 Once A Day; 09:00 AM . date ordered (MONTH) 31, (YEAR); and - .[MEDICATION NAME] (antihypertensive medication) tablet; 60 mg; oral .hold for SBP less (sic)110 Once A Day; 09:00 AM . date ordered (MONTH) 23, (YEAR). Resident 74 physician's orders [REDACTED]. Resident 74's electronic Medication Administration Record [REDACTED] - Resident 74's BP was 108/60 on (MONTH) 7, (YEAR) at 9 a.m., the resident was given [MEDICATION NAME] 60 mg; - Resident 74's BP was 104/60 on (MONTH) 10, (YEAR) at 9 a.m., the resident was given [MEDICATION NAME] 60 mg; and - Resident 74's BP was 99/77 on (MONTH) 16, (YEAR) at 9 a.m., the resident was given [MEDICATION NAME] 50 mg, [MEDICATION NAME] 60 mg, and [MEDICATION NAME] 20mg. On (MONTH) 28, (YEAR), at 10 a.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 4. LVN 4 stated when the resident have antihypertensive medication, the blood pressure (BP) should be checked first. LVN 4 stated if the blood pressure reading was below the indicated parameters, the antihypertensive medication should not be given. LVN 4 stated when antihypertensive medication was given to the resident with the blood pressure below indicated parameter, there could be a risk for the resident to have [MEDICAL CONDITION]. LVN 4 verified Resident 74 received antihypertensive medications on multiple occasions on the month of (MONTH) (YEAR), when the resident's BP was below indicated parameter. LVN 4 verified she was the nurse, as documented in the eMAR, who administered the [MEDICATION NAME], and [MEDICATION NAME] to Resident 61 below indicated parameter on (MONTH) 16, (YEAR). LVN 4 stated she should have not administered Resident 61's antihypertensive medications when the resident's BP was below indicated parameter. The facility's policy and procedure titled, Administering Medications, dated (MONTH) 6, (YEAR), indicated, .Medications shall be administered in a safe and timely manner, and as prescribed .The following information must be checked/verified for each resident prior to administering medications .Vital signs, if necessary . 4. On (MONTH) 27, (YEAR), Resident 17's record was reviewed. Resident 17 was admitted to the facility on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. Resident 17's electronic Medication Administration Record [REDACTED]. The physician's orders [REDACTED]. Further review of Resident 17's eMAR indicated, the resident did not receive his [MEDICATION NAME] dose on the following dates: - (MONTH) 15, 16, and 18, (YEAR) at 9 a.m. and 9 p.m. - (MONTH) 19, (YEAR) the dose at 9 a.m. On (MONTH) 27, (YEAR) at 10 a.m., an interview was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 stated when medications are not available, the licensed nurse should call the pharmacy and asks when the facility is going to receive the medication. LVN 2 further stated she follows up with pharmacy usually after rounds and calls the pharmacy again at the end of the shift. On (MONTH) 28, (YEAR), at 11:20 a.m., a concurrent interview and record review was conducted with LVN 3. LVN 3 verified the [MEDICATION NAME] doses were not administered to Resident 17 on (MONTH) 15, 16, 18, and 19, (YEAR). LVN 3 stated there was no assessment for pain conducted on (MONTH) 15, 16, 18, and 19, (YEAR) for Resident 17. On (MONTH) 1, (YEAR) at 10:35 a.m., an interview was conducted with Resident 17. Resident 17 stated he was aware and was notified [MEDICATION NAME] was not available by the licensed nurses. Resident 17 stated when he did not received his [MEDICATION NAME], his pain scale was 8 out of 10. Resident 17 further stated it was generalized pain and It was very bad pain for several days. 5. On (MONTH) 28, (YEAR), at 11:03 a.m., Resident 9's record was reviewed with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. Resident 9 was admitted to the facility on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. Resident 9's history and physical indicated she had the capacity to understand and make health care decisions. Resident 9's electronic Medication Administration Record [REDACTED] - .[MEDICATION NAME] (pregabalin) capsule; 75 mg .1 capsule; oral .Twice A Day .[MEDICAL CONDITION] . Reasons/Comments: Not Administered: Drug/Item Unavailable: 09/13/2018, 9:00 AM .09/13/2018, 5:00 PM .09/14/2018, 9:00 AM . In a concurrent interview MDS/LVN 2 acknowledged [MEDICATION NAME] was not administered to Resident 9 on multiple occasions because the drug was unavailable. MDS/LVN 2 stated there was no documented evidence Resident 9's pain assessments were conducted when the [MEDICATION NAME] was not administered to the resident on those dates. MDS/LVN 2 stated there was no documented evidence the physician was informed of the missed doses of [MEDICATION NAME] for Resident 9. On (MONTH) 1, (YEAR), at 10:52 a.m., Resident 9 was observed sitting on her wheelchair inside her room. In a concurrent interview, Resident 9 stated she was made aware by the nurse on multiple occasions that [MEDICATION NAME] was unavailable, but could not recall the exact dates when it was. Resident 9 stated she felt terrible when she missed her [MEDICATION NAME] medication. Resident 9 further stated she felt as if there was a tight band-aid around her fingers, and her fingers were numb, and felt like more than a tingling sensation. 6. On (MONTH) 28, (YEAR), at 10:58 a.m., Resident 56's record was reviewed with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. Resident 56 was admitted to the facility on (MONTH) 17, (YEAR), with [DIAGNOSES REDACTED]. Resident 56's history and physical indicated she had the capacity to understand and make health care decisions. Resdient 56's electronic Medication Administration Record [REDACTED] - .[MEDICATION NAME] .patch 72 hour; 12 mcg/hr (microgram per hour- a unit of measurement) .1 patch; [MEDICATION NAME] .Every 72 Hours .for pain control . Reasons/Comments: Not Administered: Drug/Item Unavailable: (MONTH) 4, (YEAR), 9:00 AM .and 8/16/2018, 9:00 AM . In a concurrent interview, MDS/LVN 2 acknowledged [MEDICATION NAME] was not administered on multiple occasions because the drug was unavailable. MDS/LVN 2 stated there was no documented evidence Resident 56's pain assessments were conducted when [MEDICATION NAME] were not administered on those dates. LVN/MDSN stated there was no documented evidence the physician was informed of the missed doses of fentanly patch for Resident 56. On (MONTH) 1, (YEAR), at 10:41 a.m., Resident 56 was observed awake and alert, while sitting at the side of her bed, rubbing her legs with her hands. In a concurrent interview, Resident 56 stated she currently had severe pain on both lower legs and she just took her pain medication. Resident 56 stated the nurse had informed her on multiple occasions when her [MEDICATION NAME] was unavailable. Resident 56 further stated she felt terrible pain' when [MEDICATION NAME] was not given to her. 7. On (MONTH) 28, (YEAR), at 10:41 a.m., Resident 28's record was reviewed with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. Resident 28 was admitted to the facility on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. Resident 28's history and physical indicated he had the capacity to understand and make medical decisions. Resident 28's electronic medicaion administration record (eMAR) for the month of (MONTH) (YEAR), indicated: - .[MEDICATION NAME] .tablet; 50 mg .50 MG; oral .Every 4 Hours .PAIN MANAGEMENT . Reasons/Comments: Not Administered: Drug/Item unavailable: 08/04/2018, 6:00 AM .08/04/2018, 10:00 AM .and 08/04/2018, 2:00 PM . Resident 28's eMAR for the month of (MONTH) (YEAR), indicated: - .[MEDICATION NAME] .tablet; 50 mg .50 MG; oral .Every 4 Hours .PAIN MANAGEMENT . Reasons/Comments: Not Administered: Drug/Item unavailable: 09/04/2018, 10:00 AM . In a concurrent interview, MDS/LVN 2 acknowledged [MEDICATION NAME] was not administered on multiple occasions because the drug was unavailable. MDS/LVN 2 stated there was no documented evidence Resident 28's pain assessment was conducted when [MEDICATION NAME] medications were not administered to the resident on those dates. LVN/MDSN stated there was no documented evidence the physician was informed of the missed doses of [MEDICATION NAME] for Resident 28. On (MONTH) 1, (YEAR), at 10:39 a.m., Resident 28 was observed awake and alert, and lying in bed. In a concurrent interview, Resident 28 stated he was made aware by the nurse on multiple occasions that [MEDICATION NAME] was unavailable, but could not recall the exact dates when it was. Resident 28 further stated when he missed his [MEDICATION NAME] medication, he felt terrible pain from his legs all the way up to his body. 8. On (MONTH) 28, (YEAR), at 10:33 a.m., Resident 76's record was reviewed with Minimum Data Set (MDS - an assessment tool) / Licensed Vocational Nurse (LVN) 2. Resident 76 was admitted to the facility on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. Resident 76's history and physical indicated the resident had the capacity to make health care decisions. Resident 76's electronic Medication Administration Record [REDACTED] - .[MEDICATION NAME] .10 mg (milligram - a unit of measurement) .1 tablet; oral .Twice A Day .chronic pain management . Reasons/Comments: Not Administered: Drug/Item unavailable: 08/09/2018, 9:00 AM .08/15/2018, 5:00 PM .08/17/2018, 9:00 AM . 8/17/2018, 5:00 PM . Resident 76's eMAR for the month of (MONTH) (YEAR), indicated: - .[MEDICATION NAME] tablet; 10 mg .0.5 tablet; oral .At Bedtime .for pain management . Reasons/Comments: Not Administered: Drug/Item unavailable: 09/07/2018, 9:00 PM .09/08/2018, 9:00 PM .09/09/2018, 9:00 PM .and 09/10/2018, 9:00 PM . In a concurrent interview MDS/LVN 2 acknowledged [MEDICATION NAME] was not administered to Resident 76 on multiple occasions because the drug was unavailable. MDS/LVN 2 stated there was no documented evidence Resident 76's pain assessments were conducted when the [MEDICATION NAME] was not administered to the resident on those dates. MDS/LVN 2 stated there was no documented evidence the physician was informed of the missed doses of [MEDICATION NAME] for Resident 76. On (MONTH) 1, (YEAR), at 10:46 a.m., Resident 76 was observed awake, alert, and lying in bed. In a concurrent interview, Resident 76 stated, he was told by the nurses when his [MEDICATION NAME] was unavailable but he could not recall the exact dates when it was. Resident 76 stated he needed the [MEDICATION NAME] to control his chronic pain. Resident 76 further stated he felt terrible pain whenever [MEDICATION NAME] was not administered to him. 9. On (MONTH) 17, (YEAR), Resident 90's record was reviewed. Resident 90 was admitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. The care plan dated (MONTH) 30, (YEAR), indicated, Problem .Resident expressed alteration in Comfort and Daily Activity due to presence of pain .Approach .Administer pain medication as ordered .[MEDICATION NAME] (nerve pain medication) 400 mg (milligrams) PO (by mouth) Q (every) 8 hours . The (MONTH) (YEAR) electronic Medication Administration Record [REDACTED]. Further review of the (MONTH) (YEAR) eMAR indicated, the [MEDICATION NAME] 400 mg was not administered to Resident 90 due to medication unavailability on t(TRUNCATED)

Based on interview and record review, the facility failed to set priorities for performance improvement activities that focus on high-risk, high volume, problem prone areas, when the facility failed to identify quality deficiencies related to medication availability. In addition, the facility failed to develop and implement action plans to correct identified qaulity deficiencies related to the unavailability of medication for the residents. This failure resulted in multiple residents not receiving their prescribed medications that could result to ineffective treatment of [REDACTED]. (Refer to F684, F755, F760) Findings: On (MONTH) 26, (YEAR), the survey team identified 33 residents had not reveived their prescribed medications as ordered due to medication unavailability from the period of (MONTH) (YEAR) to (MONTH) (YEAR). (Refer toF684, F755, F760). Quality deficiencies were identified related to medications availability in the facility. In addition, the facility failed to develop and implement an action plan to correct and identify quality deficiencies related to unavailability of medications for the residents. On (MONTH) 28, (YEAR), at 4:00 p.m., the Director of Nursing (DON) was interviewed. The DON stated the facility's pharmaceutical services for acquiring medications (new orders and refills) was impacted by the new change of medication refill order from cycle to on demand. DON further stated a breakdown was identified when there was no follow up evaluation of the effectiveness of inservices and staff education for this new changes, thus had resulted to delay in the delivery of residents medications. On (MONTH) 1, (YEAR), at 4:05 p.m., the Administrator was interviewed. The Administrator stated the facility was not aware multiple residents did not receive their precribed medications on multiple occasions due to medication unavailability. The Administrator stated the facility had just investigated the cause and it was determined that the medication unavailability was a result of the licensed nurses not being able to request a refill of the prescribed medications in a timely manner. In addition, the Administrator had stated the licensed nurses should have notified the residents' physicians and informed them of the missed doses of the prescribed medications. The Administrator further stated the licensed nurses should have requested for refill medication for the residents five days before they had ran out. The Administrator stated this was not done and it had resulted to the delayed delivery of the medications to the residents causing the medication unavailabitliy. The Administrator stated the facility did not have an action plan on ensuring the system for medication refill request to the pharmacy would be processed efficiently to help prevent the delay of medication refill deliveries. The Administrator stated the QAPI committee reviewed the cause and analysis of why an issue is not working in the facility and they modify their objectives. He confirmed the issue of medications not being available to the residents should have been identified by the committee. A review of the facility's policy and procedure titled, Quality Assurance and Performance Improvement (QAPI) Plan, revised (MONTH) 6, (YEAR), was reviewed. The policy indicated, The objectives of the QAPI plan are to provide a means to identify and resolve present and potential negative outcomes related to resident care and services .Provide structure and processes to correct identified quality and/or safety deficiencies .

Based on observation, interview, and record review, the facility failed to provide an environment free from mental abuse for Resident A, when Certified Nursing Assistant (CNA) 1, while providing care to Resident A, used a cellular telephone to record a video of Resident A showing his genital area. In addition, CNA 1 made inappropriate comments related to the video, and distributed the video through social media. This failure resulted in mental abuse to Resident A by CNA 1. Findings: On (MONTH) 30, (YEAR), an unannounced visit was conducted to investigate a facility-reported incident regarding a short video clip of Resident A, with exposed genital area that was posted in social media by CNA 1. On (MONTH) 30, (YEAR), at 10:45 a.m., the Director of Nursing (DON) was interviewed. The DON stated she received a telephone call from a non-employee of the facility. The person told the DON that he received a copy of a video clip sent by a friend of one of the facility staff (later identified as CNA 1) via Snapchat (an image messaging and multimedia mobile application used for creating messages referred to as snaps (consisting of a photo or a short video of up to 10 seconds)). The DON further stated that about the same time, the Administrator received a telephone call from the friend of CNA 1 who also received the Snapchat video clip. On (MONTH) 30, (YEAR), at 11:25 a.m., the Administrator was interviewed. The Administrator stated on (MONTH) 29, (YEAR), at around 8:45 a.m., he received a telephone call from the friend of CNA 1, informing him that a Snapchat video clip of one of the facility's residents was sent to her by CNA 1. The friend of CNA 1 told the Administrator that she thought it was a wrong thing to do and should have not been done. The Snapchat video clip was forwarded to the Administrator. On (MONTH) 30, (YEAR), at 11:30 a.m., the Snapchat video clip was observed together with the Administrator. The Snapchat video clip (approximately a total of 10 seconds long) showed a video selfie (a video that one has taken of oneself using a smartphone and shared via social media) taken by CNA 1 on (MONTH) 27, (YEAR). The first scene of approximately 3 seconds long showed CNA 1's face and followed with the statement, You think we have it easy. This is what we have to deal with every [***] ing day. The second scene of approximately 5 seconds long, showed Resident A lying in bed with a shirt on but without pants. Resident A's left leg crossed-over his bended right knee, with his genital area exposed. The scene included a close-up view of about two seconds of Resident A's genital area. Resident A's face was seen from a distant view on the video. The third scene of about 2 seconds long showed the faces of CNA 1 and Licensed Vocation Nurse (LVN) 1, laughing at the scene that was just taken on video. During a concurrent interview and record review, the Administrator presented a signed and documented Interview Record he conducted with CNA 1 on (MONTH) 29, (YEAR). The Administrator stated he showed the video clip to CNA 1. CNA 1 admitted it was the video clip she took and posted in Snapchat and sent to an acquaintance who was not a staff of the facility. The Administrator further stated CNA 1 was aware of the company's policy of not using cellphone while in resident care areas. During the concurrent interview and record review, the Administrator presented another signed and documented Interview Record he conducted with LVN 1 on (MONTH) 29, (YEAR). The Administrator stated LVN 1 entered Resident A's room to administer a medication to Resident A's roommate. LVN 1 noticed Resident A was not wearing a brief and his genital area was exposed. LVN 1 went to the hallway and asked CNA 1 to assist in getting Resident A dressed. After administering the medication to Resident A's roommate, she noticed CNA 1 had her cellphone out. LVN 1 stated she did not know that CNA 1 was taking a video of Resident A. LVN 1 thought CNA 1 was taking a selfie photo of herself. The Administrator stated LVN 1 should have investigated and reported the incident to the nurse supervisor immediately. During a concurrent interview, the Administrator stated he spoke with Resident A's wife on (MONTH) 29, (YEAR). The Administrator told Resident A's wife about the video. The Administrator stated after explaining to her the nature of the video, Resident A's wife was shocked. She could hardly believe two facility staff (CNA 1 and LVN 1) she had learned to like because of the care they have done to her husband, could do such a thing. On (MONTH) 30, (YEAR), Resident A's record was reviewed. Resident A was admitted to the facility on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. Resident A's wife was the responsible party. The Minimum Data Set (MDS - an assessment tool) dated (MONTH) 4, (YEAR), was reviewed. The MDS indicated Resident A can understand others and had the ability to make himself understood. Resident A was alert and oriented with episodes of forgetfulness and confusion. His cognitive skills for daily decision making was moderately impaired. Resident A's functional status required extensive assistance of one-person assist for toileting and bathing, limited assistance for hygiene and dressing, and independent in eating with setup help only from the staff. Resident A's balance during transition and walking was not steady, but able to stabilize without staff assistance using a walker or a wheelchair. On (MONTH) 20, (YEAR), the Riverside County Sheriff's (RCS) incident report, dated (MONTH) 7, (YEAR), was reviewed. The police report documented, .(Name of Administrator) allowed me to review the video on his cellphone with him present. I observed (name of CNA 1) who stated, You think we have it easy, this is what we have to deal with every [***] ing day. During (name of CNA 1) statement, she turned the view of the video towards (name of Resident A) who was wearing only a shirt and appeared to be sleeping and unaware of what was taking place. The video zoomed in on (name of Resident A) genitals and penis while (name of CNA 1) and (name of LVN 1) are heard laughing in the background. (Name of LVN 1) was heard saying, Hello as the video zoomed in on (name of Resident A) genitals and penis. The view of the video turns back around where (name of CNA 1) and (name of LVN 1) as seen still laughing . The police report further documented, I contacted (name of Resident A) wife, (name of Resident A's wife), who was at the location after being notified by (name of Administrator) of the incident involving her husband. (Name of Resident A's wife) stated she is the responsible party for all decisions regarding her husband because he suffers from dementia and is unable to care for himself. (Name of Resident A's wife) stated due to being shocked and distraught after hearing what had happened to her husband she was unable to make the decision on whether or not she wanted to file charges against (name of CNA 1) . On (MONTH) 22, (YEAR), the facility's policy titled Abuse and Neglect Prohibition,'' revised (MONTH) 2013, was reviewed. The policy indicated, Each resident has the right to be free from .abuse .Mental abuse include, but is not limited to humiliation . On (MONTH) 22, (YEAR), the facility's policy titled Resident Dignity & Privacy, was reviewed. The policy indicated, The facility provides care for residents in a manner that respects and enhances each resident's dignity, individuality, and right to personal privacy .Drape and dress residents appropriately at all times to avoid exposure and embarrassment . On (MONTH) 30, (YEAR), the undated facility policy for Cell Phone Use, was reviewed. The policy indicated, .employees are strictly prohibited from using cell phones .on work time and in resident care areas at all times .

Based on observation, interview, and record review, the facility failed to provide, for three sampled residents (Residents 51, 29 and 30) and one unsampled resident (Resident 41) of all 93 residents of the facility, an environment free from harassment, and physical and verbal abuse, by Resident 50. This failure resulted in emotional distress and fear for Residents 51, 41, 29 and 30, placing them in jeopardy of severe and negative psychosocial response from ongoing expressions of anger and harassment from Resident 50. Due to the facility's failure to ensure an environment free from harassment, verbal and physical abuse from Resident 50, the Administrator and the Director of Nursing (DON) were verbally notified of an Immediate Jeopardy situation on February 9, 2016, at 3:35 p.m. The Administrator and DON were informed of the observed and documented severe and negative psychosocial responses of Residents 51, 41, 29 and 30 to Resident 50's ongoing and escalating behavior towards these residents. The Administrator and DON were both informed of the lack of a plan and implemented measures to prevent an environment of abuse from Resident 50. The Immediate Jeopardy was removed, in the presence of the Administrator and DON, on February 11, 2016, at 9:30 a.m., after the facility's plan of action was reviewed and verified that Resident 50 had been placed on a one to one with a facility staff member, then discharged to a psychiatric hospital, and the facility's initiation and coordination of psychological evaluation and treatment of [REDACTED]. On February 16, 2015, a review of abuse training records confirmed approximately 137 staff members had been re-trained. During a concurrent interview with the Director of Staff Development (DSD), she stated three staff members were on medical leave and would be re-trained upon their return. Findings: An observation was made of Resident 50 on February 8, 2016, at 11:15 a.m. The resident was observed in bed watching television. The Social Services Director (SSD) stated Resident 50 had some behaviors, and had a [DIAGNOSES REDACTED]. On February 9, 2016, at 10 a.m., a group meeting was conducted. During the meeting, Residents 51 and 41 stated Resident 50 was abusive towards them. On February 9, 2016, at 11:30 a.m., an interview was conducted with the Administrator, the DON, and the Social Services Director (SSD). The Administrator and the DON stated they were not aware of the allegations of abuse by Resident 50. The SSD stated a couple of months ago, Resident 50 swatted Resident 51's hand over an argument about the television set. Resident 50 was moved to another room after the incident and the dose of [MEDICATION NAME] (anti-psychotic medication) was increased. The DON stated she did not know about the incident and indicated the incident should have been reported to her. On February 9, 2016, Resident 50's record was reviewed. Resident 50 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 50's care plan for mental illness manifested by agitation & physical aggression towards others, striking out . was updated in January 2016. The interventions included increasing the dosage for [MEDICATION NAME] for [MEDICAL CONDITION] with delusions manifested by striking out on October 23, 2015, visits by SSD to assess emotional & psychosocial well-being, and visits with the psychologist (professional who evaluated behavior and mental processes). On February 9, 2016, a review of facility documentation for Resident 50 was conducted and revealed the resident had six room changes within ten months from April 2015 through January 2016. Four residents (Residents 51, 41, 30, and 29) were affected by Resident 50's abusive behaviors as follows: 1. During the group meeting on February 9, 2016, at 10 a.m., Resident 51 stated she used to be a roommate of Resident 50 in September 2015, and was confined to her bed when Resident 50 began hitting her on the hand. Resident 51 stated she informed the DON and the Administrator. Resident 50 was transferred to another room. On February 17, 2016, at 10:45 a.m., Resident 51 was interviewed. Resident 51 stated her former roommate, Resident 50, took her nail file and accused her of stealing it on September 8 or 9, 2015. Resident 51 indicated she informed the nursing staff, and the nail file was returned to her. Resident 51 stated, Resident 50 closed their bedroom door and told her, Later, watch it, because I am going to kill you when you go to sleep. Resident 51 stated she was afraid and would sleep sitting in her wheelchair because she can't run but she would be able to wheel herself away. Additionally, Resident 51 stated in September 2015, Resident 50 requested to watch a certain show on her television. Resident 51 refused to change the channel. Resident 51 stated Resident 50 began to swat her hand. Resident 50 was transferred to another room after the incident. 2. During the group meeting on February 9, 2016, at 10 a.m., Resident 41 stated Resident 50 was abusive towards her. Resident 41 stated in September 2015, she was verbally threatened by Resident 50. Resident 41 stated, I've been tempted to leave the facility because of (Resident 50's name omitted), I don't feel it is a safe place, I feel staff are remiss because this is going on over and over again . it's uncomfortable living here and walking on egg shells, it's scary, I'm scared for those that can't speak for themselves . she threatened to hit me. Resident 41 stated after the incident occurred she reported it to the nursing staff, the nursing staff responded, Here we go again . Resident 50 was transferred to another room. 3. An interview was conducted on February 9, 2016, at 1:20 p.m., with Registered Nurse (RN) 1. RN 1 stated in January 2016, there was a quarrel between roommates involving Resident 50. RN 1 described Resident 50 as a trouble maker. RN 1 stated Certified Nursing Assistant (CNA) 1 observed Resident 50 attempting to grab Resident 30. The CNA intervened and reported the incident to a charge nurse. RN 1 indicated the incident was reported to the SSD. Resident 30 was transferred to another room. A review of Resident 30's record indicated Resident 30 was a [AGE] year old female admitted to the facility on [DATE]. 4. During review of Resident 50's medical record on February 9, 2016, the nursing documentation dated September 24, 2015, indicated, Resident 29 informed CNA 1 that Resident 50 became upset, stating, This is my room, I was here first, then she hit me . on my left arm, top of arm . The CNA reported the incident to the charge nurse. An interview was conducted with CNA 1 on February 9, 2016, at 1:35 p.m. CNA 1 indicated Resident 50 would call residents and staff names. CNA 1 stated Resident 50 could be verbally abusive, and had witnessed Resident 50 argue with her roommates. CNA 1 stated Resident 50 had her room changed approximately four times. Resident 50's former roommates included Residents 29 and 41. CNA 1 stated she reported the incidents to a charge nurse approximately six months ago. A review of the facility policy titled, Abuse & Neglect Prohibition, dated October 2004, defined abuse as the willful infliction of injury . intimidation or punishment with resulting harm, pain or mental anguish . Mental abuse includes . humiliation, harassment, and threats of punishment . Physical abuse includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment . Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents . The policy indicated the facility would protect the residents from harm during the investigation, and would make referrals to the appropriate state agencies . to ensure the protection of the resident or resident's property. On February 9, 2016, at 3:35 p.m., the Administrator and DON were informed of the observed and documented severe and negative psychosocial responses of Residents 51, 41, 29 and 30 to Resident 50's ongoing and escalating behavior towards theses residents. The Administrator and DON were both informed of the lack of a plan and implemented measures to prevent an environment of abuse from Resident 50. Due to the facility's failure to implement an environment free from harassment, verbal and physical abuse from Resident 50, the Administrator and the Director of Nursing (DON) were verbally notified of an Immediate Jeopardy situation on February 9, 2016, at 3:35 p.m. On February 11, 2016, at 9:30 a.m., the facility presented and had begun the implementation of a corrective plan of action, including but not limited to: *Resident 50 was placed on one to one staff monitoring. * An order was obtained from Resident's 50's attending physician for immediate discharge and placement to a psychiatric facility for evaluation and treatment. * Residents 51, 41, 29 and 30 were assessed for emotional distress or mental anguish, and were evaluated by the Psychologist on February 10, 2016 with no noted mental anguish or distress. * Facility staff were interviewed to ensure there were no other reportable events/ incidents pertaining to abuse. * The SSD was suspended pending investigation. The Administrator notified California Department of Public Health on February 10, 2016, that Resident 50 was transferred to a psychiatric facility, and the Immediate Jeopardy was removed on February 11, 2016, at 9:30 a.m.