Every finding on record at Monterey Post Acute

Based on interview and record review, the facility failed to ensure one of two residents (Resident 1) was provided their scheduled pain medications. This failure resulted in Resident 1 increased pain and emotional distress. During an interview on 3/3/26 at 11:19 A.M. with Resident 1, Resident 1 states he did not receive his medications on 2/13/26 , his scheduled pain medications causing him to have increased pain on the weekend. During a review of Resident 1's medical record, dated February 2026, the medication administration record (MAR) indicated Resident 1 did not receive medications on 2/14/26 scheduled at 10 a.m. During a concurrent interview and record review on 3/3/26 at 1:56 p.m. with the Director of Staff Development (DSD), the MAR for February 2026 was reviewed. The MAR indicated Resident Resident 1 received medications on 2/13/26 but not on 2/14/26. The DSD stated, if they [medications] were given or if he refused or was out of the building it would say and everything would be green [background] it is red indicating they were not given. During a concurrent interview and record review on 3/3/26 at 2:11 p.m. with Registered Nurse (RN) A, reviewing Resident 1's MAR dated February 2026 , RN A confirmed medications scheduled at 10:00 a.m. were not given, there is no documentation. Review of the facility's policy & procedure titled, Administrating Medications, dated 2001, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. If a drug is withheld, refused, or given at a time other than the scheduled, document refusal. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.

Based on observation, interview and record review, the facility failed to ensure residents received adequate supervision and monitoring to prevent accidents when one resident (Resident 1) left the facility without staff awareness and/or supervision and resulted in Resident 1 wandering along the road unprotected and was missing from the facility from 6:30 am to around 1:47 pm.This failure put Resident 1 at risk for medical complications and being struck by a motor vehicle.A review of Resident 1's medical records indicated an admission date of 4/25/25 with diagnoses including but not limited to other generalized epilepsy and epileptic syndromes, intractable, without status epilepticus (a brain condition causing repeated seizures, which are temporary surges of abnormal electrical activity in the brain), paranoid schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly), and anxiety disorder(a mental health condition characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life). A review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 7/15/25, indicated a brief interview for mental status [BIMS, a tool used to assess person's cognition level (knowing, learning, and understanding), a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact] score of 6. A review of Resident 1's elopement evaluation questionnaire dated 08/06/25 indicated:Resident 1 is able to ambulate or self-propel wheelchair independently [Yes].Does Resident have a history of elopement or an attempted elopement while at home [No]. Does Resident have a history of attempting to leave the facility without informing staff [Yes].Has the Resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door [Yes].Does the resident wander [Yes].Is the wandering behavior a pattern, goal-directed (i.e. specific destination in mind, going home, etc.) [No].Has the Resident been recently admitted or readmitted (in past 30 days) and is not accepting the situation [Yes].Does resident have a history of drug/alcohol abuse? [Yes].Does the resident have a history of homelessness [Yes]. A review of Resident 1's Physician Orders indicated, monitor behaviors of exit seeking; every shift ordered on 8/6/25. Review of Resident 1's monitoring records indicated, There were monitoring records to/for:1) Monitor behaviors for exit seeking every shift, started 8/6/25 until 8/24/25.2) Visual checks every hour for Exit Seeking, started date 8/6/25-8/31/25.3) Wander Guard/Wander Elopement Device due to poor safety awareness every shift check placement started 8/6/25 to 8/14/25, then this was changed to,4) Wander Guard/Wander Elopement Device due to poor safety awareness, check placement and function every shift - from 8/14/25 evening shift to 8/31/25. Review of Resident 1's Care Plan indicated: The Resident is an elopement risk/wanderer AEB (as evidenced by) History of attempts to leave facility unattended and continuously wandering, actual elopement. Date initiated 8/6/2025.Revision 08/24/2025. Two (2) interventions were initiated on 8/6/25: Wander Sensor #8755 - Monitor function and placement q Shift (every shift) and Hourly visual checks. The other interventions in the care plan were only initiated on 8/24/25 after Resident 1's elopement incident on 8/12/25 which included: After Actual elopement 1:1 (a dedicated staff provides continuous, constant observation and care for a single patient) was initiated; Distract Resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book; monitor for fatigue and weight loss. A review of Resident 1's progress notes dated 8/15/25 indicated, . Concern/Issue: IDT [interdisciplinary team] met to discuss resident's elopement event that happened on 8/12/25. At around 0745 nurse notified management that resident wasn't in his room and began to look throughout the facility.Resident was located at around 1347 by facility staff.Resident was evaluated by the local ER [emergency room] and returned to the facility at 1907. A review of general acute hospital records Emergency Physician Notes with date and time of service 8/12/2025 1442 indicated, ARRIVAL INFORMATION/CAVEATS: Patient presented to the Emergency Department by private vehicle. CHIEF CONCERN: Altered Mental Status (increased confusion since this morning. Patient eloped from [SNF name], patient was found by PG HS (Pacific Grove High School, which is about 3 miles away from the facility by car) and did not recall how he ended up there. HISTORY OF PRESENT ILLNESS: . resident of [SNF name], with a history of alcohol use disorder, . presents to Emergency Department with increased confusion. A staff member from [SNF name] is present at bedside and provides collateral history. She states he eloped from the facility around 6:30 AM today, and then staff found him wandering around Pacific Grove High School. They then brought him to the ED for evaluation for increased wandering and confusion over the past few days. Patient does not remember where he was or what he did today. During a concurrent interview and observation of Exit Doors on 8/22/25 at 2:27 p.m. with the Director of Nursing (DON), the DON stated all Exit Doors were locked and will sound an alarm when someone tries to open it. There were two Exit Doors at the back of the facility and an Entrance/Exit Door at the front. The DON verified at the Entrance Door, the code was posted out front for anyone who will enter the facility. The DON also verified that the receptionist leaves at 8 p.m. and returns at 8 a.m. the next day. The DON stated there was no receptionist to supervise the Entrance door from 8 p.m. to 8 a.m. The DON verified one of the Exit Doors alarmed but was unlocked. The DON walked with Nurse Surveyor out of the opened exit door and the path led to the facility parking space and onto the street outside which was open and was unsupervised. The DON stated that a resident's Wander guard will sound an alarm if the resident leaves the facility The DON stated staff could have done more visual checks on Resident 1 to prevent elopement. The DON further stated Patient 1's Wander guard was not working when he returned to the facility on 8/12/25. Further review of the acute hospital Emergency Physician Note dated 8/12/25 indicated, Initial Differential Diagnosis: Dehydration, intoxication, dementia, metabolic derangement, subdural hematoma. ED Medication Given: NS [Normal Saline, intravenous (IV, a method of administering fluids, medicines, or nutrition directly into a person's bloodstream through a needle or tube inserted into a vein ) Fluid used for rehydration, replacing fluid loss] Bolus 500 ml (milliliter, unit of measure). Test Considered but not ordered: Escalation of care was considered. However, the patient was really sent here more for evaluation of wandering behaviors and I suspect he has been trying to get his hands on beer which she endorses he did yesterday and probably earlier today as well given his alcohol level of 22. ED Clinical Impression. Alcohol Intoxication. DISPOSITION: Discharge from ED. A review of facility's policy and procedure (P&P) entitled Elopements revised 2/21/25 indicated, .1. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and monitoring for effectiveness and modifying interventions when necessary.

Based on observation, interview and record review, the facility failed to serve food at an appetizing temperature for one item out of seven food items that were served during the lunch meal. This failure had the potential for causing food-borne illness due to the food item not being at the correct temperature. Findings: During an observation on 2/10/25 at 11:45 AM, the morning cook (MC) took the temperature of a tray of fried chicken, and got a reading of 168 degrees Fahrenheit with his thermometer. Comparing it to a second thermometer used by the surveyor, the surveyor's thermometer read 152 degrees Fahrenheit. During an interview with MC on 2/10/25 at 12:25 AM, the MC said the temperature of chicken should be 165 degrees. During an interview with both the dietary manager (DM) and the visiting registered dietician (VRD) on 2/10/25 at 1:10 PM, both the DM and VRD said chicken should be at 165 degrees. Review of facility policy titled Food Preparation and Service, date unknown, indicated .The following internal cooking temperatures/times for specific foods are reached to kill or sufficiently inactivate pathogenic microorganism: 165 F -Poultry .

Based on observation, interview and record review, the facility failed to follow proper sanitation and food handling practices when multiple food items did not have a opened on or use by date even after opening the item. This failure had the potential to spread food-borne illnesses to residents in the facility. Findings: During an observation on 2/9/25 at 9:18 AM, multiple food items were noted in the refrigerator with a date that say R 2-2-25, or R 1-28-25 but with no other dates. One carton of soy milk was noted to be half full, and the cap is open, but there is no date on it. One packet of parmesan cheese had no date written on the package. One container with grated cheese had a date 1-28-25 but no indication if it was received on that date or if the cheese was supposed to be used by that date. During an interview with the dietary manager (DM) on 2/9/25 at 9:48 AM, the DM said all food items should have a received date as well as an opened on date. The DM also said there is a guide that is posted on the refrigerator to know when to discard items. For dairy products, the DM said those foods should be discarded one week after opening. Review of facility policy titled Food Receiving and Storage indicated .All foods stored in the refrigerator are covered, labeled, and dated .Refrigerated foods are labeled, dated .

Based on observation, interview, and record review, the facility failed to ensure equipment was in good repair by ensuring the water temperature for the dishwasher consistently reached 120 degrees Fahrenheit for both the wash cycle and rinse cycle. This failure had the potential to cause or spread food-borne illnesses to the residents. Findings: During an observation on 2/09/25 at 9:38 AM, dietary aide A (DA A) was observed running the dishwasher for one complete run. During the run, the water temperature got to 110 degrees Fahrenheit for the wash cycle, and during the rinse cycle the water temperature got to 124 degrees Fahrenheit. During an observation on 2/10/25 at 11:15 AM, the dietary manager (DM) was observed running the dishwasher cycle for two complete runs. During the first run, the wash cycle temperature was 95 degrees while the rinse cycle temperature was 131 degrees. During the second run, the wash cycle temperature was 108, while the rinse cycle temperature was 144 degrees. During the third run, the was cycle was 120 degrees, while the rinse cycle temperature was 156 degrees. During an interview with the DM on 2/9/25 at 9:48 AM, the DM said The dishwasher is a low temperature, it should get no higher than 130 degrees. During a follow up interview with the DM on 2/10/25 at 11:15 AM, the DM said she wants to see the temperature at 120 degrees for both the wash and rinse cycle. During an interview with the regional registered dietician (RRD), the RRD said she the staff will need to run the dishwasher three times to get the wash cycle temperature to 120 degrees. Review of manufacturer document titled Ecolab ELT Dishmachine indicated under section ELT Specifications .Operating Temperatures Wash (minimum) 120 degrees. Review of facility policy titled Dishwashing Machine Use indicated .The operator will check temperatures using the machine gauge with each dishwashing machine cycle, and will record the results in a facility approved log. The operator will monitor the gauge frequently during dishwashing machine cycle. Inadequate temperatures will be reported to the supervisor and corrected immediately.

Based on observation, interview and record review, the facility failed to ensure privacy was maintained for one of 19 residents' (Resident 6) clinical records, when registered nurse (RN) E's computer screen was left open and unattended in the resident room during medication pass. These failures had the potential to result in unauthorized access to a resident's health information. Findings During a medication administration observation on 2/10/25, at 4: 20 p.m., the med cart A containing an open laptop computer was left unattended in the hallway outside of a resident's room [ROOM NUMBER]. The laptop computer was on, and the screen displayed information about multiple residents, when RN E left to do handwashing at the nurse station after taking the blood sugar of the residents. During a concurrent observation and interview with RN E, on 2/10/25 at 4:34 p.m., RN E left the med cart A unattended while washing her hands at the nurse's station after giving the medication. RN E confirmed the laptop computer was on and the screen displayed residents' information. RN E further stated the laptop computer should be closed at all times and it was a privacy issue. A review of the title Health Insurance Portability and Accountability Act of 1996 (HIPPA), dated September 10, 2024, indicated, HIPAA Security Rule .To comply with the HIPPA Security Rule, all covered entities must ensure the confidentiality, integrity, and availability of all e-PHI. Detect and safeguards against anticipated threats to the security of the information. Protect against anticipated impermissible uses or disclosures that are not allowed by the rule.

Based on interview and record review, the facility failed to ensure one resident (Resident 32), who required a colostomy (a surgical opening {stoma} that connects the digestive tract to the surface of the belly to allow for waste material and gas to leave the body), received the necessary care and treatments when the facility failed to get a physician order, and treatments for the care of Resident 32's colostomy. This failure had the potential to place Resident 32 at risk for complications such as infection, skin breakdown, and pain. Findings: Review of Resident 32's clinical record indicated he was admitted to the facility on [DATE] with diagnoses that included colostomy status and quadriplegia (partial or complete loss of motor and sensory function in all four limbs {arms and legs}). Review of Resident 32's care plan indicated Resident 32 was at risk for complications related to altered elimination due to the presence of a colostomy. The interventions identified in Resident 32's care plan indicated to provide colostomy care as ordered by the physician and to monitor the stoma site for any skin irritation and or signs and symptoms of infection Review of Resident 32's Physician Order Sheet, dated February 2025, did not indicate any physician orders for the care of Resident 32's colostomy. Review of Resident 32's treatment administration record (TAR), dated February 2025, found no documentation that indicated colostomy care was being performed. During an interview with the director of nursing (DON) on 2/11/25 at 12:15 p.m., she was asked to review Resident 32's physician orders and TAR. The DON confirmed there were no physician orders for colostomy care for Resident 32. The DON stated there should be physician orders for the care of Resident 32's colostomy. She further stated the licensed nurses should document on the TAR when colostomy care is performed, and monitoring of the stoma should be done by licensed nurses each shift. The DON confirmed there was no documentation the licensed nurses were monitoring Resident 32's colostomy. Review of the facility's policy Colostomy Care, revised October 2010, indicated The purpose of this procedure is to provide guidelines that will aid in preventing exposure of the resident's skin to fecal matter. The following should be recorded in the resident's medical record: 1) the date and time the colostomy care was provided. 2) Any breaks in the resident's skin, signs of infection or excoriation of the skin . 6) The signature and title of the person recording the data.

Based on observation, interview, and record review, the facility failed to ensure to provide proper oxygen (a colorless, odorless gas) care and treatment services for two of 19 sampled residents (Residents 25 and Resident 224) when: 1. Resident 25 had an oxygen concentrator (a portable device that provides oxygen) at the bedside, but there was no oxygen signage posted on the door. 2. Resident 224 had an oxygen concentrator at the bedside, but there was no oxygen signage posted on the door. This deficient practice had the potential for accidents and hazards that could pose harm to residents in the facility. Findings: 1. During an observation on 2/9/25, at 10:24 a.m., Resident 25 was lying in bed, asleep, with oxygen concentrator at the bedside, a nasal cannula (NC, device placed in the nostril used to deliver oxygen) inside a plastic bag not in use. There was no oxygen signage posted on Resident 25's door. Review of Resident 25's order summary report dated 10/18/24 indicated an order for Oxygen at 2 L/min via nasal cannula PRN (pro re nata, as needed) for low oxygen or SOB (shortness of breath) as needed for Low Oxygen. During a concurrent observation and interview on 2/9/25 at 10:30 a.m., Licensed Vocational Nurse (LVN) C confirmed there was no Oxygen in use/No smoking sign posted by Resident 25's door. During an interview with IP on 2/12/25 at 4:20 p.m., IP stated anybody who has an oxygen order, or prn, its need to have signage in the room. The infection Preventionist (IP) stated there should be a sign posted by the door. She further stated oxygen is highly flammable and it can be dangerous that can cause accident. 2. During an observation on 2/10/25 at 9:38 AM, Resident 224 was observed in his room sitting up in bed. Resident 224 is wearing a nasal cannula (NC, an oxygen delivery device that delivers oxygen through the nose) hooked up to an oxygen concentrator. Outside the door there is no visible signage that the resident uses oxygen. During an interview on 2/12/25 at 8:47 AM, LVN B said there should be a sign outside the room that says no smoking for someone who is on oxygen. During an interview with the assistant Director of Nursing (ADON) on 2/13/25 at 9:54 AM, the ADON stated there should be a sign outside the door for any resident that uses oxygen in the facility.

Based on observation, interview and record review, the facility failed to routinely assess the arteriovenous fistula (AV fistula, a connection surgically made between an artery and a vein for dialysis access) for one resident (Resident 22) who received dialysis (a procedure in which a machine filters wastes and fluid from the blood). This failure had the potential to result in unidentified complications with Resident 22's AV fistula. FINDINGS: Review of Resident 22's clinical record indicated she was admitted on [DATE] and had diagnoses including end-stage renal disease (ESRD, a condition in which the kidneys no longer function normally to filter waste and excess water from the blood as urine), hypertension (increase in blood pressure), and presence of aortocoronary bypass graft (procedure to improve poor blood flow to the heart). Resident 22 was scheduled for dialysis treatment every Monday, Wednesday, and Friday. During an observation on 2/9/25 at 11:28 a.m., Resident 22 was sitting on the edge of her bed dressed in street clothes. She stated she goes to dialysis 3 times a week. She pulled up the sleeve on her blouse and revealed that she had an arteriovenous fistula (AVF, surgically created connection between an artery and vein to allow dialysis to occur) in her left forearm. Review of Resident 22's physician orders indicated there were no orders in place to assess and monitor Resident 22's AVF. There were no physician orders in Resident 22's clinical record to monitor dialysis access site for bruit (an audible vascular sound associated with turbulent blood flow) and thrill (vibration caused by blood flowing). There were no physician orders to assess the AVF for sign and symptoms of infection. During an interview and concurrent record review with the director of nursing on 2/13/25 at 12:55 a.m., she indicated nursing staff monitor Resident 22's AVF for bruit and thrill on Mondays, Wednesdays, and Fridays, before and after dialysis on the dialysis communication record. When asked if the nursing staff check for bruit and thrill on non-dialysis days, the DON stated there was no documentation that nursing staff checked bruit and thrill on Tuesdays, Thursdays, Saturdays, or Sundays for Resident 22's AVF. The DON stated nursing staff should check bruit and thrill and monitor for signs of infection every shift, every day to assess the AVF. The DON confirmed there were no physician orders in place to monitor Resident 22's dialysis access site for bruit and thrill or signs and symptoms of infection and stated there should be physician orders. Review of the facility' s policy Hemodialysis Catheters - Access and Care of , revised February 2023, indicated to Check for sign of infection (warmth, redness, tenderness or edema) at the access site when performing routine care and at regular intervals. The policy further indicated Check patency of the site at regular intervals. Palpate the site to feel the thrill or use a stethoscope to hear the whoosh or bruit of blood flow through the access.

Based on interview and record review, the facility failed to ensure a registered nurse (RN) was on duty for 8 consecutive hours for 2 days during the months of October, and December of 2024. This failure had the potential to affect resident's care, health, and wellbeing. Findings: A review of the facility's document titled Nurse Schedule, dated October 2024, indicated no RN was scheduled or was on duty on 10/31/24. A review of the facility's document titled Nurse Schedule, dated December 2024, indicated, no RN was scheduled or was on duty on 12/18/24. During an interview with the administrator (ADM) on 2/12/24 at 12:30 p.m., he stated the facility was unable to provide evidence that an RN was on duty at the facility for the above dates in October and December of 2024. The ADM confirmed there was no RN on duty on 10/31/24 and 12/18/24 and added that the facility did not have any waiver in place for the reduced RN nursing hours. The ADM further stated the facility was aware of the requirement for a registered nurse to provide resident care, 8 hours a day in a 24 hour period, 7 days a week.

Based on observation, interview, and record review, the facility failed to ensure the controlled medications (drugs with high potential for abuse or addiction) were fully accounted for on the medication administration record (MAR) to indicate they were given for three out of six residents (Residents 4, 58, and 67) for these medications that were signed out of the Control Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications). This failure had the potential for access to medications and supplies by unauthorized persons such as residents and visitors. Findings: 1. The Controlled Drug Records (CDRs) for six (6) random residents receiving PRN (meaning as needed) controlled medications were requested for review during the survey. a. A review of Resident 4's MAR indicated to give Hydromorphone (used to treat moderate to severe pain) Oral tablet 2 MG (milligram, unit of dose of measurement) by mouth every 8 hours as needed for pain with start date of 1/29/25. During a concurrent interview and record review with the ADON on 2/13/25 at 8:42 a.m., review of Resident 4's CDR for Hydromorphone HCL and the 1/2025 MAR reflected the nursing staff signed out of the CDR (meaning they removed the medication from the locked controlled medication compartment in the medication cart) but did not document the respective administration on the MAR on 1/29/25 at 10:00 a.m., The ADON verified this finding and acknowledged one (1) tablet of Hydromorphone HCL was not accounted for in the MAR. b. A review of Resident 58's MAR indicated to give Tramadol (a controlled medication for pain) HCL Oral Tablet 50 MG by mouth every 6 hours as needed for pain. During a concurrent interview and record review with the ADON on 2/13/25 at 8:42 a.m., review of Resident 58's CDR for Tramadol HCL and the 1/2025 and 2/2025 MAR reflected the nursing staff signed out of the CDR but did not document the respective administration on the MAR on 1/3/25 at 20:00 p.m.,1/5/25 at 20:00 p.m., and 2/2/25 at 20:00 p.m. The ADON verified this finding and acknowledged three (3) tramadol hcl tablet were not accounted in the MAR. c. Resident 67's had a physician's order, dated 11/25/24 for Oxycodone HCL Oral Tablet 5 MG, 2.5 tablet via PEG-Tube (a feeding tube inserted through the abdominal wall and into the stomach) every 8 hours as needed for moderate pain give before working with therapy. During a concurrent interview and record review with the ADON on 2/13/25 at 8:42 a.m., review of Resident 67's CDR for Oxycodone (used to treat moderate to severe pan ) HCl and the December 2024 MAR indicated the nursing staff signed out two tablets on 12/24/24 at 05:52 a.m., and 12/29/24 at 10:40 a.m., in the CDR but did not document the administration on the MAR. The ADON verified this finding and acknowledged two (2) tablets of Oxycodone HCL were not accounted for in the MAR. The ADON further stated it should be documented and signed off both on the CDR and MAR. A review of the facility's policy and procedures (P&P) titled Administering Medication revised dated April 2019, the P&P indicated: 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication .

Based on interview and record review, the facility failed to monitor for side effects and target behaviors (behaviors intended to be changed or eliminated by medications) for one of five residents (Resident 69) who received psychotropic medications (medications that cause changes in mood, feelings or behavior). This failure had the potential to compromise the facility's ability to determine if the psychotropic medications were effective. This failure also put Resident 69 at risk for experiencing harmful effects from the medications. Findings: Review of Resident 69's clinical record indicated she was admitted to the facility on [DATE] with diagnoses that included Dementia (a decline in mental capacity affecting daily function) with behavior disturbance, Alzheimer's disease (a progressive mental deterioration due to generalized degeneration of the brain) and Schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly). Review of Resident 69's medical record indicated she had a physician's order, dated 2/5/25, for Seroquel (medication used to regulate the mood, behaviors, and thoughts)) 25 milligrams (mg, unit of dose measurement) by mouth at bedtime. There was no documentation of side effects monitoring for the use of Seroquel. Review of Resident 69's medication administration record (MAR) indicated she had received Seroquel every day, starting on 1/28/25. Review of Resident 69's medical record indicated she had a physician's order, dated 11/19/24, for Bupropion HCL (medication used to treat major depressive disorder) 100 mg two times a day. There was no target behavior specified in the Bupropion HCL order and no documentation of side effects monitoring for the use of Bupropion HCL. Review of Resident 69's MAR indicated she had received Bupropion HCL every day, starting on 11/19/24. Review of Resident 69's medical record indicated she had a physician's order, dated 11/20/24, for Depakote Sprinkles 250 mg in the morning and 500 mg in the evening. There was no target behavior specified in the Depakote order and no documentation of side effects monitoring for the use of Depakote. Review of Resident 69's MAR indicated she had received Depakote every day, starting on 11/20/24. During an interview and concurrent record review with the director of nursing (DON) on 2/13/25 at 9:59 a.m., she reviewed Resident 69's medical record and confirmed there was no documentation of side effects monitoring for the use of Seroquel for Resident 69. The DON further confirmed there was no documentation of side effects monitoring or target behavior monitoring for the use of Bupropion and Depakote for Resident 69. The DON stated that for residents receiving psychotropic medications, nurses should monitor for side effects every shift and document this on the MAR or treatment administration record (TAR). The DON confirmed each psychotropic medication should have a specific target behavior. She stated the nurses should monitor for target behaviors every shift and document this on the MAR or TAR. The facility's policy titled Psychotropic Medication Use, dated June 2021, indicated All medication used to treat behaviors must have a clinical indication . should be monitored for a) Efficacy, b) Risks, c) Benefits, and d) Harm or adverse consequences. The policy further indicated Facility staff should monitor behavioral triggers, episodes, and symptoms. Facility staff should document the number and/or intensity of symptoms.

Based on observation, interview, and record review, the facility had a medication error rate of 11.9% when five medication errors occurred out of 42 opportunities during the medication administration observation for three of six residents (Residents 7, 63, and 75) when: 1. Resident 7 did not receive three medications, Amlodipine Besylate tablet, Acidophilus Xtra Oral Tablet, and Methenamine Hippurate Oral tablet as prescribed; 2. Resident 63 did not receive the medication Ferrous Gluconate as scheduled; 3. Resident 75 did not receive the medication ferrous sulfate as scheduled.; and 4. The nursing staff did not flush the resident's gastrostomy tube (G-tube; a tube surgically inserted through the abdomen into the stomach to administer nutrition and medications) as ordered by the physician during medication administration for Resident 67. The failures had the potential for the residents not receiving the full therapeutic effect of medications, and compromising the health of residents. Findings: 1. During a medication administration observation on 2/10/25 at 10: 47a.m., Licensed Vocational Nurse (LVN) F was observed preparing 11 medications for Resident 7. LVN F stated to Resident 7 that Acidophilus Xtra (used as a probiotic) Oral Tablet, Amlodipine Besylate (used to treat high blood pressure and chest pain) tablet and Methenamine Hippurate (used as preventive treatment for recurrent urinary tract infections) Oral tablet are not available. A review of Resident 7's medication administration record indicated to give Acidophilus Xtra Oral Tablet (Probiotic Product) 2 tablet by mouth one time a day for probiotic, with start date of 06/18/2023 at 09:00 am, Amlodipine Besylate Oral Table 5 mg (milligram , unit of dose measurement),with start date of 09/12/24 at 09:00 am, and Methenamine Hippurate Oral Tablet 1 GM (gram, unit of dose measurement) 1 tablet by mouth two times a day for recurrent UTIs (urinary tract infection, an infection of the urinary system which includes the kidneys, bladder , ureters, and urethra ), with start date of 12/13/2024. During an interview with LVN F on 2/10/25 at 12:23 p.m., LVN F confirmed that the medications Acidophilus Xtra Oral Tablet, Amlodipine Besylate tablet and Methenamine Hippurate Oral table was not administered at the scheduled time. 2. During a medication administration observation on 2/10/25 at 10:17 a.m., LVN F was observed preparing four medications for Resident 63. LVN F stated to Resident 63 that ferrous gluconate (an oral iron supplement used to treat or prevent iron deficiencies) was not available. A review of Resident 63's physician's order indicated to give Ferrous Gluconate oral tablet 325 (37.5) MG 1 tablet by mouth one time a day every other day for supplement, order dated 12/13/2014. During an interview with LVN F on 2/10/25 at 12:57 p.m., LVN F confirmed that the medication Ferrous Gluconate was not given. 3. During a medication administration observation on 2/10/25 at 10: 25 a.m., LVN F was observed preparing five medications for Resident 75. LVN F stated to Resident 75 that ferrous sulfate (type of iron that's used as a medicine to treat and prevent iron deficiency anemia) was not available. A review of Resident 75's medication administration record indicated to give Ferrous Sulfate Oral Tablet Delayed Release 324 (65 Fe) MG (Ferrous Sulfate) 1 tablet by mouth one time a day for supplement, with start date of 02/08/2025 at 09:00 am. During an interview with LVN F on 2/10/25 at 12:51 p.m., LVN F confirmed ferrous sulfate was not administered. A review of the facility's policy and procedure (P&P) titled Administering Medications, revised date April 2019, the P&P indicated Medications are administered in a safe and timely manner, and as prescribed. 5. Medications are administered in accordance with prescriber orders, including any required time. 4. During a medication administration observation on 2/10/2 at 9: 45 a.m., LVN F was observed preparing two medications (one powder packet and one capsule medications) for Resident 67. LVN F removed the powder in the capsule and individually poured in the medicine cup separately then brought the medications, along with an 8-ounce cup of water, to the resident's overbed table (a rolling table designed to provide a convenient surface for residents while in bed or a chair). LVN F was observed diluting the powdered medication with 5 milliliters (ml, a unit of measure) of water and prepared 1 cup of 30 ml water. On 2/10/25 at 9:50 a.m., LVN F was observed attaching the syringe to Resident 67's G-tube and flushed with 30 ml water, then poured the diluted powdered medication into the G-tube. LVN F then flushed the G-Tube with 15 ml of water. LVN F administered the second diluted medication. LVN F flushed the G- tube with 15 ml of the remaining water. During an interview post medication administration, on 2/10/25 at 12:59 p.m., LVN F acknowledged she should have flushed the tubing with 30 ml of water after the last medication. A review of Resident 67's physician orders indicated to flush tube with 30 ml of water before and after medication administration every shift and enteral feed: Flush tube with 5 ml of water in between each medication every shift between medication. A review of the facility's policy and procedure (P&P) titled Administering Medications through an Enteral Tube, revised date November 2018, the P&P indicated, Step in procedure :13. If administering more than one medication, flush with 15 ml warm purified water (or prescribed amount) between medications. 14. When the last of the medication begin to drain from the tubing with 15 ml of warm purified water (or prescribed amount). The physician's order and the facility policy does not concur.

Based on observation, interview, and record review, the facility failed to ensure proper labeling and storage of medications according to the facility's policy and procedures (P&P) and/or manufacturer's specifications when: 1. One insulin vial with no vial flip -off cap (type of closure used for packing and sealing pharmaceutical products) was found with no open date in the medication refrigerator; 2. One insulin pen expired in the medication cart; 3. Medications were not properly labeled and stored in two of three inspected medication carts; a. Seven insulin pens had no open dates; b. Five Artificial Tears eye drop were unlabeled; c. One bottle of Brimonidine 0.2% Eye drops had no open date; d. One Albuterol Sulfate HFA Inhalation Aerosol had no label and identifier; 4. No temperature monitoring for two days in [DATE] for the medication refrigerator; 5. Medication Cart C was left unlocked; 6. One open bottle of mucus relief DM tablet had no open date in the medication storage room. These deficient practices had the potential for residents to receive medications with reduced potency and had the potential to result in medication errors. Findings: 1. During an inspection of medication storage room and concurrent interview with Assistant Director of Nursing (ADON) on [DATE] at 1:20 p.m., there was one vial of insulin lispro (a rapid acting insulin used to lower blood glucose) stored in the medication refrigerator with no open date and no vial flip-off cap. ADON confirmed the above observation and stated it should have a cap and open date once it's opened. A review of the facility's policy and procedure (P&P) titled Administering Medications, revised date [DATE], the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. 12. The expiration /beyond use date on the medication label is checked prior to administering. When opening a multi dose container the date opened is recorded on the container. 2. During a concurrent medication cart B inspection and interview with Licensed Vocational Nurse (LVN) B on [DATE] at 11:28 a.m., one insulin Lispro pen was identified without any patient specific labeling, and it had an open date in the insulin pen dated [DATE]. The plastic bag had residents name, open date of [DATE] and handwritten expiry date of [DATE]. LVN B confirmed no label or identifier of the resident in the insulin pen itself and it was already expired. A review of the facility's policy and procedure (P&P) titled Administering Medications, revised date [DATE], the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. 17. Insulin pens are clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the Nurse verifies that the correct pen is used for that resident. 3a. During a concurrent medication cart C inspection and interview with LVN G on [DATE] at 10:01 a.m., there were three insulin pens inside the medication cart C without open dates: 3a1. Lantus (long-acting insulin used to manage blood sugar levels in adults and children), 3a2. Basaglar Kwik pen (a long-acting insulin used to control high blood sugar, and 3a3. Humalog (fast acting insulin). LVN G confirmed no open dates were on the insulin pens, and further stated the plastic bag can be lost and not knowing the date when the pens were opened was not per policy. During a concurrent medication cart B inspection and interview with LVN B on [DATE] at 11:03 a.m., four Lantus insulin pens had no open dates written on the label of the insulin pens. LVN B confirmed the observation. During an interview with the Pharmacy Consultant (PC)on [DATE] at 9:59 a.m., the PC stated the open date should be written on the insulin pen to know the date it was opened. She further stated she informed the facility on that practice. 3b. During a concurrent medication cart C inspection and interview with LVN G on [DATE] at 10:28 a.m., two over the counter (OTC)bottles of Artificial Tears (for eye lubrication) were identified in the medication cart B with no resident's name and no open date. LVN G verified the findings and further stated the medication should have a name on the bottles. During a concurrent medication cart B inspection and interview with LVN B on [DATE] at 11:03 a.m., three over the counter (OTC) bottles of Artificial Tears were identified in the medication cart B with no resident's name and open date. LVN B verified the findings further stated the medication should have an identifier in the medications. 3c. During a concurrent medication cart C inspection with LVN G on [DATE] at 10:32 a.m., one bottle of Brimonidine 0.2% Eye drop (used to lower pressure in the eyes in patient who have glaucoma [high pressure in the eyes that damage nerves and cause vision loss] had no open date. LVN G confirmed the medication had no open date. During an interview with the PC on [DATE] at 10:01 a.m., the PC stated that eye drop even artificial tears should have a name in the bottle. A review of the facility's policy and procedure (P&P) titled Medication Labels, undated, the P&P indicated Medications are labeled in accordance with facility requirements and state and federal laws. Only the dispensing pharmacy can modify or change prescription labels. 3d. During a concurrent medication cart B inspection and interview with LVN B on [DATE] at 11:19 a.m., one bottle of Albuterol Sulfate HFA Inhalation Aerosol (used to prevent and treat wheezing and shortness of breath caused by breathing problems) 90 mcg (microgram, metric unit of mass equal to one millionth of a gram) drop, had no resident identifier on the medication container. LVN B confirmed the medication had no resident's identifier. A review of the facility's policy and procedure (P&P) titled Medication Labels, undated, the P&P indicated Medications are labeled in accordance with facility requirements and state and federal laws. Only the dispensing pharmacy can modify or change prescription labels. A. Labels are permanently affixed to the outside of the prescription . the label may be affixed to an outside container or carton, but the resident 's name at least, must be maintained directly on the actual product container. 4. During a concurrent interview and record review with ADON on [DATE] at 1:11 p.m., the [DATE] medication storage temperature log was incomplete and not consistently monitored. There was no temperature taken on [DATE], and [DATE]. ADON confirmed the temperature log was blank on the specified dates. A review of the facility's policy and procedures (P&P) titled, Storage of Medications, dated [DATE], the P&P indicated, Medication storage conditions are monitored on a routine basis and corrective action taken . 5. During a medication administration observation on [DATE], at 4: 20 p.m. and 4:34 p.m., the medication cart A was left unlock in the hallway outside of resident 25's room. Registered Nurse (RN) E confirmed the medication cart A was left unlocked and stated it should always be locked at all times. A review of the facility's policy and procedures (P&P) titled Administering Medications, revised date [DATE], the P&P indicated, Medication are administered in a safe and timely manner, and as prescribed. 19. During administration of medications, the medication cart is kept closed and locked when out of sight off the medication nurse or aide .the cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or other passing by. 6. During an inspection of medication storage with ADON on [DATE] at 1:11 p.m., one opened bottle of Dextromethorphan HBr (used to temporarily relive cough caused by the common cold, flu, or other conditions) 20 mg (milligram, unit of mass) Guaifenesin (used as expectorant medication that thins mucus) 400 mg was found with no open date. ADON confirmed the medication had no open. A review of the facility's policy and procedures (P&P) titled Medication Label, undated, the P&P indicated: Medications are labeled in accordance with facility requirements and state and federal laws. Only the dispensing pharmacy can modify or change prescription labels.

Based on observation, interview, and record review, the facility failed to follow their infection prevention and control policy and procedures when an uncovered nebulizer (a machine that turns liquid medicine into mist that is inhaled into the lungs) mouthpiece was found on Resident 30's bedside table. This failure had the potential for the resident to acquire an infection. Findings: During an observation on 2/9/25 at 9:34 a.m., an exposed nebulizer mouthpiece was found on Resident 30's bedside table. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) D on 2/9/25 at 9: 41 a.m., LVN D confirmed the mouthpiece was exposed. LVN D stated it should be cleaned, washed, dried, and then placed inside the plastic bag because of infection control. During an interview with Infection Preventionist on 2/12/25 at 4:22 p.m., IP stated the nebulizer mouthpiece should be placed in a plastic bag and not left exposed. A review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 09/18/2023, the P&P indicated An infection prevention control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infection.

Based on observation, interview, and record review, the facility failed to ensure residents' environment was maintained safe and sanitary when Resident 17's bedside table was damaged. This failure had the potential for injury, decreased self-esteem and the potential to affect Resident 17's psychosocial well-being. Findings: Review of Resident 17's clinical record indicated he was admitted to the facility on [DATE] with diagnoses that included Parkinsonism (a group of symptoms that affect movement, including slowness, stiffness, and shakiness), contracture left hand (shortening and hardening of muscles, tendons, and other tissue, often leading to deformity and rigidity of joints), epilepsy (nerve cell activity is disturbed in the brain causing seizures), major depressive disorder (mental health condition showing persistent low mood and loss of interest that significantly interfere with daily life), hemiplegia and hemiparesis of left side (partial or total paralysis), anxiety disorder (feeling of worry, anxiety or fear strong enough to interfere with daily activities), and visual field defects (loss of part of the usual field of vision). Review of Resident 17's minimum data set (MDS, an assessment tool) dated 12/27/24 indicated his cognition was intact. During an observation on 2/10/25 at 10:18 a.m., Resident 17's bedside table was positioned in front of him while he was lying upright in the bed. The bedside table surface material was not intact. The bedside table was cracked and multiple areas on the table had brownish material exposed beneath the original surface of the table. The plastic material that contours the edges of the tray table was broken and sharp plastic edges were exposed. Resident 17 was asked about his bedside tray table, and he responded It's ugly, not smooth at all. Looks bad to me. During an observation and interview with the Director of Nursing (DON) on 2/10/25 at 10:45 a.m., she went to Resident 17's room and viewed his bedside tray table. The DON stated It's not good. It needs to be replaced.

Based on observation, interview, and record review, the facility failed to ensure food was palatable when brown rice was served undercooked for 18 Residents. This failure had the potential to harm the digestive tract (pathway for food to travel to the body) of residents and cause further health issues. Findings: During an interview with Resident 1 on 10/4/24 at 11:05 a.m., Resident 1 stated I don ' t like the food here. It ' s horrible. A lunch test tray conducted on 10/4/24 at 12:42 p.m. with Certified Dietary Manager (CDM). A regular diet tray was tested for temperature and palatability. The test tray plate included fish, brown rice, and beans. CDM agreed the brown rice was undercooked, and the texture was rough. CDM stated she usually tasted food prior to serving but today, she did not. During a concurrent observation and interview with Resident 2 on 10/4/24 at 12:53 p.m., Resident 2 was sitting on the bed with her lunch tray on the bedside table. Resident 2 ' s lunch tray consisted of string beans, brown rice and chicken with white sauce on top. Resident 2 stated the chicken was tough and rice was not fully cooked. During an interview with Dietary [NAME] (DC) on 10/4/24 at 1:11 p.m., DC stated brown rice was cooked for one hour. DC stated he tasted it prior to serving. During a concurrent interview and record review with CDM on 10/4/24 at 2:11 p.m., CDM verified the [NAME] Rice recipe provided by the facility indicated, .bake at 350F for 30 minutes in a conventional oven or 25 minutes in a convection oven . CDM stated it took one hour to cook the brown rice because they did not use convection oven. CDM stated there is no recipe available for cooking the brown rice for one hour. CDM also stated she oversees checking the breakfast tray and the Registered Dietician (RD) is in charge of checking the lunch tray. During an interview with RD on 10/4/24 at 2:16 p.m., RD stated that the CDM tastes the food and not the RD. RD also stated the DC must taste the food before serving to the residents. RD stated he checked the tray accuracy for lunch and dinner. A review of facility provided document entitled, Cook/Kitchen Staff, the document indicated, Duties and Responsibilities .Food Service Functions .Prepare and serve meals that are palatable and appetizing in appearance. Policy for following menus was requested but was not provided.

Based on interview and record review, the facility failed to provide care and services in accordance with professional standards of practice for one of four sampled residents (Resident 1) when: 1. There were multiple days for which there was no documentation of treatment to Resident 1's right heel wound; and 2. There were multiple Weekly Summary Documentations (resident assessments done on a weekly basis) that were not accurately completed. Failure to provide treatments had the potential to result in worsening of Resident 1's right heel wound. Failure to accurately assess had the potential to compromise the facility's ability to plan care and provide interventions. Findings: 1. Review of Resident 1's medical record indicated he was admitted on [DATE] and had diagnoses including diabetes (disorder characterized by difficulty in blood sugar control and poor wound healing). Review of Resident 1's Change in Condition Evaluation, dated 5/7/24, indicated he had a deep tissue injury (DTI, pressure-related injury to the skin and underlying tissue) on the right heel. Further review of Resident 1's medical record indicated this right heel wound was later classified as a diabetic foot ulcer (a wound that occurs in diabetics due to lack of sensation and decreased blood flow). Review of Resident 1's IDT (interdisciplinary team) Wound document, dated 5/23/24, indicated Resident 1's right heel wound healed. Review of Resident 1's IDT Wound document, dated 6/6/24, indicated Resident 1 had a reoccurrence of his previously resolved right heel wound. The IDT Wound document further indicated a current treatment of, Betadine paint [a medication applied to a wound to prevent infection and promote healing] and cover with gauze. Further review of Resident 1's medical record indicated there was no documentation that the facility treated Resident 1's right heel wound until 6/11/24 (five days after the reoccurrence of the wound). During an interview and concurrent record review with licensed nurse A (LN A) on 9/30/24, at 10:27 a.m., LN A reviewed Resident 1's medical record and confirmed the documentation indicated a reoccurrence of Resident 1's right heel wound on 6/6/24. LN A confirmed that from 6/6/24 to 6/10/24, there was no documentation that indicated the facility provided treatment to Resident 1's right heel wound. The facility's policy titled Skin Integrity Management, dated 5/26/21, indicated to implement wound care treatments as indicated. 2. Review of Resident 1's IDT Wound document, dated 6/6/24, indicated Resident 1 had a reoccurrence of his previously resolved right heel wound. Review of Resident 1's treatment administration record (TAR) indicated the facility provided treatments to Resident 1's right heel wound from 6/11/24 to 8/11/24. Resident 1's Weekly Summary Documentations were reviewed. Section P-1 of the document was designated to indicate whether or not the resident had skin issues. On 6/7/24, 6/14/24, 6/20/24, 6/28/34, 7/25/24, 8/2/24, and 8/5/24, the person who completed the Weekly Summary Documentation selected No for section P-1, indicating Resident 1 did not have skin issues. During an interview and concurrent record review with LN A on 9/30/24, at 10:27 a.m., LN A reviewed Resident 1's medical record and confirmed the Weekly Summary Documentations for the above dates did not accurately reflect Resident 1's skin condition. The facility's policy titled Guidelines for Charting and Documentation, revised 6/2021, indicated documentation should be concise, accurate, and complete.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 2) received a medication as ordered. This failure had the potential to compromise the resident's health and well-being. Findings: Review of Resident 2's medical record indicated she was admitted on [DATE] and had diagnoses including dislocation of the left hip and fractures of the neck, forearm, spine, pelvis, and tibia (large bone in the lower leg). Review of Resident 2's Order Summary Report indicated she had a physician's order, dated 12/7/23, for Enoxaparin Sodium Injection Solution Prefilled Syringe (medication used to prevent blood clots) 40 milligrams per 0.4 milliliters (mg/ml, unit of dose measurement) inject 1 syringe subcutaneously (beneath the skin) every 12 hours to prevent deep vein thrombosis (DVT, a blood clot in a deep vein, usually in the legs). Review of Resident 2's medication administration record (MAR), dated 12/2023 and 1/2024, indicated she was scheduled to receive the above Enoxaparin Sodium Injection every day at 9:00 a.m. and 9:00 p.m. Further review of the MAR indicated this medication was not documented as administered on the following dates and times: 12/13/23 at 9:00 a.m., 12/17/23 at 9:00 a.m. and 9:00 p.m., 12/18/23 at 9:00 p.m., 12/19/23 at 9:00 a.m., 12/25/23 at 9:00 a.m. and 9:00 p.m., 12/31/23 at 9:00 a.m., 1/4/24 at 9:00 a.m., and 1/5/24 at 9:00 a.m. Resident 2's Progress Notes were reviewed. The documentation indicated for the above dates and times, Resident 2's Enoxaparin Sodium Injections were pending delivery from the pharmacy. During an interview and concurrent record review with licensed nurse A (LN A) on 9/30/24, at 2:31 p.m., LN A reviewed Resident 2's medical record and confirmed the Enoxaparin Sodium Injections were not documented as administered on the above dates and times. LN A confirmed Resident 2 did not receive the medication because it had not been delivered from the pharmacy. LN A acknowledged that either the nurses did not order the medication refills on time, or the pharmacy did not deliver the refills on time. The facility's policy titled Medication Administration Schedule, revised 11/2020 indicated, Medications are administered according to established schedules. The facility's policy titled Pharmacy Services, revised 4/2019, indicated the facility shall accurately obtain and provide routine medications. The policy further indicated, Residents have sufficient supply of their prescription medications and receive medications (routine, emergency or as needed) in a timely manner.

Based on interview and record review, the facility failed to ensure the safety of one of two residents (Resident 1) when the Certified Nursing Assistant A (CNA A) did not provide appropriate physical assistance/support in accordance with Resident 1's needs and did not make sure the shower chair was close enough to Resident 1 during transfer from bed to shower chair. This failure put Resident 1's safety at risk. Findings: Review of Resident 1's medical record indicated diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body), abnormal gait and mobility, and muscle weakness. Review of Resident 1's Fall Risk Assessment (FRA, an assessment to determine the likelihood of falling) dated 9/26/23 indicated he was unable to independently come to a standing position and had a score of 20 (a score of 20 means high risk for fall). Review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 6/20/24 indicated he had impairment on one side of upper and lower extremities. He needed partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) during chair/bed-to-chair transfer. He used manual wheelchair for locomotion (to move from one place to another). Review of the Weekly Nursing Notes Summary for Resident 1 dated 8/3/24 indicated he needed limited assistance with one-person during transfer. Review Resident 1's medical record dated 8/7/24 indicated he had a witnessed fall during transfer from bed to shower chair. During an interview with the CNA A on 9/11/24 at 1:24 p.m., he stated on 8/7/24 between 7:00 a.m. to 8:00 p.m., he placed his hand resting on top of Resident 1's shoulder when Resident 1 was about to transfer from bed to shower chair. The CNA A stated he did not put any of his hands under Resident 1's upper arm for support. The CNA A further stated the front of the shower chair was far from Resident 1's buttocks when Resident 1 sat down in the shower chair which caused the shower chair to be kicked out backward and Resident 1 fell on the floor. The CNA stated the incident of fall happened so fast. The CNA notified the Charge Nurse and assessed Resident 1. During an interview with CNA B on 9/23/24 at 10:52 a.m., she stated for resident that required one-person assistance with transfer from bed to shower chair, she always used gait belt. CNA B further stated she made sure shower chair is situated close to the resident to ensure safety transfer. During an interview with Licensed Vocational Nurse C (LVN C) on 9/23/24 at 11:00 a.m., she stated for resident that required one-person assistance with transfer from bed to shower chair, the staff needs to provide support by putting the hand under the resident's armpit or utilize holding resident's waist to ensure resident's safety. LVN C further stated the shower chair should be placed close enough to the resident to ensure safe transfer from bed to shower chair. During an interview with the Director of Staff Development (DSD) on 9/23/24 at 11:08 a.m., she acknowledged CNA A should have supported Resident 1 by placing his hand under Resident 1's armpit and should have made sure the shower chair is placed close enough for Resident 1 to sit during transfer to ensure Resident 1's safety. Review facility's revised policy and procedures dated 10/2020 titled Certified Nursing Assistant: Personal Nursing Care Function indicated, Assist residents in accordance to their needs ranging from minimal assistance to total dependence care on activity of daily living (ADLs). Review facility's revised policy and procedures dated 7/2017 titled Safe Lifting and Movements of Residents indicated, Staff responsible for direct care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices.

Based on interview and record review, the facility failed to ensure a resident (Resident 1) was free from physical and mental abuse, and failed to ensure a staff (certified nursing assistant B, CNA B) who was a witness had immediately reported the incident for one of two sampled residents when: 1. Nurse Assistant A (NA A) pinned down Resident 1; and when 2. CNA B did not immediately report the incident to the charge nurse upon witnessing it. This failure resulted in emotional distress to the resident and the failure of late reporting delayed action to protect Resident 1 and other residents from the potential of further abuse. Findings: Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 1/6/21, indicated the resident did not have any problems with memory and with daily decision skills. During an interview on 3/4/21 at 2:15 p.m., Resident 1 stated, Yesterday evening [NA A] kicked my door and the door swung open. I said to her you need to get out of here. [NA A] then grabbed my wrists and pinned me down. When I said you need to let me go, [NA A] responded, 'If I don't, what are you going to do?' Resident 1 stated, The incident scared the hell out of me. Review of Resident 2's MDS, dated [DATE], indicated the resident had mild impairment with memory and daily decision-making skills. During an interview on 3/4/21 at 2:08 p.m., Resident 2 stated she witnessed the following, Yesterday evening, [NA A] kicked the door open, making a booming sound, which startled [Resident 1]. [NA A] entered the room and hugged me. [Resident 1] said what are you doing? [NA A] pinned [Resident 1]'s arms down. When [Resident 1] said get your hands off of me, [NA A] said, 'What are you going do, beat me up?' [CNA B], who saw the incident, 'freaked out' and went out of the room to get help. [Resident 1] cried. Resident 2 stated she knew NA A for a while and NA A's behaviors were loud, rude and acting out. During an interview on 3/4/21 at 3:10 p.m., charge nurse C (CN C) stated yesterday, when passing medications around 8:15 to 8:30 p.m., Resident 1 informed her about being abused by NA A. CN C stated Resident 1 was crying and had a terrified look on her face. CN C stated Resident 1 told her she had not been pinned down like that since she was a child. CN C stated she felt terrible and she called CNA B to ask what happened. During an interview on 3/4/21 at 3:25 p.m., CNA B stated she witnessed the incident. CNA B stated, Yesterday, around 7:30 to 7:40 p.m., [NA A] was in the hallway, had her back against [Resident 1]'s door with hands raised near the head level and she was repeatedly knocking the door with her foot and hands. She asked [NA A] to stop. [NA A] entered the room, hugged [Resident 2] and approached [Resident 1]. [Resident 1] said, 'Don't do that,' referring to the door knocking. [NA A] held down [Resident 2]'s shoulders with both of her hands and asked [Resident 1], 'What are you going to do about it?' I told [NA A] to stop and [NA A] left the room. [Resident 1] said, 'Do not let [NA A] back in my room.' CNA B stated she did not immediately report the incident because CN C was on dinner break and that she also went on break. Later that evening CN C called and asked her what happened. Review of Resident 1's Health Status Note, dated 3/3/21 at 11:31 p.m., indicated Resident 1 reported NA A kicked her door, pinned her right and left wrists down and stated to her, What are you going to do about it? The same entry indicated Resident 1 did not want NA A in her room again. During an interview on 3/4/21 at 1:30 p.m., the administrator stated the incident likely happened because both Resident 1 and CNA B said the same things regarding NA A pinning down Resident 1. She stated CN C informed her yesterday evening and she suspended NA A. During a follow-up interview on 3/4/21 at 5 p.m., the administrator stated staff should have reported the incident right away before going on a break. Review of the facility's ABUSE PROHIBITION AND PREVENTION POLICY AND PROCEDURE, dated 03/2018, indicated this facility prohibits and prevents abuse. Under the Reporting/Response section, it indicated all mandated reporters were to report reasonable suspicion of a crime against a resident. The policy did not indicate the timeframe for reporting. Under the Protection section, it indicated if the suspected perpetrator was an employee to remove employee immediately from the care or vicinity of residents.

Based on interview and record review, the facility failed to provide care and treatment for one of three sampled residents (Resident 1) when Resident 1 was identified as having weight loss. Resident 1's (MONTH) (YEAR) care plan interventions of added snacks were not implemented. After weight loss in (MONTH) (YEAR), the care plan was not revised. Resident 1 did not have a dehydration care plan in place after weight loss and his daily fluid intake was not assessed by the nurse to ensure Resident 1's hydration status met his assessed fluid requirements. These failures resulted in Resident 1 becoming severely malnourished and dehydrated, leading to death. Findings: During a review of the clinical record for Resident 1, the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. pacemaker (device to regulate heart rate), and major [MEDICAL CONDITION]. On [DATE], he had the [DIAGNOSES REDACTED]. During a review of the clinical record for Resident 1, the Nutritional Risk assessment dated [DATE], indicated the reason for assessment as Initial for new admission to the facility. Resident 1's weight on admission was 143.3 pounds (lbs.). The goal weight was documented as 145 lbs. (plus or minus) 5 lbs., and was a Healthy weight. Resident 1's intake (how much food he ate) averaged 88% and the goal intake was 75% or more. The assessment indicated Resident 1 had swallowing difficulties. The Nutritional Assessment and Mini Nutritional Assessment, both dated [DATE], indicated Resident 1 .gradually losing weight over the year and wt. (weight) is no longer within goal range. BMI (body mass index-measure of body fat based on height and weight. Underweight = <18.5; Normal weight = 18XXX,[DATE].9; Overweight = ,[DATE].9; Obesity = BMI of 30 or greater) remaining in healthy range, but further wt. loss not desired .Will monitor wt. and will (follow up) as needed .Near underweight BMI goals . The assessment indicated Resident 1 was at risk for malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat). The Registered Dietician (RD) ordered snacks three times a day and discontinued the liquid nutritional supplement. There was no documentation the Medical Doctor (MD) or Responsible Party (RP) were notified of Resident 1's weight loss. During an interview with the RD on [DATE] at 1:30 p.m., she stated she had discontinued the nutritional supplement because Resident 1 did not like it. When asked if she had attempted different liquid nutritional supplements, she stated she did not. When asked if the MD or RP were notified of Resident 1's weight loss, she stated she did not notify them. During an interview with the Assistant Director of Nursing (ADON) on [DATE] at 10:59 a.m., reviewed the clinical record for Resident 1 and was unable to find documentation the MD or RP were notified of the weight loss. The RD Note dated [DATE], indicated Significant Weight Change; current weight was 124.3 lbs. with a weight change of 5.7 lbs. (4.4 %) in one month. The goal weight was documented as 125 lbs. (previous goal weight was 145 lbs.). The RD recommended to continue with the current diet order and to weigh Resident 1 weekly to monitor for significant changes. There were no other recommendations made. The IDT Progress Note (Interdisciplinary Team; team including nurses, pharmacy, RD, MD, therapy etc. to coordinate care) dated [DATE] indicated Resident 1 ate an average of 80% of meals, weight remains in goal range. Wt. loss likely (related) to variable .intake. There were no new orders for laboratory tests related to the weight loss. Resident 1's Care Plan indicated Resident 1 was at nutritional risk. Interventions included monitor labs and snacks three times a day. There were no interventions related to risk of dehydration. During an interview with the Assistant Director of Nursing (ADON) on [DATE] at 11:50 a.m., she reviewed the clinical record and was unable to find a care plan related to the risk of dehydration. During an interview with the RD on [DATE] at 1:30 p.m., she reviewed the clinical record for Resident 1 and was unable to find documentation of a hydration assessment after ,[DATE]. The RD stated she did not order any lab work for Resident 1, and she was not aware of the weight loss in June. During a review of the clinical record for Resident 1, the Order Summary Report indicated an order on [DATE] for snacks to be given three times a day. The Documentation Survey Report for ,[DATE], ,[DATE] and ,[DATE], indicated snacks were given as needed. Sixty-nine of 77 days were documented as NA for morning, evening and night snacks. For [DATE] morning, [DATE] evening, [DATE] morning, [DATE] evening, [DATE] morning, [DATE] evening, [DATE] evening and [DATE] morning, Resident 1 was offered a snack and ate ,[DATE]% of it. During an interview with CNA 2 on [DATE] at 1:35 p.m., she reviewed the clinical record for Resident 1 and verified the documentation of NA on the Document Summary Report for snacks. She stated NA meant a snack was not offered. She further stated, if Resident 1 had refused a snack, the documentation would indicate RR. CNA 2 verified there was no documentation Resident 1 had refused snacks. The Multidisciplinary Care Conference (IDT meeting) dated [DATE], indicated the registered nurse, social worker and dietary personnel were at the conference. The Nutritional/Dietary Summary section of the Care Conference was blank. The section for concerns and goals did not mention weight management. During an interview with Consultant 1 on [DATE] at 3:34 p.m., she reviewed the clinical record for Resident 1 and verified the Nutritional/Dietary Summary section of the Multidisciplinary Care Conference dated [DATE] was blank. The Mini Nutritional assessment dated [DATE], indicated Resident 1's current weight was 121 lbs., with a BMI less than 19 (underweight), and was Malnourished. Surveyor calculation indicated Resident 1's BMI was 18.4. There was no documentation the MD or RP were notified of the weight loss. There was no documentation the IDT met to discuss Resident 1's weight loss. There was no documentation of new interventions to prevent further weight loss. During an interview with Consultant 1 on [DATE] at 3:34 p.m., she reviewed the clinical record for Resident 1 and verified the IDT did not discuss Resident 1's weight on [DATE]. She further stated the RD was the healthcare professional who signed the Mini Nutritional Assessment on [DATE]. During a review of the clinical record for Resident 1, the Nutritional assessment dated [DATE], indicated Resident 1 required 1,710 ml (milliliters) of fluids per day for hydration. The Documentation Summary Report for ,[DATE] indicated the following daily total fluid intake for Resident 1: [DATE]-650 ml [DATE]-0 ml [DATE]-900 ml [DATE]-900 ml [DATE]-550 ml [DATE]-430 ml [DATE]-980 ml [DATE]-600 ml [DATE]-1200 ml [DATE]-1840 ml [DATE]-1100 ml [DATE]-550 ml [DATE]-480 ml [DATE]-350 ml [DATE]-660 ml Resident 1 met the fluid intake requirements one of 15 days. Resident 1 did not meet his fluid intake by half for nine of 15 days. There was no documentation the MD was notified of Resident 1's fluid intake. During an interview with Consultant 1 on [DATE] at 3:34 p.m., she stated the nurse assigned to the resident should assess fluid intake. She reviewed the clinical record for Resident 1 and was unable to find documentation a nurse assessed the fluid intake for ,[DATE]. During a review of the clinical record for Resident 1, the ED (emergency department) Evaluation dated [DATE], indicated Resident 1 was unresponsive when he arrived at the ED. He was noted to have a stage two pressure injury (partial thickness skin loss) to his coccyx (tailbone area), extremely dry mucous membranes (moist membrane which lines areas like the mouth, inside of the nose, eyes, etc.). His admitting [DIAGNOSES REDACTED]. Resident 1's weight in the acute care hospital was 114.6 lbs. (6.4 lbs. weight loss from 15 days earlier) with a BMI of 16.9 (underweight). His nutritional [DIAGNOSES REDACTED]. The acute care hospital Discharge Summary indicated Resident 1 died on [DATE]. The documented cause of death was cerebral [MEDICAL CONDITION] (reduced supply of oxygen to the brain) with contributing factors [MEDICAL CONDITION] (severe infection of the blood), healthcare associated pneumonia (infection of the lungs which occurs during a healthcare stay), probable aspiration pneumonitis (inflammation of the lung tissue due to inhaling substances), [MEDICAL CONDITION] candidiasis (infection of the windpipe) and fungemia (fungal infection of the blood). Other Diagnosis: [REDACTED]. The facility policy and procedure, Change of Condition, Resident dated ,[DATE], indicated It is the policy of this facility to identify, inform the physician and resident or resident representative, and intervene to provide medical or nursing care for a resident experiencing an acute medical change of condition in a timely and effective manner .Upon noting or receiving report of a change in a resident's physical, mental or psycho social status, the licensed nurse will evaluate the resident's condition .Document assessments and interventions on the clinical record . The facility policy and procedure, Weight Management System dated ,[DATE], indicated The Interdisciplinary Team will meet weekly to review .residents with significant weight changes, and residents with significant changes in eating patterns .