Every finding on record at Motion Picture and T.V. Hosp D/P SNF

Based on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards for four of eight sampled residents (Resident 5, 35, 67, 96) reviewed for accidents by failing to: 1. Ensure Resident 5's bilateral (both sides) fall mats (a protective, impact-absorbing cushion placed on the floor alongside a patient's bed) were provided per plan of care and physician's orders when the right-side fall mat was not in place. 2. Ensure floor mats designed to reduce injury from falls, were free from objects over the mats for Residents 67 and Resident 96. These failures had the potential to result in resident falls resulting in injuries like fractures (broken bones) and lacerations for Residents 5, 67, and 96. 3. Ensure a color-coded identification strip was placed to Resident 35's picture on the door, as part of the facility's fall risk identifier for the residents. This failure had the potential to result in negative outcomes by omitting preventative measures and not identifying Resident 35 who was at risk for fall which can increase likelihood of falls resulting in severe injuries. Findings: 1.During a review of Resident 5's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 12/15/2022. During a review of Resident 5's History and Physical (H&P), dated 8/31/2025, the H&P indicated the resident's most recent admission was 9/6/2023 with diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), chronic pain, and depression (persistent feelings of sadness and loss of interest that can interfere with daily living). During a review of Resident 5's Minimum Data Set (MDS – resident assessment tool) dated 5/5/2026, the MDS indicated the resident usually was able to understand others and usually was able to make himself understood. The MDS further indicated that the resident was dependent on staff for eating, oral and personal hygiene, toileting, bathing, mobility and dressing. During a review of Resident 5's Physician Orders, the Physician Orders indicated orders for the following: - Beveled Floor Mat, place beveled floor mat on both sides of bed when resident is in bed, may be removed and stored when resident is out of bed. Indication: provide comfort and reduce impact from fall, dated 4/16/2026. During a review of Resident 5's Care Plan (CP) regarding the resident is at risk for fall related to Parkinson's, dementia . impaired vision and hearing, immobility, and poor safety judgment, dated 9/6/2023. The CP indicated a goal that the resident would be free of fall and complication with interventions that included to place beveled mats on both sides of the bed when the resident is in bed to provide comfort and reduce impact from fall, mat may be removed and stored when the resident is out of the bed. During an observation on 7/13/2026 at 3:41 p.m., observed Resident 5, in bed awake. Observed a fall mat placed on the floor on the left side of the bed. Observed no fall mat on the floor on the right side of the bed. During an observation on 7/16/2026 at 7:33 a.m., observed Resident 5, in bed asleep. Observed a fall mat placed on the floor on the left side of the bed. Observed no fall mat on the floor on the right side of the bed. During an observation on 7/16/2026 at 10:05 a.m., observed Resident 5, in bed awake while Licensed Vocational Nurse (LVN) 6 administered medications to the resident. Observed a fall mat placed on the floor on the left side of the bed. Observed no fall mat on the floor on the right side of the bed. During a concurrent observation and interview on 7/16/2026 at 3:55 p.m., in the hallway outside Resident 5's room, with Certified Nursing Assistant (CNA) 5, CNA 5 stated Resident 5 was at risk for falls and had fall mats on both sides of the bed. Observed CNA 5 entered Resident 5's room and stated there was only a fall mat on the left side of the resident's bed and there were no other fall mats in the room. During a concurrent interview and record review on 7/16/2026 at 4 p.m., in the MP [NAME] Nursing Station, with LVN 7, reviewed Resident 5's orders and CPs. LVN 7 stated fall mats are used to prevent injury when a resident falls. LVN 7 stated he was caring for Resident 5 and the resident had orders and CPs for bilateral fall mats, so bilateral fall mats should be in place, but the right side was not there. During a concurrent interview and record review on 7/17/2026 at 2:05 p.m. with the Clinical Supervisor (CS), reviewed the facility policy and procedures (P&P) regarding fall prevention and accident prevention. The CS stated fall mats are used in the facility for residents at risk of falling to reduce the impact of a fall when it occurs. The CS stated the interdisciplinary team (IDT) determined that Resident 5 needed bilateral fall mats and the resident had an order to provide the mats and monitor that they were in place. The CS stated if the staff determined that the resident did not have a need for bilateral floor mats then the IDT should have discussed it, but they did not. The CS stated the facility P&P was not followed when Resident 5 did not have a fall mat on the right side of the bed potentially resulting in injury from falls. During a review of the facility P&P titled, Accident Prevention, approved 12/4/2025, the P&P indicated, POLICY STATEMENT: To ensure the environment is as free as possible from accident hazards and identify residents who require supervision and/or assistive devices to prevent accidents. II. PROCEDURE: . A. Identify Types of Accident Hazards, including: . Falls. 8. Ongoing Environment of Care Rounding. 1. Conduct routine rounding to identify and mitigate environmental hazards including: . o Assistive Devices. During a review of the facility P&P titled, Falls, approved 12/4/2025, the P&P indicated, Residents are evaluated for their risk for falls using the Fall Risk Evaluation. B. Recent falls will be reviewed during the IDT meetings. Interventions will be implemented in accordance with the resident's need . 2a. During a record review of Resident 67's FS, the FS indicated the facility originally admitted the resident on 3/6/2024 and readmitted on [DATE], with diagnoses including Alzheimer's disease, unspecified (a disease characterized by a progressive decline in mental abilities); Type 2 diabetes mellitus with other circulatory complications (a disorder characterized by difficulty in blood sugar control and poor wound healing that has caused problems blood circulation); unspecified glaucoma (an eye disease that can slowly damage vision because of increased pressure or damage to the optic nerve (the nerve that sends message to the brain of you can see). During a review of Resident 67's MDS, dated [DATE], the MDS indicated the resident makes self-understood and understands others and had intact cognitive function (normal thinking). The MDS indicated that Resident 67's needs are dependent to maximal assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a record review of Resident 67's Fall Risk Evaluation (FRE), dated 5/1/2026, the FRE indicated the resident was a low risk for falls. During a concurrent observation and interview on 7/13/2026, at 12:11 p.m., with Restorative Nurse Assistant (RNA) 1, inside Resident 67's room, observed on the right side of the resident's bed the floor mat that had the trash can on top of it. RNA 1 stated the floor mat is to protect resident from getting serious injuries in case resident were to fall. RNA 1 stated that the trash can should not be on top of the floor mat because if Resident 67 were to fall then resident can get injured with the trash can. During a concurrent interview and record review on 7/16/2026, at 12:16 p.m., with Clinical Supervisor (CS) reviewed Resident 67's FRE. CS stated Resident 67 is a low risk for falls. CS stated there should be no objects on top of the floor mat because it prevents the mat from serving its protective purpose in case resident were to fall. CS stated the purpose of the floor mat is for soft landing in case resident were to fall and if the resident were to fall then the resident would potentially hit the trash can and can cause injuries such as skin tears, abrasions, or fractures. The CS stated the policy titled, Accident Prevention, was not followed. 2b. During a record review of Resident 96's FS, the FS indicated the facility admitted the resident on 6/25/2015, with diagnoses Alzheimer's disease, with early onset (a disease characterized by a progressive decline in mental abilities at a younger age than usual age); essential (primary) hypertension (high blood pressure with no known specific cause); depression, unspecified (a condition that causes sadness, loss of interest in activities, low energy, and changes in sleep, appetite, or concentration, can affect a person's feelings, thoughts, and daily activities) During a review of Resident 96's H&P, dated 2/25/2026, the H&P indicated the resident was alert and with continued slow/progressive cognitive and physical decline. During a review of Resident 96's MDS, dated [DATE], the MDS indicated the resident rarely/never makes self-understood and rarely/never understands others and had severe cognitive impairment (very limited memory, thinking, decision-making and needs help with daily activities). The MDS indicated that Resident 96's needs are dependent assistance on mobility and ADLs. During a record review of Resident 96's Nursing Orders dated 4/16/2025, the Nursing Orders indicated an order for floor mat every shift, Request Type: Stat Indication: Routine, Comments: Place floor mat on both sides of the bed when resident is in bed, mat may be removed and stored when resident is out of bed. Indication: Provide comfort and reduce impact from fall. During a record review of Resident 96's Fall Risk Evaluation (FRE), dated 6/5/2026, the FRE indicated the resident was a high risk for falls. During a concurrent observation and interview on 7/13/2026, at 11:06 a.m., with Certified Nurse Assistant (CNA) 4, inside Resident 96's room, observed on the right side of the resident's bed the floor mat that had a metal chair on top of it. CNA 4 stated the floor mat is to protect resident from injuries in case resident were to fall. CNA 4 stated that if Resident 96 were to fall then resident can get injured with the chair. During a concurrent interview and record review on 7/17/2026, at 1:40 p.m., with Registered Nurse (RN) 1 reviewed Resident 96's FRE and RN 1 stated Resident 96 is high risk for falls. RN 1 stated that the purpose of the floor mat is to reduce the impact from a fall and if an object is on top of the floor mat, it compromises the effectiveness of the floor mat. RN 1 stated the resident can potentially fall and sustain an injury such as abrasion, skin tear, or other physical injury with the metal chair. RN 1 stated the policy, Accident Prevention was not followed. During a review of the facility's provided policy and procedure (P&P) titled, Accident Prevention, last reviewed on 12/4/2025, the P&P indicated to ensure the environment is as free as possible from accident hazards and identify residents who require supervision and or assistive devices to prevent accidents. Procedure: B. Ongoing Environment of Care Rounding -Assistive devices/ environment hazards - Other environmental hazards as identified 3.During a review of Resident 35's FS, the FS indicated the facility admitted the resident on 5/13/2026, with diagnoses including dementia (a progressive state of decline in mental abilities), hypertension (HTN, high blood pressure), and hard of hearing. During a review of Resident 35's MDS, dated [DATE], the MDS indicated that the resident had severe cognitive impairment (a serious decline in mental capacity affecting memory, reasoning and orientation). The MDS also indicated that Resident 35 needs partial/moderate assistance (helper does less than half the effort) with eating, transfers or repositioning, and substantial/maximal assistance with oral, toileting and personal hygiene. During a review of Resident 35's Care Plan dated 5/13/2026, titled Resident is at risk for fall related to dementia as evidenced by fourteen or greater on Fall Assessment, psychotropic or sedating medications, impaired vision, hearing, communication, (.), use of mobility devices, and poor safety judgement with interventions including re-orient [NAME] to place, environment, person and time as needed, assist resident with ambulation and/or transfers, bed remote monitoring device is in place (BS) and working properly, resident is high fall risk, red identification arm bang/tag, and keep any assistive devices needed by the resident within reach. During a review of Resident 35's Fall Risk Evaluation dated 7/12/2026, the resident was high risk for fall, indicating that resident was impulsive, lacks understanding of physical and cognitive limitations, with one to two falls in the past 3 months, was ambulatory/incontinent, had visual and hearing impairments, balance problems while standing and walking. requires assistive devices (i.e., cane, wheelchair, walker, furniture) During a concurrent observation and interview on 7/15/2026 at 11:55 a.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated that the facility has a treatment plan and interventions for fall prevention. CNA 2 stated that residents identified as being at high risk for fall are closely monitored. CNA2 stated that it is staff's responsibility to ensure that walkers are positioned within residents' reach at all times. CNA 2 stated that Resident 35 is high risk for fall and that she had already fallen back in May and another just recently. CNA 2 stated facility is providing CNAs with a phone that is connected to the bed, wherein motion is detected when residents are moving in bed, it is also used for repositioning. CNA 2 was questioned regarding a photograph of residents outside the room at the door specifically about the significance of the red strip visible in one resident's photo. CNA 2 stated that it may have been part of the picture and said that there are no other interventions posted anywhere else. During an interview on 7/15/2026 at 1:54 p.m. with Clinical Supervisor (CS), the CS stated that a color-coding system is used to identify the level of risk for fall residents. The CS stated that the facility uses a red strip underneath placed underneath the photo of the residents posted by the door. During an interview on 7/16/2026 at 9:53 a.m. with Licensed Vocational Nurse 2, LVN 2 stated Resident 35 had a recent fall and fall interventions are in place for the resident. LVN 2 stated that interventions such as bed sensor (BS) connected to mobile device for tracking resident's movement while in bed, posted sign indicating high fall risk by the lamp or head of bed are being used. LVN 2 stated that she is uncertain if residents must wear a wristband or of any other interventions. During an interview on 7/16/2026 at 10:48 a.m. with Clinical Supervisor (CS), the CS stated that part of the intervention was to place a red strip on the resident's photo by the door. CS stated that it is important to have the red strip for other staff to be aware and recognize that the residents are at a high risk for fall. CS also stated that the resident had a fall in May 2026. During the second interview on 7/17/2026 at 2:39 p.m. with the CS, the CS indicated that door in the picture was not labeled with red strip and further stated that the policy was not being followed regarding fall interventions. During a review of the facility's Policy and Procedure (P&P) titled, Falls reviewed on 12/04/2025, the P&P indicated Residents are evaluated for their risk for falls using the Fall Risk Evaluation. Residents are evaluated for their fall risk upon admission to the facility, (.), following a fall. Recent falls will be reviewed during the IDT meetings; interventions will be implemented in accordance with the resident's needs. Fall risk identifier: Based upon the score of the Evaluation, residents will be provided with color identification Yellow color identification for low risk – a score of 13 and below. Red color identification for high risk – a score of 14 and above. Any resident without a color identification will be considered high fall risk until clarified. Fall Intervention Guidelines: The evaluation of fall risk for each resident will be completed by using the Fall Risk Evaluation. These guidelines for falls prevention can be individualized based on the resident's needs evaluation. -High fall risk (14 points and above represents high risk).

Based on observation, interview, and record review, the facility failed to ensure residents who need respiratory care were provided care consistent with professional standards of practice for two of two sampled residents (Resident 8 and 93) reviewed under the Respiratory care area by failing to: 1. Ensure supplemental oxygen (O2) was administered per physician orders, documented when administered, and monitored while in use for Resident 93. 2. Ensure Resident 8's nasal cannula (NC, a small plastic tube, which fits into the nostrils for providing supplemental O2) tubing was identified by CNA 2 when it was on the ground, was not placed by RNA 2 on the resident's bed linens after being removed from the ground and was replaced by LVN 9 after the tubing was on the ground. These failures had the potential to place Resident 93 and Resident 8 at risk for respiratory distress with a delay in necessary care and treatment and respiratory infections from cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) Findings: 1. During a review of Resident 93's History and Physical (H&P), dated 2/11/2026, the H&P indicated the resident was admitted on [DATE] with diagnoses that included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), bronchiectasis (a chronic lung disease causing the airways, called bronchi, to become damaged and widened over time), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and chronic use of supplemental O2. During a review of Resident 93's Minimum Data Set (MDS - resident assessment tool) dated 5/19/2026, the MDS indicated the resident usually was able to understand others and usually was able to make himself understood. The MDS further indicated the resident required partial/moderate assistance from staff for oral and personal hygiene, toileting, bathing, and mobility. During a review of Resident 93's Physician Orders, the Physician Orders indicated orders for the following: - Oxygen Therapy at bedtime: Routine O2, three (3) liters per minute (LPM - a unit of measurement) via NC, place on O2 during sleep every night for COPD, dated 2/11/2026. - Oxygen Therapy daily as needed (PRN) O2, 3 LPM via NC, use during the day if napping or if O2 saturation (Sa O2 - a unit of measurement) was less (<) 90 percent (%) for COPD, dated 2/11/2026 and discontinued 4/6/2026. - Monitor Sa O2 twice a day, notify medical provider if Sa O2 is below 90%, dated 4/6/2026. During a review of Resident 93's Care Plan (CP) titled, (Resident 93) has alteration in respiratory function related to COPD . dated 2/11/2026, the CP indicated a goal that the resident would maintain oxygenation as demonstrated by decreased work of breathing and would maintain a respiratory pattern and rate within accepted parameters. The CP interventions to achieve these goals included to observe for signs of respiratory distress including shortness of breath and decreased Sa O2 and notify the physician as indicated. During a concurrent observation and interview on 7/13/2026 at 10:21 a.m., with one (1): 1 Sitter (S) 2, observed Resident 93 sitting at bedside while administered O2 at 3 LMP via NC. S2 stated Resident 93 required a 1:1 Sitter and uses continuous O2 via NC 24 hours a day. S2 stated Resident 93 had been administered O2 all morning. During an interview on 7/14/2026 at 12:30 p.m., with Family Member (FM) 1, FM 1 stated he visits Resident 93 often and the resident was administered O2 on and off during the day. FM 1 stated the surveyor would need to speak with the facility staff regarding when the O2 was administered. During a concurrent observation and interview on 7/15/2026 at 8:50 a.m., observed Resident 93 sitting at bedside while administered O2 at 2 LMP via NC. S2 stated Resident 93 had been administered O2 since she arrived at about 7 a.m. During a concurrent interview and record review on 7/15/2026 at 9:18 a.m. with Licensed Vocational Nurse (LVN) 11, LVN 11 reviewed Resident 93's physician orders and medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). LVN 11 stated the facility procedure for administering O2 is to check the resident's Sa O2 and administer O2 per the physician's orders. LVN 11 stated Resident 93 was administered supplemental O2 at night and as needed during the day when the residents Sa O2.was < 90%. LVN 11 stated Resident 93 sometimes needed O2 during the day when he was short of breath or complained that he could not breathe. LVN 11 stated Resident 93 was currently being administered O2 via NC. LVN 11 reviewed Resident 93's physician orders and noted the resident had not had an order to administer PRN O2 during the day since 4/6/2026. LVN 11 stated since 4/6/2026, Resident 93's orders indicated to check the resident's Sa O2 and call the physician if it was <90%. LVN 11 stated without a physician's order, the resident should not be administered O2, but he was. LVN 11 stated when oxygen is administered it should be documented in the MAR and monitored. LVN 11 stated he did not know who placed the O2 via NC on the resident or when it was administered because there was no documentation in the resident record because there was no physician's order to administer it. During a follow up interview on 7/15/2026 at 12:58 p.m. with LVN 11, LVN 11 stated it was important to obtain a physician's order prior to administering O2 via NC because the LN cannot do anything without a physician's order. LVN 11 stated the physician determines the treatments for residents. LVN 11 stated it was important to monitor and document a resident's need for and use of O2 via NC because the staff needs to know how the resident is doing and the resident may have a change of condition (COC) when the need for supplemental O2 increases. LVN 11 stated when Resident 11 was administered O2 via NC without a physician's order, without documentation, and was not monitored while administered O2 via NC there was the potential to result in a missed COC and a delay in care for the resident. During an interview on 7/15/2026 at 3:25 p.m. with RN 1, RN 1 stated supplemental O2 is considered a medication. RN 1 stated when a resident has a physician's order for O2 via NC only at night and then requires O2 during the day, the process is to notify the physician and get a physician's order to administer during the day. RN 1 stated when supplemental O2 via NC is administered the process is to document the administration and monitor the use. RN 1 stated she had observed Resident 93 administered O2 via NC during the day on occasion, but she assumed the resident had an order for PRN O2 via NC, but he did not. RN 1 stated when Resident 93 was administered O2 via NC on 7/13/2026, 7/14/2026, and 7/15/2026 during the day without a physician's order, was not documented as administered, and was not monitored while administered, it was considered a medication variance potentially resulting in worsening of COPD or potentially resulting in an unidentified COC with a delay in treatment leading to a serious injury like respiratory failure. RN 1 stated the LNs did not follow the standard of practice to assess the resident for increased need of O2 via NC, notify the physician, obtain an order for administration, document the administration of O2 via NC, and monitor the resident while O2 via NC was administered. During a concurrent interview and record review on 7/17/2026 at 2:05 p.m., with the Clinical Supervisor (CS), the CS reviewed Resident 93's Vital Signs for Sat O2 from 5/2026 to 7/2026 and policy and procedure for oxygen and medication administration. The CS stated the process for when a resident has a new need for oxygen is to assess for the need, then notify provider, check the order before administering the O2 via NC, monitor the use, and document. The CS stated the LN needed to monitor the O2 administration to ensure it was effective and that the resident was not getting worse resulting in a COC. The CS stated the resident could decompensate and become hypoxic (low levels of oxygen in the body tissues) leading to altered mental status (AMS) and falls. The CS stated all of this needs to be documented in the resident's record for the interdisciplinary team (IDT) to evaluate the resident needs and determine the plan of care. The CS reviewed Resident 93's vital signs for Sa O2 and stated the resident was documented as using O2 via NC on the following dates and times without a physician order, documentation of need and length of use, or monitoring: On 5/1/2926 at 2:43 p.m., Resident 93's Sa O2 was 95.0% on 3 LPM O2 via NC On 5/5/2026 at 3:38 p.m., Resident 93's Sa O2 was 98.0% on 2 LPM O2 via NC On 5/21/2026 at 8:16 a.m., Resident 93's Sa O2 was 93.0% on 2 LPM O2 via NC On 5/29/2026 at 2:23 p.m., Resident 93's Sa O2 was 90.0% on 3 LPM O2 via NC On 6/14/2026 at 12:20 p.m., Resident 93's Sa O2 was 92.0% on O2 via NC, no LPM indicated On 6/18/2026 at 8:20 a.m., Resident 93's Sa O2 was 93.0% on 2 LPM O2 via NC On 6/18/2026 at 10:37 a.m., Resident 93's Sa O2 was 97.0% on 2 LPM O2 via NC On 6/21/2026 at 8:39 a.m., Resident 93's Sa O2 was 90.0% on 3 LPM O2 via NC On 6/23/2026 at 8:18 a.m., Resident 93's Sa O2 was 90.0% on 4 LPM O2 via NC On 6/24/2026 at 7:57 a.m., Resident 93's Sa O2 was 90.0% on 2 LPM O2 via NC On 6/25/2026 at 7:58 a.m., Resident 93's Sa O2 was 91.0% on 3 LPM O2 via NC On 6/30/2026 at 6:26 p.m., Resident 93's Sa O2 was 96.0% on 2 LPM O2 via NC On 7/2/2026 at 9:02 a.m., Resident 93's Sa O2 was 92.0% on 2 LPM O2 via NC On 7/4/2026 at 4 p.m., Resident 93's Sa O2 was 90.0% on 2 LPM O2 via NC On 7/9/2026 at 6:06 p.m., Resident 93's Sa O2 was 94.0% on 2 LPM O2 via NC On 7/15/2026 at 9 a.m., Resident 93's Sa O2 was 93.0% on 3 LPM O2 via NC The CS stated the facility P&P was not followed for Resident 93's use of supplemental O2 via NC potentially resulting in delay of care and necessary treatment for the resident. During a review of the facility P&P titled, Oxygen Therapy - Oxygen Concentrator, last reviewed 12/4/2025, the P&P indicated, I.POLICY. To safely administer oxygen via mask (simple mask) or nasal cannula to treat and prevent the symptoms of hypoxia. Only an RN or medical provider can initiate or adjust oxygen liter flow or concentration. II. PROCEDURE. 2. Check the medical provider's order . 10. Document in the Electronic Medical Record. During a review of the facility procedure titled, Medication Administration, last reviewed 12/4/2025, the P&P indicated, Medication shall be accurately and safely administered. 2. A physician's order must include: a. Date and time of the order b. Name of the medication and dose c. Dosage form and strength/concentration d. Frequency e. Route f. Reason for PRN administration g. Indication h. Duration, if applicable i. Date, Time and Signature of MD/RN. 2. During a review of Resident 8's H&P, dated 12/26/2025, the H&P indicated the resident was admitted to the facility 11/1/2022 with diagnoses that included Alzheimer's Disease, heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs), and hypertension (HTN-high blood pressure). During a review of Resident 8's MDS, dated [DATE], the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident required partial/moderate assistance from staff for eating and toileting and required substantial/maximal assistance from staff for oral and personal hygiene and dressing. During a review of Resident 8's Physician Orders, the Physician Orders indicated orders for the following: - Oxygen Therapy: Routine O2, 2 LPM via NC, continuous - notify the provider if Sa O2 < 90%, dated 7/8/2026. During a review of Resident 8's CP titled, Short Term CP: ineffective breathing pattern related to hypoxia., dated 7/8/2026, the CP indicated a goal that the resident would have no signs and symptoms of respiratory distress and would not develop any complications. The CP interventions to achieve these goals included to check proper placement of oxygen tubing every shift and PRN. During an observation on 7/13/2026 at 12:30 p.m., inside Resident 8's room, observed Resident 8 sitting in bed administered O2 via NC, observed the NC tubing prongs at the resident's nostrils, the NC tubing was connected to the concentrator (device used to provide supplemental O2) placed on the right side of the bed. Observed the connected NC tubing was resting on the ground on the right side of the bed and not placed in the provided clear plastic bag located at the left side of the bed. Observed Certified Nursing Assistant (CNA) 2 standing on the right side of the bed speaking with the resident. Observed CNA 2 exited the room and the NC tubing remained on the ground. During a concurrent observation and interview on 7/13/2026 at 12:55 p.m., inside Resident 8's room, with Restorative Nurse Assistant (RNA) 2, observed Resident 8 sitting in bed while administered O2 via NC, observed the NC tubing remained on the ground on the right side of the bed. Observed RNA 2 entered the room, confirmed the NC was on the ground, and stated NC tubing should not be on the ground. Observed RNA 2 picked the NC tubing up off the ground and placed it on the Resident's bed. During a concurrent observation and interview on 7/13/2026 at 1:10 p.m. with LVN 9, at HH East Nursing Station, LVN 9 stated NC tubing should not be on the ground. LVN 9 stated all staff are responsible for notifying the LN if a resident's NC is found on the ground. LVN 9 stated she was assigned to Resident 8 and was not informed that the NC was on the ground, but she would go check the resident. LVN 9 reviewed a photo provided by the surveyor of Resident 8's NC tubing on the ground. Observed LVN 9 walked to Resident 8's room and stated the NC tubing was no longer on the ground and exited the room. LVN 9 then stated the NC tubing only needed to be changed when the nasal prong portion of the NC was on the ground. During an interview on 7/13/2026 at 1:15 p.m. with LVN 11, LVN 11 stated NC tubing should not be on the ground. LVN 11 stated when NC tubing is found touching the ground, the NC should be changed and not placed back on the resident's bed for infection control reasons. During an interview on 7/13/2026 at 1:20 p.m. with the CS, the CS stated NC tubing should never be on the ground because there are bags for each resident that hold the tubing to ensure the tubing is kept off the floor. The CS stated if NC tubing is found on the ground, the NC should be removed and changed and not moved from the ground to the clean bed. The CS stated when Resident 8's NC was not identified as being on the ground by the CNA, was moved from the ground to the bed by the RNA and was not changed by the LVN there was the potential to result in respiratory infections in the resident. During a follow- up concurrent interview and record review on 7/17/2026 at 2:05 p.m. with the CS, reviewed the facility P&P regarding oxygen therapy and infection control. The CS stated when Resident 8's NC was on the ground, placed on the bed, then not changed, the facility P&Ps were not followed because the P&P indicates to change the NC PRN and to keep the tubing in the bag to prevent it from becoming contaminated on the ground. During a review of the facility P&P titled, Oxygen Therapy - Oxygen Concentrator, last reviewed 12/4/2025, the P&P indicated, I. POLICY. To safely administer oxygen via mask (simple mask) or nasal cannula to treat and prevent the symptoms of hypoxia. 6. Attach appropriate oxygen accessories to the oxygen outlet: a. Attach oxygen tubing to the connector. c. Attach mask or nasal cannula to oxygen concentrator. 8. Place mask or nasal cannula on resident/patient, comfortably and with appropriate positioning. 9. Hang a set-up bag on the wall . 11. Oxygen tubing is dated and replaced weekly and as needed.

Based on observation, interview, and review, the facility failed to ensure safe provision of pharmaceutical services by: 1. Failing to label Resident 38's cyclosporine eye drop (a medicine used to help people with chronic dry eye disease by reducing swelling in the eye) with an open date during the inspection of one (1) of three (3) medication carts (Medication Cart 1) reviewed during the Medication Storage and Labeling task. 2. Failing to indicate the open date and discard Resident 56's ipratropium-albuterol sulfate (also known as duoneb, a prescription liquid solution or medicine that people breathe in through a nebulizer [a small machine that turns liquid medicine into a mist so a person can breathe it directly into the lungs] to help the airway open up and make it easier to breathe) two (2) weeks after opening as indicated in the medication label. 3. Failing to label Olopatadine HCL (Pataday - eyes drops that help relieve itchy, red, watery eyes caused by allergies, such as pollen and dust) with an open date for one resident (Resident 76) during the inspection of one of five medication carts (Medication Cart 2) investigated during the Medication Storage and Labeling task. 4. Failing to label two floor stock bottles of Milk of Magnesia (a medication used to relieve constipation by drawing water into the intestines, which softens the stool and makes it easier to have a bowel movement) with an open date during the inspection of two of five medication carts (Medication Cart 2 and Medication Cart3) investigated during the Medication Storage and Labeling task. These failures had the potential to administer expired/outdated medications to residents that can cause adverse reactions (an unwanted, unpleasant, or harmful effect caused by medicine or medical treatment), for medication error and contaminate the medications stored inside the medication cart. 5. Failing to ensure the narcotic (is a strong pain medication that is carefully controlled because it can be habit-forming and has a risk of misused) key was not left unattended in Medication Cart during the inspection of one of three medication carts (Medication Cart 2) investigated during the Medication Storage and Labeling task. This failure had the potential to allow unauthorized access to controlled substances, increasing the risk of medication diversion, theft, or misuse and compromising the security of controlled medication. 6. Failing to ensure medications were securely stored by leaving the medication waste container unlocked while it contained discarded medication including one bubble pack of Pregabalin (Lyrica) (is a medication used to treat nerve pain, certain types of seizures) capsules for one resident (Resident 31) and a Liraglutide (medication that helps lower blood sugar and can help people lose weight) injection. This failure had the potential to allow unauthorized access to medications, resulting in diversion, misuse, accidental ingestion, or harm to residents, staff, or visitors. Findings: 1a. During a review of Resident 38's Face Sheet, the Face Sheet indicated the facility admitted the resident on [DATE]. During a review of Resident 56's History and Physical (H&P) dated [DATE], the H&P indicated that Resident 56 was alert and oriented to person and place. The H&P further indicated the following diagnoses for Resident 56, dementia (a progressive state of decline in mental abilities), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 38's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 38 had intact cognition (mental action or process of acquiring knowledge and understanding) and was rarely able to understand others and usually able to make her needs known. The MDS further indicated that Resident 38 required partial or moderate assistance with eating, substantial or maximal assistance with oral hygiene and sitting to lying/lying to sitting, and total assistance from staff with all other activities of daily living (ADLs – activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 38's Physician's Orders dated [DATE], the Physician's Orders indicated an order dated [DATE] for cyclosporine 0.05 percent (% - out of one hundred) instill one (1) drop into both eyes every 12 hours for dry eye syndrome. During a concurrent observation and interview on [DATE] at 2:36 p.m., during an inspection of Medication Cart (Med Cart) 1 in the presence of Licensed Vocational Nurse (LVN) 4, LVN 4 stated that Resident 38's cyclosporine eye drop was open and not labeled with an open date. LVN 4 stated that the practice in the facility is to indicate the date when a medication was opened as the eye drops are only good for 28 days. LVN 4 stated that the licensed nurse who opened Resident 38's cyclosporine eye drop should have labeled the bottle with the open date so the nurses would know that the medicine is not past the use by date or expired. LVN 4 stated that if the eye drop was past the 28 days eye drop would not be effective anymore when used. During a concurrent interview and record review on [DATE] at 3:13 p.m., reviewed Resident 38's physician's orders and a photo of the cyclosporine box and medication label with the Clinical Supervisor (CS). The CS stated that Resident 38's cyclosporine box and label was not labeled with an open date. The CS stated that the licensed nurses are supposed to label the eye drops with the open date as they are only good for 28 days and need to be discarded after that. The CS stated that the licensed nurse who opened Resident 38's cyclosporine should have labeled the eyed drop with the open date so the other licensed nurses would know when to discard the eye drop. The CS stated that Resident 38's cyclosporine would not be effective in treating the dry eyes anymore if past the 28 days. During an interview on [DATE] at 4 p.m. with the Chief Nursing Officer (CNO), the CNO stated that per facility policy, multidose vials of medications such as injectables, eye drops, and insulin should be labeled with an open date unless otherwise specified by the manufacturer. The CNO stated that Resident 38's cyclosporine eye drop should have been labeled with an open date as the medication is only good for 28 days. The CNO stated that the policy was not followed. 2 a. During a review of Resident 56's Face Sheet, the Face Sheet indicated the facility admitted the resident on [DATE]. During a review of Resident 56's H&P, dated [DATE], the H&P indicated that Resident 56 was alert and oriented to person and place. The H&P further indicated the following diagnoses for Resident 56, dementia (a progressive state of decline in mental abilities), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 56's MDS, dated [DATE], the MDS indicated Resident 568 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was rarely able to understand others and usually able to make her needs known. The MDS further indicated that Resident 38 required partial or moderate assistance with eating, substantial or maximal assistance with oral hygiene and sitting to lying/lying to sitting, and total assistance from staff with all other ADLs. During a review of Resident 56's Physician's Orders dated [DATE], the Physician's Orders indicated the following physician's orders: - [DATE] to [DATE]: ipratropium-albuterol sulfate (Duoneb) 0.5 – three (3) milligrams (mg – a unit of measurement for medication dosage or amount) per 3, inhale 1 nebule (a small, sealed glass or plastic container that holds a single dose of medicine) inhalation every 12 hours for COPD. - [DATE] to [DATE]: Duoneb 0.5 –3 mg per 3, inhale 1 nebule inhalation every 4 hours while awake for a maximum of 4 doses every 24 hours for COPD with bronchospasms (a condition that occurs when the muscles lining the tubes that carry air to the lungs tighten making it hard to breathe). - [DATE] to [DATE]: Duoneb 0.5 – 3 mg per 3, inhale 1 nebule inhalation every 12 hours for COPD. During a concurrent observation and interview on [DATE] at 2:45 p.m., during an inspection of Medication Cart (Med Cart) 1 in the presence of Licensed Vocational Nurse (LVN) 4, LVN 4 stated that Resident 56's box of ipratropium-albuterol sulfate 0.5 – three (3) milligram (mg – a unit of measurement for medication dosage or amount) ampule (a small sealed glass or plastic container that holds a single dose of medicine) with 18 ampules remaining inside an opened foil packaging, did not indicate a date of when it was opened. LVN 4 stated that the medication label indicated to discard the medication 2 weeks after opening. LVN 4 stated that the nurses are supposed to read the medication label and check for the open date and when to discard the medication. LVN 4 stated that if the box of medication was not labeled with an open date and the medication label indicated to discard 2 weeks after opening, the licensed nurses would not be able to know when to discard. LVN 4 stated that if the ipratropium-albuterol was opened past the 2 weeks, the medication would not be effective when administering thru the nebulizer and placed Resident 56 at risk for worsening COPD with bronchospasms. During a concurrent interview and record review on [DATE] at 3:15 p.m., reviewed Resident 56's physician's orders and a photo of the duoneb medication label with the Clinical Supervisor (CS). The CS stated that Resident 56's duoneb medication label did not indicate an open date and the medication label indicated to discard the medication after 2 weeks of opening the foil packaging. The CS stated that the licensed nurses are supposed to indicate on the duoneb box the open date once the foil packaging inside was opened. The CS stated that the licensed nurse who opened Resident 56's duoneb foil packaging should have labeled the box with the open date so the other licensed nurses would know when to discard the unused nebules. The CS stated that Resident 56's cyclosporine would not be effective when administering the duoneb and placed Resident 56 at risk for worsening of the COPD. During an interview on [DATE] at 4 p.m. with the Chief Nursing Officer (CNO), the CNO stated that per facility policy, only multidose vials of medications such as injectables, eye drops, and insulin should be labeled with an open date unless otherwise specified by the manufacturer. The CNO stated that if Resident 56's duoneb medication indicated to discard 2 weeks after opening the foil packaging, the medication should have been labeled with the open date so that the licensed nurses would know when to discard the unused duoneb nebules should have been labeled with an open date as the medication is only good for 28 days. The CNO stated that the policy was not followed. 3a. During a record review of Resident 76's Face Sheet, the Face Sheet indicated the facility admitted the resident on [DATE], with diagnoses including dry eye syndrome of left lacrimal gland (a condition where the eye does not make enough tears, causing the eye to feel dry and irritated); other chronic allergic conjunctivitis (a long-term eye allergy that causes ongoing irritation and inflammation of the lining of the eye). During a review of Resident 76's H&P, dated [DATE], the H&P indicated the resident remained alert, oriented, and cooperative. During a review of Resident 76's MDS, dated [DATE], the MDS indicated the resident had memory problems and some difficulty in new situation. During an observation of Medication Cart (Med Cart) 2 on [DATE] at 1:28 p.m. with Licensed Vocational Nurse (LVN) 8, observed the following: 1. LVN 8 opened the top left drawer of the cart and observed there was no open date on Resident 76's Pataday eye drops and LVN 8 stated the eye drops need an open date because the eye drops are only good for 28 days. LVN 8 stated that with the eye drops not having an open date, staff will not know how long the drops have been opened and can cause Resident 76 eye irritation, redness or might not be effective. 2. LVN 8 open right middle drawer observed a facility stock bottle of Milk of Magnesia with no open date and other bottles of Milk of Magnesia had an open date. LVN 8 stated was not sure if multidose bottles need an open date. LVN 8 stated was going to find out. 3. LVN 8 opened the right upper drawer and observed keys with a black stretchy plastic band. LVN 8 stated that one of the keys was the narcotic key and should not have left it inside the medication cart. LVN 8 stated that the narcotic key is supposed to be always carried by the licensed nurse and by the end of shift passed on to the oncoming nurse. LVN 8 stated that if key is left behind anyone can grab the key and use it to open the narcotic drawer and possibly take medication. During an interview on [DATE], at 2:25 p.m., with Registered Nurse (RN) 1 stated that eye drops are supposed to have an open date because they are only good for 28 days after opening. RN 1 stated that the open date is needed to prevent infection contamination and maintain patency and if it does not have an open date then staff will not know if the eye drops are effective. During an interview on [DATE] at 9:50 a.m., with Chief Nursing Officer (CNO), CNO stated the eye drops need to have an open date because the eye drops are only good for 28 days after opening. The policy titled, Dating of Multidose Vials was reviewed and CNO stated that the policy was not followed. During an interview on [DATE], at 2:25 p.m., with Registered Nurse (RN), RN 1 stated that narcotic keys should not be left inside medication cart the licensed nurse always has to carry the key and give it to next shift nurse. RN 1 stated licensed nurse need to carry key because there are controlled substances (medication that has a risk for misuse, abuse, or addiction, so it is regulated by law) in the lock drawer and whoever gets the key they can open drawer and it becomes a safety risk, compromises the cart count, and there is a risk for diversion of narcotics. During an interview on [DATE] at 9:25 am with Pharmacist (Pharm) 2, Pharm 2 stated floor nurse keeps the narcotic key to the medication cart and is passed to next shift nurse. Pharm 2 stated that the licensed nurse needs to always carry the narcotic key and key should not have been left inside medication cart because anyone who has access to the cart can get the key and can get access to the narcotics. Pharm 2 stated that the policy titled Controlled Drugs, was not followed. During a review of Medication Cart (Med Cart) 3 on [DATE] at 1:45 p.m. with Licensed Vocational Nurse (LVN) 10, open the right middle drawer and observed a facility stock bottle of Milk of Magnesia with no open date. LVN 10 stated that liquid multidose bottles are supposed to have an open date. During an interview on [DATE] at 9:50 am with Chief Nursing Officer (CNO), CNO stated the Milk of Magnesia bottle needs to have an open date because it expires 60 days after open date according to manufacturer. 6a. During a record review of Resident 31's Face Sheet, the Face Sheet indicated the facility admitted the resident on [DATE], with diagnoses including history of right-side shingles with chronic neuropathy (a painful rash on one side of the body cause by a virus and the nerves on the right side of the body continue to cause pain, burning, tingling, or numbness even after the rash has healed). During a review of Resident 31's H&P, dated [DATE], the H&P indicated the resident was alert, oriented, calm, pleasant and cooperative. During a review of Resident 31's MDS, dated [DATE], the MDS indicated the resident can make self understood and had the ability to usually understand others. During a review of Resident 31's Pharmacy Orders, the Pharmacy Order Indicated Pregabalin (Lyrica) 50 mg, Give 50 mg (1 capsule) by mouth twice a day with an order of date [DATE]. During a review of Medication Storage and Labeling task in Med Storage 1on [DATE] at 1:30 p.m., with Registered Nurse (RN) 2 observed medication waste container not locked and observed inside container a bubble pack of Lyrica capsules for Resident 31 and Liraglutide injection. RN 2 stated that the medication waste container needs to be always locked because anyone can open the lid and get the medication that is inside the container and misuse it. During an interview on [DATE] at 9:25 am with Pharmacist (Pharm) 2, Pharm 2 stated that the medication waste container is supposed to be always locked so no one unauthorized can get any medications out of the container. Pharm 2 stated that the medication waste container is for medication vials, pills, and insulin pens. During a review of the facility's policy and procedure (P&P) titled, Dating of Multidose Vials, last reviewed on 4/2025, the P&P indicated that all multiple dose vials such as multi-dose injectable vials, eye drops, and insulin containing a preservative are given a consistent expiration date. The P&P further indicated: - Beyond Use Dating (BUD): - Commercially Prepared Unaltered Medications: Unless otherwise specified by the manufacturer, the BUD for any commercially prepared medication that has not been compounded, admixed, or otherwise altered, shall be the expiration date listed by the manufacturer. If the manufacturer had established a shorter BUD once the medication has been accessed, then that shall be be considered the BUD. - BUD for Multi-dose Vials: Unless otherwise specified by the manufacturer, the BUD for multi-dose medication vials with antimicrobial preservatives which have been opened or entered, is 28 days. If the manufacturer has established a shorter BUD once the medication has been accessed, then that shall be considered the start of the 28-day BUD. The BUD must be noted on the medication vial. - Procedure: 1. Date multi-dose vial after opening. 2. The person opening the vial should initial the vial. 3. 28 days from the date of opening, the vial will be discarded and deemed expired. During a review of the facility's Policy & Procedure (P&P) titled, Controlled Drugs reviewed on 6/2024, the P&P indicated storage areas must be kept locked at all times. Only persons licensed to administer controlled drugs can control the keys to the storage areas. The keys cannot be left in any area or special place for access but must be carried by someone licensed to administer controlled drugs.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by: 1. Failing to ensure a bag of shredded lettuce was not sealed and not labeled with an open date. 2. Failing to ensure the test strip used to check the sanitizing solution was not expired. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 97 out of 97 medically compromised residents who received food from the kitchen. Findings: During an observation while performing the initial kitchen tour on 7/13/2026 at 8:15 a.m. inside the walk-in produce refrigerator with the Director of Hospitality (DH), observed an open bag of lettuce and not labeled with an open date. The DH stated that the kitchen staff are supposed to seal and label items in the kitchen when opened. The DH stated that the facility has a new labeling machine that was implemented in the past year and that the kitchen staff were in-serviced on how to use them. The DH stated that the kitchen staff who opened the bag was supposed to seal the bag after when opened and labeled with the open date. The DH stated that if the bag of shredded lettuce was left open it could get contaminated and cause stomach issues with the residents. The DH stated that if the bag did not indicate a label with open date, the staff would not be able to know if the shredded lettuce was past the best by date. During an interview while conducting a follow up visit in the kitchen on 7/16/2026 at 11:35 a.m. with the Registered Dietitian (RD) in the nourishments or snacks preparation area. The RD stated that each kitchen staff have their own red bucket for the sanitizing solution to clean the preparation area surfaces when soiled and before and after each preparation. During a concurrent observation and interview on 7/16/2026 at 11:37 a.m. in the nourishments and snacks preparation area with Tray Line Worker (TLW) 1, TLW 1 demonstrated how to test the sanitizing solution by using the Quat Test Paper (QTP) 1 strip. When TLW 1 was asked to check the holder or case for the test QTP 1, the test strip case indicated an expiration date of 4/1/2026. TLW 1 stated that the test strip was expired and unable to tell the last time the test strip was used. TLW 1 stated that if the QTP 1 strip was expired, the result of the test would not be accurate and the sanitizing solution would not be effective in cleaning the surfaces and can lead to cross-contamination (transfer of harmful bacteria, allergens, or chemicals from one food, surface, piece of equipment, or person to another which can cause foodborne illnesses [an illness caused by consuming contaminated foods or beverages]). During a concurrent observation and interview on 7/16/2026 at 11:45 a.m., with the DH, The DH stated that the QTP 1 strip that TLW 1 attempted to use prior to testing the sanitizing solution had an expiration date of 4/1/2026. The DH stated that the tray line workers might just be replacing the roll of test strip when finished instead of using a new holder or container for the QTP 1 strip each time the test strip is changed. The DH stated that TLW 1 should have checked the expiration date on the test strip case prior to checking the quat for the sanitizing solution as the reading or result would not be accurate and not be effective in cleaning the surfaces and can cause cross-contamination. During an interview on 7/17/2026 at 1:35 p.m. with the Clinical Supervisor (CS), the CS stated that bag of shredded lettuce should have been sealed and labeled with an open date. The CS stated that if the bag of shredded lettuce was left open, the contents would be exposed to possible contaminants and get contaminated and cause stomach issues to the residents. The CS stated that the kitchen staff should have labeled the bag of shredded lettuce with an open date to ensure the staff would know when to discard. During a review of the facility's policy and procedure (P&P) titled, Sanitizing Food Contact Surfaces, last reviewed on 2/19/2026, the P&P indicated: - Each work area should be equipped with sanitizing solution. - Sanitize food contact surfaces after they have been thoroughly washed and rinsed. - Follow the instructions on the test strip package for the temperature of the solution when tested and the process that must be followed. - Use one of the following products: - Sanitizing Solution (SS) 1 at a concentration of 200-400 parts per million (ppm - measures the concentration of the active chemical in the mixture). - Other approved chemical sanitizer that is applied in accordance with manufacturer's usage directions. - Sanitizer test strips are readily available whenever sanitizer is dispensed - Red Buckets: - Use a clean bucket each time sanitizer solution is replaced - Change sanitizer solution whenever it becomes heavily soiled and/or falls out of the effective usage range (200-400 ppm). Best practice: change it out to a minimum of every two (2) hours. - Adhere to the concentration listed above. During a review of the facility's P&P titled, Food and Supply Storage, last reviewed on 2/19/20206, the P&P indicated all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. The P&P further indicated: - Most, but not all, products contain an expiration date. The words sell by, best-by, enjoy-by, or use by should precede the date. The sell by date is the last date that food can be sold or consumed; do not sell products in retail areas or place on patient trays/resident plates past the date on the product. Foods past the use by, sell by, best by, or enjoy by date should be discarded. - Cover, label and date unused portions and open packages. Use the Medvantage/Freshdate labeling system or complete all sections on an orange label. Products are goof through the close of business on the date noted on the label. - Date and rotate items; first in, first out. Discard food past the use-by or expiration date.

Based on observation, interview, and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for one of five sampled residents (Resident 5) for duloxetine (a psychotropic medication [any medication capable of affecting the mind, emotions, and behavior] classified as an anti-depressant [treats persistent feelings of sadness and loss of interest that can interfere with daily living]). This failure had the potential to result in the use of unnecessary psychotropic drugs resulting in adverse effects (an undesired and harmful result of a treatment or intervention, such as a medication or surgery) and a violation of Resident 5's right to make medical decisions regarding the use of psychotropic medications. Findings: During a review of Resident 5's Face Sheet (admission Record), the Face Sheet indicated the facility originally admitted the resident on 12/15/2022. During a review of Resident 5's History and Physical (H&P), dated 8/31/2025, the H&P indicated the resident's most recent admission was 9/6/2023 with diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), chronic pain, and depression (persistent feelings of sadness and loss of interest that can interfere with daily living). During a review of Resident 5's Minimum Data Set (MDS - resident assessment tool), dated 5/5/2026, the MDS indicated the resident usually was able to understand others and usually was able to make himself understood. The MDS further indicated the resident was dependent on staff for eating, oral and personal hygiene, toileting, bathing, mobility, and dressing. The MDS indicated Resident 5 was taking high risk antidepressant medication. During a review of Resident 5's Physician Orders, the Physician Orders indicated an order for the Duloxetine HCL, 30 milligrams (mg, a unit of measurement) one (1) capsule by mouth daily per physician recommendations for chronic musculoskeletal pain, dated 4/25/2026. During a review of Resident 5's Care Plan (CP) regarding the resident experienced an alteration in comfort related to complaints of back pain, dated 9/6/2023 with a target date of 8/31/2026, the CP indicated a goal that the resident would not exhibit untoward behavior such as agitation, irritability, and restlessness while awake with interventions that included to administer pain medication as ordered and monitor for psychotropic side effects of duloxetine including appetite changes, nausea, vomiting, diarrhea, falls, dry mouth, headache, anxiety, hypertension (HTN - high blood pressure), and insomnia. During an interview on 7/13/2026 at 3:41 p.m., observed Resident 5, in bed awake. Resident 5 stated he gets back pain. During a concurrent interview and record review on 7/16/2026 at 10:40 a.m., with Registered Nurse (RN) 1, reviewed Resident 5's physician orders and informed consent forms for psychotropic medication. RN 1 stated psychotropic medications are high risk medications that manage resident behaviors and affect the brain. RN 1 stated the physician obtains informed consent prior to the administration of psychotropics to ensure the residents and family are aware of the risks of taking the medication. RN 1 stated antidepressants are psychotropic medications. RN 1 then stated Resident 5 was prescribed and administered duloxetine, an antidepressant, for off label use for pain management and there was no documented evidence that informed consent was received for Resident 5's use of duloxetine. RN 1 stated she (RN 1) was not sure if informed consent was needed when duloxetine was administered for pain management. During a concurrent interview and record review on 7/17/2026 at 8 a.m. with the Chief Nursing Officer (CNO), reviewed the facility P&Ps regarding psychotropic medication and informed consent. The CNO stated duloxetine was a psychotropic medication and required informed consent be completed by the primary care provider prior to administration. The CNO stated it was an oversite that informed consent was not obtained for Resident 5's use of duloxetine because the medication was prescribed for pain management, but it should have been. The CNO stated the facility P&P was not followed when Resident 5 was administered duloxetine for pain management without being aware of the risks of the medication potentially resulting in possible adverse effects. The CNO stated when a psychotropic medication is used without informed consent it may potentially be considered the unnecessary use of psychotropics leading to a chemical restraint. During a review of the facility policy and procedure (P&P) titled, Psychotherapeutic Medication-Monitoring/Informed Consent, approved on 12/4/2025, the P&P indicated Psychotherapeutic drug is a drug to control behavior or to treat thought disorder processes, The use of psychotherapeutic medications in the Long Term Care setting shall be instituted only when resident's symptoms and behaviors have not responded to non-pharmaceutical approaches and with the informed consent of the resident and/or representative. Psychotherapeutic medication will never be administered for the use of discipline or nursing convenience. II. PROCEDURE. A. When psychotherapeutic drugs are used: 1. The lowest effective dose will be prescribed. 2. Residents will be monitored to determine the drug's effectiveness for the treatment of the stated condition and any adverse reaction 3. Medical Provider orders are to include the following elements: . e. Documentation of obtaining informed consent. During a review of the facility P&P titled, Obtaining Informed Consent, approved on 6/2017, the P&P indicated, This policy will establish guidelines and principles in obtaining an informed consent. each resident/patient has a right to have his or her cultural, psychosocial, spiritual, and personal values, beliefs, and preferences respected. informed consent be obtained by the physician prior to any . procedures considered high risk and any procedure for which informed consent is required by law. All conversations with patient, family or surrogate decision makers shall be documented in the medical record. If the individual is unable to make healthcare decisions (in the opinion of a medical doctor and/or psychiatrist), the appropriate surrogate may act as an agent on behalf of the individual. to be informed, the patient/resident must receive in understandable terms all information that would affect a reasonable decision to consent or refuse a treatment or procedure. During a review of the facility P&P titled, Patient Rights and Responsibilities, last reviewed on 9/2019, the P&P indicated Consistent with our Mission and Values, . supports the assurance of patient rights . These rights include the patient's right to: . to be free from psychotherapeutic drugs used as a chemical restraint as defined in Section 72018, except in an emergency which threatens to bring immediate injury to the patient or others. If a chemical restraint is administered during an emergency, such medication shall be only that which is required to treat the emergency condition and shall be provided in ways that are least restrictive of the personal liberty of the patient and used only for a specified and limited period of time.

Based on observation, interview, and record review, the facility failed to keep the call light (an alerting device for residents to call a nursing personnel to assist them when needed) within reach of the resident for two of two sampled residents (Residents 67 and 76). This failure had the potential to place Residents 67 and 76 at risk for delayed assistance, potentially affecting safety and timely care. Findings: 1. During a record review of Resident 67's Face Sheet (admission Record), the Face Sheet indicated the facility originally admitted the resident on 3/6/2024 and readmitted on [DATE], with diagnoses Alzheimer's disease, unspecified (a disease characterized by a progressive decline in mental abilities); Type 2 diabetes mellitus with other circulatory complications (a disorder characterized by difficulty in blood sugar control and poor wound healing that has caused problems blood circulation); unspecified glaucoma (an eye disease that can slowly damage vision because of increased pressure or damage to the optic nerve (the nerve that sends message to the brain of you can see). During a review of Resident 67's Minimum Data Set (MDS- a resident assessment tool), dated 5/9/2026, the MDS indicated the resident can make self understood and can understand others and had intact cognitive function (normal thinking). The MDS indicated that Resident 67's needed dependent to maximal assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a record review of Resident 67's Fall Risk Evaluation (FRE), dated 5/1/2026, the FRE indicated the resident was a low risk for falls. During a concurrent observation and interview on 7/13/2026, at 12:11 p.m., with Restorative Nurse Assistant (RNA) 1, inside Resident 67's room, observed the call light on top of the nightstand. RNA 1 observed call light on the nightstand and RNA 1 stated call light is not within reach of Resident 67. RNA 1 stated Resident 67 can potentially fall trying to reach for the call light. During a concurrent interview and record review on 7/16/2026, at 12:16 p.m. with Clinical Supervisor (CS), Resident 67's FRE was reviewed. CS stated Resident 67 was at risk for falls. CS stated that call light should always be within reach of Resident 67 so the resident can call for assistance. CS stated that if call light is not within reach, then Resident 67 can potentially fall trying to reach for call light. CS stated the facility's policy titled, Call Light, was not followed. 2. During a record review of Resident 76's Face Sheet, the Face Sheet indicated the facility admitted the resident on 6/30/2021, with diagnoses including hemiplegia following cerebral infarction affecting left nondominant side (a stroke (blocked blood flow in the brain) caused damage in the brain, leading to either weakness or complete loss of movement on the left side of the body); essential (primary) hypertension (high blood pressure with no known specific cause); type 2 diabetes mellitus with other circulatory complications (a disorder characterized by difficulty in blood sugar control and poor wound healing that has caused problems blood circulation) . During a review of Resident 76's History and Physical (H&P), dated 8/21/2025, the H&P indicated the resident remains alert, oriented, and cooperative. During a review of Resident 76's Minimum Data Set (MDS- a resident assessment tool), dated 6/6/2026, the MDS indicated the resident had memory problems and some difficulty in new situation. The MDS indicated that Resident 76 needed dependent to moderate assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a record review of Resident 76's FRE, dated 5/12/2026, the FRE indicated the resident was a high risk for falls. During a record review of Resident 76's Care Plan (CP) Report, the focus indicated Resident 76 was at risk for falls related to chronic stroke with left side hemiplegia as evidence by psychotropic (drugs that help treat mental health) or sedation medications, impaired vision (difficulty seeing), age greater than 70, impaired mobility. The CP Report indicated the goal is to eliminate or reduce the frequency of falls with an intervention of keep call light within reach. During a concurrent observation and interview on 7/13/2026, at 1:26 p.m., with Licensed Vocational Nurse (LVN) 8 in Resident 76's room, observed resident lying in bed, resident had a sling on left arm and call light was hanging down to the floor from the left upper siderail. Resident 76 stated that the call light should be within reach of the resident because resident can potentially fall trying to reach for the call light. LVN 8 stated the call light is hanging from left bed side rail and the resident would not be able to reach it to call for assistance. LVN 8 stated the resident would not be able to contact the staff and it could be an emergency. LVN 8 stated resident can potentially fall trying to reach for the call light. During a concurrent interview and record review on 7/16/2026, at 11:51 a.m. with Clinical Supervisor (CS), Resident 76's CP and FRE were reviewed. CS stated Resident 76 was a high risk for falls. CS stated call light should have been on the right side of Resident 76 so that resident would be able to call with arm that did not have a sling. CS stated the call light was not within reach of Resident 76 and resident could have fallen trying to reach for things or the call light. CS stated Resident 76's Care Plan and the facility's policy titled, Call Light was not followed. During a review of the facility's Policy and Procedure (P&P) titled, Call Light, last reviewed on 10/2025, the P&P indicated to alert nursing staff that resident has a request or need and to ensure resident has access to call light at all times. Procedure: 8. Ensure the call light is within reach of the resident. If the resident is ambulatory or mobile in a wheelchair, ensure that there is easy access to the call light.

Based on observation, interview, and record review, the facility failed to maintain a safe and comfortable homelike environment for one of one sampled resident (Resident 96) by not ensuring the floor mat was maintained in good condition or replaced when damaged. This failure had the potential for the damaged floor mat to create a trip hazard, increasing the risk for falls and possible injury for Resident 96. Findings: During a record review of Resident 96's Face Sheet (admission Record), the Face Sheet indicated the facility admitted the resident on 6/25/2015, with diagnoses including Alzheimer's disease, with early onset (a disease characterized by a progressive decline in mental abilities at a younger age than usual age); essential (primary) hypertension (high blood pressure with no known specific cause); depression, unspecified (a condition that causes sadness, loss of interest in activities, low energy, and changes in sleep, appetite, or concentration, can affect a person's feelings, thoughts, and daily activities). During a review of Resident 96's History and Physical (H&P), dated 2/25/2026, the H&P indicated the resident was alert and with continued slow/progressive cognitive and physical decline. During a review of Resident 96's Minimum Data Set (MDS- a resident assessment tool), dated 6/5/2026, the MDS indicated the resident rarely/never made self understood and rarely/never understood others and had severe cognitive impairment (very limited memory, thinking, decision-making and needs help with daily activities). The MDS indicated that Resident 96 needed dependent assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a record review of Resident 96's Nursing Orders, dated 4/16/2025, the Nursing Orders indicated an order for floor mat every shift (QSHIFT), Request Type: Stat Indication: Routine, Comments: Place floor mat on both sides of the bed when resident is in bed, mat may be removed and stored when resident is out of bed. Indication: Provide comfort and reduce impact from fall. During a record review of Resident 96's Fall Risk Evaluation (FRE), dated 6/5/2026, the FRE indicated the resident was a high risk for falls. During an observation on 7/13/2026, at 10 a.m., inside of Resident 96's room observed bilateral mats, one on each side of the resident's bed. The floor mat on the left side had some tears and the corner of the mat was torn, open, lifting, exposing the inner cushion. During a concurrent observation and interview on 7/17/2026, at 9:00 a.m., with Restorative Nurse Assistant (RNA) 3, inside of Resident 96's room observed the floor mat that had tears on the corner and on top of the floor mat. RNA 3 stated the floor mat should not have tears, the floor mat is not in good condition. RNA 3 stated the floor mat should have been replaced, the staff need to report it to central supply personnel so they can replace it. RNA 3 stated that people can trip on the tears of the floor mat. RNA 3 stated that the floor mat having tears does not provide a homelike environment for Resident 96. During an interview for Resident 96 on 7/17/2026, at 9:42 a.m., with Registered Nurse (RN) 1, RN 1 stated the floor mat was damaged and was not promoting homelike environment, can negatively impact Resident 96 on how the resident feels, and can potentially injure staff. During an interview for Resident 96 on 7/17/2026, at 9:50 a.m., with Chief Nursing Officer (CNO), the CNO stated the floor mat should not have been in that condition because it is damaged and it is not on their standards. CNO stated the floor mat will be replaced immediately. During a review of the facility's Policy & Procedure (P&P) titled, Patient Rights and Responsibilities, reviewed on 9/2019, the P&P indicated written policies regarding the rights of patients shall be established and shall be made available to the patient, to any guardian, next of kin, sponsoring agency or representative payee, and the public. Those policies and procedures shall ensure that each patient admitted to the facility has the following rights and is notified of the following facility obligations, in addition to those specified by regulation: (e) The facility shall be clean sanitary and in good repair at all times.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 79) was free from the use of chemical restraints (any drug that is used for discipline or staff convenience and not required to treat medical symptoms) by failing to ensure clonazepam (medication used to treat anxiety disorder [a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear)]) was prescribed, administered, and monitored for specific, measurable behavioral manifestations. This failure had the potential to result in the administration of unnecessary psychotropic medication (medications that affect the mind, emotions, and behavior) and placed residents at increased risk for adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to psychotropic medication therapy, such as sedation, drowsiness, dry mouth, blurred vision, muscle tremor, agitation, and possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status. Findings: During a review of Resident 79's History and Physical (H&P), dated 12/11/2025, the H&P indicated the resident was admitted on [DATE] with diagnoses that included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and hypertension (HTN - high blood pressure). During a review of Resident 79's Minimum Data Set (MDS - resident assessment tool) dated 6/12/2026, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident required supervision or touching assistance for staff for eating, oral and personal hygiene, toileting, bathing, mobility and dressing. The MDS further indicated that the resident was taking high risk medications that included an antianxiety medication. During a review of Resident 79's Physician Orders, the Physician Orders indicated orders for the following: - clonazepam, one (1) milligrams (mg - a unit of measurement), give 1 tablet by mouth daily at 6 p.m. Indication: anxiety manifested by (m/b) agitation, dated 2/2/2026. - clonazepam 0.25 mg, give o.25 mg (one tablet) by mouth every 24 hours as needed. Indication: anxiety m/b agitation, dated 7/1/2026. During a review of Resident 79's Care Plan (CP) regarding the resident's psychological condition and receives psychotropic medications, dated 12/11/2025 with a target date of 9/30/2026, the CP indicated a goal that the resident would have reduced incidents of mood or behavior changes and would be free of falls/injury while receiving the medication with interventions that included to monitor the frequency of exhibited mood / behaviors and to evaluate for effectiveness and side effects of medications for possible decrease / elimination of psychotropic drugs. During an interview on 7/16/2026 at 11:40 a.m., with Pharmacist (Pharm) 1 and Pharm 2, Pharm 2 stated psychotropic medications are considered high risk medications. Pharm 2 stated the goal of psychotropic medication administration is to help the residents become as comfortable as possible with the lowest effective dose of the medication. Pharm 1 stated the lowest effective dose is used to avoid over sedation potentially resulting in adverse effects like dizziness and falls. Pharm 1 stated this goal is achieved by analyzing and making recommendations based on the tallied behavior episodes that are documented and collected by the licensed nurses (LNs). During a concurrent interview and record review on 7/16/2026 at 12:07 p.m. with Licensed Vocational Nurse (LVN) 9, reviewed Resident 79's physician orders and Behavioral Monitoring form dated 7/2026. LVN 9 stated psychotropic behavioral episode monitoring is completed every shift and then tallied monthly by the LN. LVN 9 stated Resident 79 has orders for clonazepam daily and PRN for agitation. LVN 9 stated Resident 79 demonstrates agitation with demanding behaviors, and he verbalizes a desire to elope (leave the facility). LVN 9 stated the resident used to be monitored for verbalizing desire to elope and demanding behavior, but the monitoring changed on 7/12/2026. LVN 9 stated from 7/12/2026 until now, Resident 79 has only been monitored for agitation and not the behavioral manifestation of verbalizing a desire to elope and demanding behavior. During a concurrent interview and record review on 7/17/2026 at 9:30 a.m. with Registered Nurse (RN) 1, reviewed Resident 79's physician orders and Behavior Monitoring form dated 7/2026. RN 1 stated the facility process is psychotropic medications are ordered, administered, and monitored for resident specific behaviors. RN 1 stated it was important to indicate specific behavioral manifestations, so the LN knows when to administer PRN medication and so the LNs can effectively monitor the behavioral episodes with the goal to decrease the use of high-risk medication. RN 1 stated Resident 79's current orders and Behavioral Monitoring form indicated to monitor for agitation. RN 1 stated agitation is a broad term and agitation looks different in different residents. RN 1 stated agitation can manifest in some residents as pacing back and forth and others as yelling or harassing others. RN 1 stated when Resident 79 gets agitated he paces and verbalizes wanting to leave. RN 1 stated when clonazepam was ordered to be administered and monitored for agitation, the PRN order did not indicate the resident's specific behaviors and the monitoring was not for specific behaviors potentially resulting in the resident not receiving the appropriate treatment leading to the administration of unnecessary psychotropic medication. RN 1 stated it was important to not administer unnecessary psychotropic medication because there was a high risk for side effects leading to resident confusion and injuries. During a concurrent interview and record review on 7/17/2026 at 2:05 p.m. with the Clinical Supervisor (CS), reviewed the facility policy and procedures (P&P) regarding psychotropic medications. The CS stated psychotropic medications have the potential for side effects like psychomotor issues (unintentional and purposeless motions and restlessness) and drowsiness resulting in falls. The CS stated psychotropic medications should be administered and monitored for the focus behaviors a resident exhibits to ensure the resident is treated appropriately and unnecessary psychotropic medication is not administered. The CS stated Resident 79's clonazepam was ordered and monitored for agitation. The CS stated agitation was not specific enough to ensure that the LNs were administering PRN clonazepam for the appropriate behaviors and to ensure clonazepam was monitored for the same behaviors with a goal of decreasing the medication. The CS stated the facility P&P was not followed for Resident 79's PRN administration and monitoring for clonazepam. During a review of the facility P&P titled, Patient Rights and Responsibilities, approved on 9/2019, the P&P indicated Consistent with our Mission and Values (facility name) supports the assurance of patient rights . These rights include the patient's right to: . to be free from psychotherapeutic drugs used as a chemical restraint . During a review of the facility P&P titled, Psychotherapeutic Medication-Monitoring/Informed Consent, approved 12/4/2025, the P&P indicated Psychotherapeutic drug is a drug to control behavior or to treat thought disorder processes, The use of psychotherapeutic medications in the Long Term Care setting shall be instituted only when resident's symptoms and behaviors have not responded to non-pharmaceutical approaches and with the informed consent of the resident and/or representative. Psychotherapeutic medication will never be administered for the use of discipline or nursing convenience.II. PROCEDURE. A. When psychotherapeutic drugs are used: 1. The lowest effective dose will be prescribed. 2. Residents will be monitored to determine the drug's effectiveness for the treatment of the stated condition and any adverse reaction 3. Medical Provider orders are to include the following elements:. e. Indication Behaviorally specific manifestations i.e. psychoses manifested by disturbing delusions ll. PROCEDURE, BEHAVIOR MONITORING FOR PSYCHOTHERAPEUTIC MEDICATIONS. 2. Behaviors are documented by nursing on the electronic health record (EHR). Licensed vocational nurse (LVN) summarizes total monthly behavior count, it is then reviewed and signed by medical provider . 3. Behaviors are documented every shift by the LVN. 4. Behaviors are tallied monthly. 5. All medications will be reviewed quarterly in Resident Care Plan meeting and as needed.

Based on observation, interview, and record review, the facility failed to assess the risk of entrapment (an event in which a resident is caught, trapped, or entangled in spaces in or about the bed rail, mattress, or hospital bed frame) from bed rails/side rails (safety devices, typically metal or plastic bars, that attach to the sides of a bed to help prevent falls or provide support for residents) for one (1) of two (2) sampled residents (Resident 84) reviewed for physical restraints (are any action or procedure that prevents a person's free body movement to a position of choice and/or normal access to the body by the use of any method, attached or adjacent to a person's body that the person cannot control or remove easily) by failing to complete the bed rail risk assessment prior to use of bilateral bed rails. This failure placed Resident 84 at risk for potential accidents such as body parts being caught between the rails and falls that may occur if the resident attempts to climb over, around, between, or through the rails. Findings: During a review of Resident 84's Face Sheet, the Face Sheet indicated the facility admitted the resident on 12/30/2025. During a review of Resident 84's History and Physical (H&P), dated 12/30/2025, the H&P indicated Resident 84 had the capacity to understand and make decisions. The H&P further indicated that Resident 84 had bilateral legs (both legs) lymphedema (a long-lasting swelling caused by a block in the body's drainage system), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and anxiety disorder (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress). During a review of Resident 84's Minimum Data Set (MDS, a resident assessment tool), dated 6/30/2026, the MDS indicated Resident 84 had an intact cognition (mental action or process of acquiring knowledge and understanding) and was able to understand others and make her needs known. The MDS further indicated that Resident 84 required supervision or touching assistance with eating, partial or moderate assistance with oral hygiene, and total assistance from staff with all other activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 84's Physician's Orders, dated 6/26/2026, the Physician's Orders indicated a physician's order dated 3/4/2026 for bilateral bed rails. During a review of Resident 84's consent for the use of bed rails, dated 3/4/2026, the consent indicated the reason for use as a mobility enabler (a device, support, or intervention used to assist a resident or patient in moving, repositioning, or transferring, especially in bed or during ADLs) and signed by the resident representative. During a review of Resident 84's Bed Safety Assessment form, dated 3/3/2026, the Bed Safety Assessment form indicated a recommendation for use of left upper and right bed rails as a non-restraint. During a review of Resident 84's Bed Rail Risk Assessment, there was no documented evidence that the Bed Rail Risk Assessment was completed prior to installation of the bed rails. During a review of the Resident 84's interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the patients) care conference notes dated 3/3/2026, the IDT notes indicated a recommendation for the use of both upper bed rails for positioning assistance. During a review of Resident 84's Care Plan (CP) titled, At risk for injury and physical deconditioning, entrapment, skin tears, discoloration, and emotional distress initiated on 3/4/2026, the CP indicated IDT discussion on use of bed rails, identify the resident's specific risks associated with the use of bed rails, and assess the resident for risk of entrapment from bed rails prior to installation as a few of the interventions for Resident 84 to remain free of injuries and will not show any sign or symptoms of emotional distress. During a concurrent observation and interview on 7/13/2026 at 11;30 a.m., inside Resident 84's room, Resident 84 stated that the bed rails on both sides of the bed helps her when turning and repositioning, especially during ADL care. During a concurrent interview and record review on 7/17/2026 at 1:45 p.m. with Registered Nurse (RN) 2, reviewed Resident 84's physician's order, care plan, bed safety assessment, bed rail risk assessment, IDT notes, and the facility's untitled policy and procedure (P&P) on comprehensive clinical and behavioral assessments and P&P titled, Bed Safety. RN 2 stated that Resident 84 had a physician's order for the use of bilateral bed rails as enabler and a non-restraint, a bed safety assessment and IDT were completed on 3/3/2026 with a recommendation for the use of both upper bed rails for bed mobility and positioning assistance. RN 2 stated there was no Bed Rail Risk Assessment completed for Resident 84 prior to use of the bilateral bed rails. RN 2 stated that the untitled P&P about comprehensive assessments indicated that a bed safety assessment is completed upon admission, annually, and with change of condition and that the bed rail risk assessment is completed before initiating an order for bed rails then annually and with applicable change of condition. RN 2 stated that the P&P titled, Bed Safety, indicated that the resident should be assessed for risk of entrapment from bed rails or bed positioning prior to use. RN 2 stated that a bed safety assessment should be completed upon admission, annually, and with change in condition and the bed rail risk assessment is completed prior to initiation of the order to ensure the resident's safety prior to use of the bed rails. RN 2 stated the P&Ps were not followed which placed Resident 84 at risk for discomfort, entrapment, and other risks associated with the bed rail use. During an interview on 7/17/2026 at 2 p.m. with the Chief Nursing Officer (CNO), the CNO stated that the facility's untitled P&P on frequency of comprehensive clinical and behavioral assessments indicated that both the bed safety assessment and bed rails risk assessment are completed prior to initiation of the use of bed rails. The CNO stated that the bed safety assessment is to ensure that the resident is safe to use bed rails to determine their bed mobility and what type of bed rails to use. The CNO stated that after determination by the IDT the type of bed rails use for a resident, a bed rail risk assessment needs to be completed prior to use to assess the resident safety and risk for entrapment. The CNO stated that the facility missed the completion of Resident 84's bed rail risk assessment prior to use. The CNO stated that the facility's P&P was not followed and that Resident 84's bed rail risk assessment should have been completed prior to use to ensure that Resident 84 was safe and there was not risk of entrapment. During a review of the facility's P&P titled, Bed Safety, last revised on 9/2025 and approved by the governing body (a group of individuals or officials that holds ultimate authority and responsibility for overseeing the administration of an organization) on 12/4/2025, the P&P indicated that it is the policy of the facility to identify and reduce safety risks and hazards associated with bed use to achieve sustainable quality outcomes including individual bed rail evaluations to provide a safe, clean, comfortable, and homelike environment. The P&P further indicated: - Bed Rail/Bed Positioning: - The facility's priority is to ensure safe and appropriate bed rail use and to prevent entrapment and other safety hazards associated with bed rail use of bed positioning. - Bed rails may be utilized, and care planned with informed consent of the resident/resident representative and medical provider order to meet the individualized need. - Upon admission, annually and on a necessary basis, residents will be screened to include the level of independence with bed mobility, assess the need for special equipment or accessories such as bed rails, assess the resident to identify appropriate alternative prior to installing bed rails, and assess the resident for risk of entrapment from bed rails or bed positioning prior to use. During a review of the facility's untitled P&P on comprehensive clinical and behavioral assessments, with an effective date of 7/2026, the P&P indicated that the that the licensed nurses shall perform timely comprehensive, and ongoing clinical and behavioral assessments for all residents admitted to or receiving services within the skilled nursing facility. The P&P further indicated: - Bed Safety Assessment is completed upon admission, annually, and with applicable change in condition. - Bed Rail Risk Assessment is completed before initiating the order for bed rails then annually and with applicable change in condition.

Based on interview and record review, the facility failed to act upon the pharmacist's recommendation for one of five sampled residents (Resident 22) reviewed for Unnecessary Medications, Psychotropic (medications capable of affecting the mind, emotions, and behavior) Medications, and Medication Regimen Review (MRR-a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) care area by failing to follow-up with Resident 22's physician or medical provider regarding the consultant pharmacist's MRR recommendation. This failure placed Resident 22 at risk for receiving inappropriate medication, which could lower their well-being or increase the likelihood of adverse drug effects. Findings: During a review of Resident 22's Face Sheet, the Face Sheet indicated the facility admitted the resident on 4/16/2025. During a review of Resident 22's History and Physical (H&P), dated 4/28/2026, the H&P indicated Resident 22 was alert but disoriented to time and situation. The H&P further indicated that Resident 22 had diagnoses including dementia (a progressive state of decline in mental abilities), chronic pain on the neck and back, and polyneuropathy (a condition that involves damage to many nerves outside the brain and spinal cord causing numbness, tingling, and weakness in the hands and feet). During a review of Resident 22's Minimum Data Set (MDS, a resident assessment tool), dated 7/3/2026, the MDS indicated that Resident 22 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) but had the ability to understand others make her needs known. The MDS further indicated that Resident 22 required supervision or touching assistance with eating, total assistance with bathing self, partial or moderate assistance with oral hygiene, bed mobility, and transfers, and substantial/maximal assistance with all other activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 22's Physician's Orders dated 6/26/2026, the Physician's Orders indicated an order for: - 7/23/2025: loperamide hydrochloride (also known as Imodium, a medication used to control and relieve symptoms of acute [sudden or short term] and chronic [long-lasting or constantly recurring] diarrhea) two (2) milligrams (mg - a unit of measurement) by mouth 2 times a day as needed if more than 2 loose stools for chronic diarrhea During a review of Resident 22's electronic medication administration records (eMAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of 5/2026, 6/2026, and 7/2026, the eMAR did not indicate that Resident 22 received loperamide hydrochloride. During a review of Resident 22's Pharmacy Monthly Chart Review form dated 6/24/2026, the Pharmacy Monthly Chart Review form indicated a recommendation to consider discontinuing loperamide due to not being used. During a review of Resident 22's medical provider's notes dated 7/1/2026, 7/2/2026, 7/6/2026, and 7/15/2026, the medical provider's notes did not address the pharmacist's recommendation to consider discontinuing the loperamide hydrochloride. During an interview on 7/16/2026 at 12:06 p.m. with Pharmacist (Pharm) 2, Pharm 2 stated the medical providers are quick to respond in addressing any pharmacist recommendations to discontinue certain medications. Pharm 2 stated that if there was a pharmacist recommendation to discontinue Resident 22's loperamide on 6/24/2026, it should have been addressed already by the medical provider. During a concurrent interview and record review on 7/17/2026 at 1:02 p.m., reviewed Resident 22's physician's orders, eMAR, Pharmacy Monthly Chart Review, and medical provider's notes with Registered Nurse (RN) 2. RN 2 stated that the Pharmacy Monthly Chart Review dated 6/24/2026 indicated a recommendation to consider discontinuing loperamide hydrochloride. RN 2 stated that Resident 22's medical provider's notes dated 7/1/2026, 7/2/2026, 7/6/2026, and 7/15/2026 did not address the pharmacy recommendation. RN 2 stated the medical providers are in the facility five (5) days a week. RN 2 stated that the medical providers had seen Resident 22 three (3) times since 6/24/2026 and reviewed the chart and should have addressed the pharmacy recommendation as the resident had a medication that is no longer needed. During a concurrent interview and record review on 7/17/2026 at 2 p.m., reviewed Resident 22's Pharmacy Monthly Chart Review dated 6/24/2026 and the medical provider's notes with the Chief Nursing Officer (CNO). The CNO stated that Resident 22's Pharmacy Monthly Chart Review indicated a recommendation to consider discontinuing the loperamide hydrochloride and was not addressed or acted upon by the medical providers. The CNO stated that the medical providers are in the facility 5 times a week and should be able to review the pharmacy recommendations in the electronic medical record (EMR). The CNO stated that Resident 22's pharmacist recommendation to discontinue the loperamide should have been addressed already as the resident had a medication that is no longer necessary. During a review of the facility's policy and procedure (P&P) titled, Drug Regimen Review, last reviewed on 3/2024 and approved by the governing body (a group of individuals or officials that holds ultimate authority and responsibility for overseeing the administration of an organization) on 6/2024, the P&P indicated that a pharmacist reviews each resident's EMR and checks medication orders for completeness and appropriateness using his clinical expertise in complying with the regulatory requirements. The P&P further indicated: - The drug regimen of each resident is assessed for appropriate medication use. - The pharmacist communicates in writing with the prescribers and nursing staff to note opportunities for drug therapy improvements via the Pharmacy Monthly Chart Review note in the EMR. - The pharmacist will follow up to determine that there is evidence that the prescriber responds to concerns raised by the Drug Regimen Review process. - Medications are discontinued when there is evidence that the resident has not taken the drug for some time and the drug could therefore be discontinued. - As needed drugs not used in the last 30 days will be re-evaluated for need and any unnecessary drugs will be discontinued.

Based on observation, interview, and record review, the facility failed to honor resident dietary preferences for one of six sampled residents (Resident 23) reviewed during the Dining Observation task by failing to ensure the resident was provided milk and a banana for lunch on 7/13/2026. This failure had the potential to result in resident dissatisfaction leading to psychosocial issues resulting in decreased meal intake and unintentional weight loss. Findings: During a review of Resident 23's History and Physical (H&P), dated 11/25/2025, the H&P indicated the resident was admitted [DATE] with diagnoses that included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), coronary artery disease (the buildup of plaque in the heart's arteries), and depression (persistent feelings of sadness and loss of interest that can interfere with daily living). During a review of Resident 23's Minimum Data Set (MDS - resident assessment tool) dated 7/10/2026, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident required supervision or touching assistance from staff for eating, oral and personal hygiene, toileting, bathing, mobility and dressing. During a review of Resident 23's Nutrition Risk Assessment (NRA), dated 10/20/2025, the NRA indicated the resident was at risk for weight loss due to dementia and depression. The NRA further indicated to provide the diet as ordered and monitor food intake During a review of Resident 23's Care Plan (CP) regarding nutrition, dated 11/29/2023, the CP indicated the resident had chronic conditions that may affect nutrition. The CP indicated a goal with a target date of 10/30/2026 that Resident 23 would be able to have the highest level of quality of life possible within the disease limitations. During a review of Resident 23's Monday Lunch Meal Ticket, the Monday Lunch Meal Ticket indicated Personal Menu Items: one (1) banana and 8.0 fluid ounces (fl. oz - a unit of measurement) whole milk. During a dining observation on 7/13/2026 at 12:24 p.m., with Resident 23, observed Resident 23 sitting at a dining table near HH East Nursing Station with the lunch tray in front of the resident. Resident 23 stated he did not always get the food he requested. Resident 23 stated for example, today he asked for a banana and milk and did not receive it. Reviewed the resident's Monday Meal Ticket indicated Personal Menu Items: 1 banana and 8.0 fl. oz whole milk and observed the resident's tray did not include a banana or milk. During a concurrent observation, interview, and record review on 7/13/2026 at 12:40 p.m., with Certified Nursing Assistant (CNA) 2, reviewed Resident 23's Monday Meal Ticket. CNA 2 stated the meal ticket indicated Resident 23 requested a banana and milk and the tray did not have a banana or milk on it. Observed CNA 2 then walked away to assist another resident. During an interview on 7/13/2026 at 12:45 p.m., with CNA 1, CNA 1 stated all the items on the meal ticket should be on the tray provided by the kitchen. CNA 1 stated sometimes the kitchen forgets to provide items on the meal tray and the CNA should call the kitchen to get the missing food. CNA 1 stated she had not called the kitchen for any missing items today. CNA 1 stated she provided Resident 23 his lunch tray and did not notice that anything was missing. During a concurrent observation, interview, and record review on 7/13/2026 at 12:48 p.m., with Restorative Nurse Assistant (RNA) 2, reviewed Resident 23's Monday Meal Ticket. RNA 2 stated when items are listed on the meal ticket, the kitchen should provide the items on the tray. RNA 2 stated Resident 23's meal ticket indicated a banana and milk, but a banana and milk were not provided. RNA 2 then walked down the hall to assist another resident and then returned and removed the resident's tray after the resident stated he was done eating. Observed RNA 2 did not call the kitchen to request the missing banana and milk. During a concurrent observation and interview on 7/13/2026 at 1 p.m., with CNA 1, in the hallway outside Resident 23's room, CNA 1 stated the kitchen should have provided Resident 23 with the banana and milk, but they did not. Observed CNA 1 entered Resident 23's room and asked the resident if he still wanted the banana and milk and the resident replied yes. CNA 1 stated she would call the kitchen to provide the banana and milk because it was the kitchen's fault for not providing them. During a concurrent interview and record review on 7/16/2026 at 8:27 a.m., with the Director of Hospitality (DH), reviewed the Policy and Procedure (P&P) regarding meal service. The DH stated the facility process is residents have the right to request food items. The DH stated the day prior to the meal service that the staff make rounds to review the menu and speak with the residents regarding their preferences. The DH stated when it is identified by a CNA that food is missing, they are responsible for calling the kitchen to ensure the food is provided. The DH stated Resident 23 had a request for a banana and milk for the 7/13/2026 lunch and the resident should have been provided with those items at lunch but was not. The DH stated the P&P was not followed when Resident 23 was not provided with a banana and milk during lunch potentially creating an issue with the resident that triggers behavioral symptoms that may negatively affect the resident's psychosocial wellbeing. During a review of the facility P&P titled, RESIDENT MEAL SERVICE, last revised 1/2026, the P&P indicated, Provide each resident with a nourishing, palatable, well-balanced, attractive meal, at a safe and appetizing temperature that meets their daily nutritional needs. Residents will be offered menu choices for all meals, beverages and snacks and are based on their prescribed diet, food preferences, allergies, intolerances, preferences and consistent with their plan of care. Promote independence and dignity by respecting each individual's culture, religious and ethnic preferences, and preferred dining schedule served in an environment that is as home-like as possible. PROCEDURES. Menu Choices.Offer choice and honor resident rights. Allow resident, family, resident representative and/or staff may make menu selections in advance based on food preferences and diet prescription. Meal Service and Dignity in Dining guidelines: . Provide dining in a home like environment that is appealing, safe and clean: .Utilize Menu tickets and/or diet extension report during meal service to ensure meal accuracy and resident safety.Monitor meals service to ensure timeliness and appropriateness. During a review of the facility provided Resource titled, Standard of Practice for Individualized Honoring Choices, dated 8/2011, the Resource indicated, Residents have the right to make an informed choice regarding their diet. The interdisciplinary team should work closely to develop a system promoting resident choice while maintaining quality of care. Choices with meaningful options in accordance with the person's preferences are offered to each resident numerous times daily.

Based on observation, interview, and record review, the facility failed to properly document the medical record for one of three sampled residents (Resident 66) by failing to accurately document resident's weight and documented 220 pounds (lbs., the standard unit of weight to measure how heavy something or someone is) on 3/07/2026. This failure has the potential to result in incomplete, inaccurate, or delayed records that could lead to miscommunication between healthcare providers and resident harm for Resident 66. Findings: During a review of Resident 66's Face Sheet (FS), the FS indicated the facility admitted the resident on 1/08/2026, with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), hyperlipidemia (high levels of fats in the blood), and dysphagia (difficulty swallowing) During a review of Resident 66's History and Physical (H&P), dated 1/08/2026, the H&P indicated that the resident has inability to comprehend and follow simple commands. During a review of Resident 66's Minimum Data Set (MDS, a resident assessment tool), dated 5/29/2026, the MDS indicated the resident was dependent (helper does all the effort) on all activities of daily living (ADLs, routine task/activity such as bathing, dressing and toileting a person performs daily to care for themselves), with substantial/maximal assistance (helper does more than half the effort) with transfers and repositioning. During a review of Resident 66's Care Plan (CP) titled, Nutrition/hydration dated 1/08/2026, the CP indicated interventions including monthly weights every month (.) and received and accept necessary assistance during and between meals with food and fluids. During a concurrent interview and record review on 7/17/2026 at 8:10 a.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated that one of the CNAs responsibilities is to weigh residents based on the order, if weekly or monthly weigh checks. CNA stated after weighing the resident, she informs the nurse in charge of the resident, or she documents it herself in the electronic chart. CNA 1 stated that any questionable weight gain or weight loss must be rechecked and reported to the supervisor. CNA 1 stated that CNA 1 stated that documentation needs to be accurate because it will show in the medical record. During a concurrent interview and record review on 7/17/2026 at 8:12 a.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated weights are documented by CNAs or LVNs in the electronic chart. LVN 1 upon record review of Resident 66's electronic chart stated the weight documented in the electronic chart on 3/07/2026 must be an error when the weight shown on the following 2/11/2026 of 127.2 lbs. / 57.70 kg; on 3/07/3036 222.0 lbs. / 100.70 kg; on 3/10/2026 124.6 lbs. / 56.52 kg; and on 4/01/2026 122.4 lbs. / 55.52 kg. LVN 1 stated there was no documentation that it was charted as an error and should have been corrected right away. LVN 1 stated documentation in electronic chart is important for residents to get appropriate care plans. During a concurrent interview and record review on 7/17/2026 at 10:01 a.m. with the Registered Dietician (RD), the RD stated that the documentation of 220 lbs. on 3/07/2026 for Resident 66 must be an error. The RD stated that documentation is important because it is a medical record. The RD stated the weight must be accurately documented to see if the weight gain is caused by edema, nutrition, or side effects of medication. The RD further stated that improper documentation could lead to not catching the real picture of nutritional status of the residents. During an interview and record review on 3/17/2026 at 2:25 p.m. with the Clinical Supervisor (CS), the CS stated that documentation is important because the treatment and plan of care is based on the documentation. The CS stated that the error in documentation of Resident 66's weight should have been corrected and should not have been ignored. The CS stated that the policy in documentation was not being followed. During a review of the facility's Policy and Procedures (P&P), titled Documentation, Nursing Weekly Summary reviewed on 12/04/2025, the P&P indicated to provide an accurate and concise summation of the resident's health status and review the Plan of Care. All areas of the Nursing Weekly Summary must be completed. Documentation of the Weekly Summary is completed in the Electronic Health Record (EHR). The Narrative Summary will include any changes of condition that have occurred in that week.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to implement the facility policy and procedure for one randomly observed resident (Resident 37) when Certified Nursing Assistant (CNA) 6 failed to doff (remove) disposable gloves and perform hand hygiene (HH - process of cleaning hands using soap and water or antibacterial hand rub) prior to exiting the resident's room after providing care with lift equipment (device used to assist with resident transfers). This failure had the potential to result in the spread of infectious microorganisms amongst staff, residents, and visitors. Findings: During a review of Resident 37's History and Physical (H&P), dated 1/7/2026, the H&P indicated the resident was admitted [DATE] with diagnoses that included heart failure (HF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), and hypertension (HTN - high blood pressure) During a review of Resident 37's Minimum Data Set (MDS - resident assessment tool) dated 7/7/2026, the MDS indicated the resident was able to understand others and was able to make herself understood. The MDS further indicated that the resident was dependent on staff for eating, oral and personal hygiene, toileting, bathing, and mobility. During an observation on 7/16/2026 at 3:50 p.m., observed CNA 6 in the hallway at MP [NAME] Nursing Station wearing disposable blue gloves. Observed CNA 6 obtained the lift equipment from the hallway and walked toward MP East Nursing Station. During a concurrent observation and interview on 7/16/2025 at 4:06 p.m. with CNA 6, observed CNA 6 exited Resident 37's room without performing HH and wearing blue disposable gloves while pushing the lift equipment down the hall. Observed CNA 6 placed the lift equipment at the side of the hallway, walked away from the lift equipment toward MP East Nursing Station, then removed the disposable gloves and placed them in the trash bin. CNA 6 stated she used the lift equipment to place Resident 37 in bed. CNA 6 stated she did not remove the gloves and perform hand hygiene after placing the resident in bed and exiting the room. CNA 6 then stated she wore disposable gloves in the hallway after providing care to Resident 37, but she should not have. CNA 6 stated it was important to remove the gloves and perform HH before exiting the resident's room for infection control and to prevent contamination from Resident 37's room to other residents. During an interview on 7/16/2026 at 4:20 p.m. with Registered Nurse (RN) 1, RN 1 stated gloves are considered dirty after providing resident care and should be immediately removed with HH performed prior to exiting the resident's room for standard precautions (an infection control measure aimed to prevent spread of infection). RN 1 stated disposable gloves should never be worn in the facility hallways after exiting a resident's room. RN 1 stated when CNA 6 did not follow standard precautions to remove the gloves and perform HH after providing care to Resident 37 and prior to exiting the room with the lift equipment, there was the potential for the spread of infections among staff and residents. During a concurrent interview and record review on 7/17/2026 at 2:05 p.m. with the Clinical Supervisor (CS), reviewed the facility policy and procedures (P&P) regarding HH, glove use, and standard precautions. The CS stated the facility P&P was not followed when CNA 6 did not remove used disposable gloves and perform hygiene prior to exiting Resident 34's room potentially resulting in resident infections when the CNA touched surfaces outside of the resident's room like the lift equipment that would then be used on other residents. During a review of the facility P&P titled, Hand Hygiene, last reviewed 10/2025, the P&P indicated, PURPOSE. To reduce the incidence of healthcare-associated infections. DEFINED. 1. Hand Hygiene is defined as the following: handwashing, or alcohol-based hand rub (ABHR). 1. All healthcare staff should comply with hand hygiene practices as defined in this policy. It is the single most important procedure for preventing healthcare associated infections . 3. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in the following clinical situation:. E. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient/resident. During a review of the facility P&P titled, Infection Precaution Techniques, last reviewed 10/2025, the P&P indicated, The policies and procedures for precaution techniques specify the minimal essential practices necessary for preventing transmission of infections. Hand hygiene is the single most important procedure for preventing HCA (healthcare-associated) infections. 2. Hand Hygiene using an alcohol-based hand gel should be utilized (when hands are not visibly soiled) in the following situations: . F. Any situation where microbial contamination of the hands is like to occur. 3. Hand Hygiene should be utilized, even when gloves are used. Hands hygiene should always be performed after glove removal. TO REMOVE GLOVES: Pull off from the cuff, turning inside out as they are removed. Wash hands or use hand gel before leaving the room. During a review of the facility P&P titled, LISTING OF CATEGORY-SPECIFIC ISOLATION PRECAUTION TECHNIQUES, last reviewed 10/2025, the P&P indicated, A. Standard Precautions: . Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals. 2. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands after direct or indirect contact with the patient/resident and their environment.Gloves. Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another patient, and wash hands immediately to avoid transfer of microorganisms to other patients or environments.

Based on interview and record review, the facility failed to complete an inventory of one of one sampled resident's (Resident 1) home medication. This deficient practice resulted in Resident 1's home medication mismanagement; in addition, failure to inventory a patient's home medication upon admission to a facility creates a high risk of lost belongings, medication omissions, and discrepancies in treatment.During a review of Resident 1's History and Physical (H&P, a comprehensive assessment of a patient's medical history and physical examination), dated 12/11/2025, the H&P indicated Resident 1 was admitted to the Skilled Nursing Facility (SNF, a licensed facility that provides 24/7 high-level nursing and rehabilitative care for short-term recovery or chronic conditions) 1 on 12/11/2025, having been diagnosed with dementia (a progressive syndrome characterized by a decline in memory, thinking, behavior, and functional ability). The H&P also indicated Resident 1 was prescribed Norco (a prescription combination medication containing hydrocodone, a potent opioid pain reliever and acetaminophen, a non-opioid pain reliever, and is used to treat moderate to severe pain) and Klonopin (a prescription benzodiazepine used to treat panic disorder and certain seizure disorders).During a review of Resident 1's Resident Belongings/ Valuables - admission Inventory (a document used by SNF to inventory and safeguard a resident's personal effects and property), dated 12/11/2025, the admission Inventory did not reflect any inventory of Resident 1's home medications. The form was unsigned and noted that Resident 1 was unable/refused to sign.During an interview on 3/12/2025 at 11:55 A.M. with the Chief Nursing Officer (CNO1), CNO1 stated that Resident 1 was a transfer from an assisted facility last December. Resident 1 came with his belongings and valuables, including his home medications. CNO1 stated Resident 1's daughter came by a couple of days after, and Resident 1's home medications were returned to Resident 1's daughter. CNO1 stated Resident 1's daughter, a day or two afterward, made claims that Resident 1's medications were not returned to her. CNO1 added that the Nurse Practitioner who admitted Resident 1 reviewed Resident 1's home medication and took them to the pharmacy. CNO1 stated the facility did this to check if there was any medication not available in the pharmacy to dispense so they could temporarily use residents' home medication if ordered. CNO1 further stated none of Resident 1's home medication was needed as it was all available in the pharmacy; the pharmacy kept Resident 1's home medication and the home medication was later given back to Resident 1's daughter a few days later. CNO1 stated none of Resident 1's home medications were inventoried or documented.During an interview on 3/12/2025 at 12:10 A.M. with the Director of Risk Management (DRM1), DRM1 stated that the typical practice when a resident arrives with home medication was that it went to nursing staff and pharmacy for review, then it be given back to family. DRM1 stated the facility did not keep home medication; in the case of Resident 1, Resident 1's daughter came by, and all the home medication was handed back to her by the social worker. DRM1 stated Resident 1's home medications were kept in pharmacy for storage and the pharmacy did not inventory or document Resident 1's home medication. DRM1 added that it was not the facility's practice to include and document residents' home medication in the Resident Belongings and valuables form (a document used by SNF1 to inventory and safeguard a resident's personal effects and property). At that time, the facility had no separate process in place to track, inventory, or document patient home medication. During a review of the facility's policy and procedures (P&P), titled Use of Patient-Supplied Medications, with last revised date of 12/2025, the P&P indicated, When medications are brought in at admission: (a) they will be returned to the family/responsible party whenever possible; (b) if no responsible party is present, the medications will be transferred in a tamper-evident bag to Pharmacy, where unit staff and the pharmacist will jointly verify and count, document receipt in a log, and secure the medications until return to family or destruction is authorized.During a review of the facility's P&P, titled Inventory of Personal Effects, with last revised date of 7/2019, the P&P indicated the following: When a resident is admitted to the facility, an inventory of the resident's personal effects shall be done by a staff member of the facility. The inventory should include the recording of all personal clothing, valuable articles, etc. which are brought into the facility with the resident and retained by the resident. These personal effects shall be recorded on the Resident Belongings and valuables form or in EHR (Electronic Health Record). When any personal item which may have a direct or indirect bearing on the resident's health and safety is brought into the facility for a resident after admission, the item shall be recorded in resident belonging list.

Based on interview and record review, the facility failed to ensure the resident rights for one resident (Resident 1), were upheld and ensured their right to receive care in a safe environment.This failure resulted in physical harm to Resident 1 by a facility staff employee with the potential to have resulted in serious injury to Resident 1.Findings:During a review of Resident 1's History and Physical (H&P), dated 4/16/2025, the H&P indicated, Resident 1 admitted to the facility on [DATE] due to dementia (a progressive state of decline in mental abilities). Resident 1 had a past medical history of multiple Venous thromboembolism (VTE - is a medical condition where a blood clot forms in blood vessel), chronic kidney disease (CKD - condition where kidneys are damaged progressively and irreversibly), fibromyalgia (a chronic condition characterized by widespread muscle pain and fatigue) and spinal stenosis (a painful condition where the spaces within spine narrow).During an interview on 8/4/2025 at 11:55 AM with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated, he had witnessed on 6/30/2025 at approximately 11:05 PM, Certified Nurse Assistant 2 (CNA 2), forcefully assist Resident 1 to the commode. CNA 1 stated he witnessed CNA 2 become frustrated while assisting Resident 1 to the commode, in which he witnessed CNA 2 manhandle Resident 1 in her armpits and slam her to the commode with aggressive and excessive force.During an interview on 8/4/2025 at 1:39 PM with the Director of Risk Management and Regulatory Affairs (DRM), the DRM stated the facility found CNA 2's behavior to have raised to a level of misconduct due to the rough handling of Resident 1.During a review of Resident 1's document titled California Standard admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities, dated 4/18/2025, the document indicated, Your Rights as a Resident[:] Residents of this Facility keep all their basic rights and liberties as a citizen or resident of the United Stated when, and after, they are admitted . Attachment F, entitled Resident [NAME] of Rights, lists your rights, as set forth in State and Federal law.During a review of the facility's document titled, Attachment F Resident [NAME] of Rights, undated, indicated, Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated . Patients shall have the right . To be free from mental and physical abuse . To be treated with consideration, respect.

Based on interview and record review, the facility failed to enforce for one resident (Resident 1), their own policy and procedures regarding abuse prevention and reporting.This failure resulted in Resident 1 to be in an unsafe environment due to continued exposure to an alleged perpetrator.Findings:During a review of Resident 1's History and Physical (H&P), dated 4/16/2025, the H&P indicated, Resident 1 admitted to the facility on [DATE] due to dementia (a progressive state of decline in mental abilities). Resident 1 had a past medical history of multiple Venous thromboembolism (VTE - is a medical condition where a blood clot forms in blood vessel), chronic kidney disease (CKD - condition where kidneys are damaged progressively and irreversibly), fibromyalgia (a chronic condition characterized by widespread muscle pain and fatigue) and spinal stenosis (a painful condition where the spaces within spine narrow).During an interview on 8/4/2025 at 11:55 AM with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated, he had witnessed on 6/30/2025 at approximately 11:05 PM, Certified Nurse Assistant 2 (CNA 2), forcefully assist Resident 1 to the commode. CNA 1 stated he witnessed CNA 2 become frustrated while assisting Resident 1 to the commode, in which he witnessed CNA 2 manhandle Resident 1 in her armpits and slam her to the commode with aggressive and excessive force.During a review of Resident 1's medical record titled Nursing Note, dated 7/8/2025, the record indicated Resident 1 had a physical assessment completed with no injuries or discoloration noted on her body.During an interview on 8/4/2025 at 1:39 PM with the Director of Risk Management and Regulatory Affairs (DRM), the DRM stated the facility found CNA 2's behavior to have raised to a level of misconduct due to the rough handling of Resident 1.During a concurrent interview and record review, on 8/4/2025 at 12:29 PM with the DON, CNA 2's Employee Timecards, dated multiple dates was reviewed. The timecard indicated, CNA 2 had worked:- On 6/30/2025, from 11:00 PM to 7:30 AM- On 7/2/2025, from 11:00 PM to 7:30 AM- On 7/3/2025, from 11:00 PM to 7:30 AM- On 7/4/2025, from 11:00 PM to 7:30 AM- On 7/6/2025, from 3:00 PM to 11:30 PM and 11:30 PM to 7:23 AM.The DON stated CNA 2 should had been suspended the same day the incident occurred with Resident 1 on 6/30/2025 without any delay. The DON stated that by waiting the facility left Resident 1 exposed to the possibility of further abuse from CNA 2.During a review of the facility's document titled Code of Conduct, undated, the document indicated, Patients and residents shall be treated at all times with care, concern and respect.During a review of CNA 2's document titled Code of Conduct Employee Acknowledgement, dated 12/15/2017, the document indicated, CNA 2 received a copy of the facility's Code of Conduct and acknowledged an understanding to adhere to the Code of Conduct.During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention and Reporting (Suspected Elder and Dependent Adult Abuse and Neglect, dated 3/6/2025, indicated, VIII. Protection[,] During the course of an investigation, the patient and/or resident will be protected from possible harm by the suspected abused. If the suspected abused is an employee, that employee will be suspended.During a review of the facility's P&P titled, Corrective Action Disciplinary Procedures, dated 9/4/2020, indicated, Investigatory Suspension[:] An employee may be placed on a n investigatory leave, with or without notice, to permit [name of facility] to review or investigate actions including . acts endangering patients or others, or other conduct which warrants removing the employee from the work site.

Based on interview and record review, the facility failed to report the alleged abuse incident of one resident (Resident 1), in accordance with facility policy.This failure resulted in delayed investigation of the incident by the state agency and law enforcement that may have a negative impact on the care and treatment received by patient.Findings:During a review of Resident 1's History and Physical (H&P), dated 4/16/2025, the H&P indicated, Resident 1 admitted to the facility on [DATE] due to dementia (a progressive state of decline in mental abilities). Resident 1 had a past medical history of multiple Venous thromboembolism (VTE - is a medical condition where a blood clot forms in blood vessel), chronic kidney disease (CKD - condition where kidneys are damaged progressively and irreversibly), fibromyalgia (a chronic condition characterized by widespread muscle pain and fatigue) and spinal stenosis (a painful condition where the spaces within spine narrow).During an interview on 8/4/2025 at 11:55 AM with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated, he had witnessed on 6/30/2025 at approximately 11:05 PM, Certified Nurse Assistant 2 (CNA 2), forcefully assist Resident 1 to the commode. CNA 1 stated he witnessed CNA 2 become frustrated while assisting Resident 1 to the commode, in which he witnessed CNA 2 manhandle Resident 1 in her armpits and slam her to the commode with aggressive and excessive force.During a review of Resident 1's medical record titled Nursing Note, dated 7/8/2025, the record indicated Resident 1 had a physical assessment completed with no injuries or discoloration noted on her body.During an interview on 8/4/2025 at 1:39 PM with the Director of Risk Management and Regulatory Affairs (DRM), the DRM stated the facility found CNA 2's behavior to have raised to a level of misconduct due to the rough handling of Resident 1.During a concurrent interview and record review, on 8/4/2025 at 12:29 PM with the Director of Nursing (DON), the facility's document titled, Fax, dated 7/8/2025 was reviewed. The document indicated the facility had reported the incident to licensing agency, local law enforcement and ombudsman via fax message on 7/8/2025. The DON stated the facility reported the incident late; she stated the report should have been made to the licensing agency within 24 hours of the incident occurring on 6/30/2025. The DON also stated the facility should have reported this incident to law enforcement via telephone call within 24 hours of the incident occurring on 6/30/2025, in addition to, the faxed written report sent to law enforcement.During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention and Reporting (Suspected Elder and Dependent Adult Abuse and Neglect, dated 3/6/2025, indicated, VI. Reporting/Response . If the suspected abuse does not result in serious bodily injury:1. A telephone report shall be made to the local law enforcement within 24 hours.2. Within 24 hours, a written report shall be made to local ombudsman, corresponding licensing agency (CDPH) and local law enforcement.

Based on interview and record review, the facility failed to ensure the residents and/or responsible party (RP) were informed in advance, of the risks and benefits of psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior) for two of two sampled residents (Residents 21 and 3) reviewed for informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) by failing to ensure: 1. Resident 21's lorazepam (also known as Ativan, a drug that is used to treat anxiety and certain seizure disorders), mirtazapine (also known as Remeron, an antidepressant medicine), escitalopram (also known as Lexapro, a medication used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest] and generalized anxiety disorder [mental health conditions characterized by excessive and persistent worry, fear, and unease that can interfere with daily life]), and gabapentin (also known as Neurontin, a medication that works in the brain to prevent seizures and relieve pain for certain conditions in the nervous system) had informed consents from the resident or representative. 2. Resident 3's escitalopram had informed consent from the resident or representative. These deficient practices violated the residents' right to make an informed decision regarding the use of psychoactive medications. Findings: 1. During a review of Resident 21's Face Sheet, the Face Sheet indicated the facility admitted the resident on 11/30/2023. During a review of Resident 21's History and Physical (H&P), dated 11/26/2024, the H&P indicated the resident was awake, alert, pleasant, and cooperative. The H&P indicated the resident had a history of depression, insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep), and atrial fibrillation (an irregular heartbeat that occurs when the electrical signals in the atria [the two upper chambers of the heart] fire rapidly at the same time). During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool), dated 2/14/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had moderate impaired cognition (a person is experiencing significant, noticeable difficulties with thinking and memory, which starts to affect their daily activities). The MDS indicated the resident was taking the following high-risk drug class medications: antianxiety (medications or treatments that help reduce feelings of excessive worry, fear, or anxiety), antidepression (medications used to treat symptoms of depression and other mental health conditions), and anticonvulsant (A type of drug that is used to prevent or treat seizures or convulsions by controlling abnormal electrical activity in the brain) medications. During a review of Resident 21's Active Orders, the Active Orders indicated Resident 21 was ordered the following: On 5/9/2024, gabapentin 600 milligrams (mg - a unit of measurement for mass). Give 600 mg (one [1] tablet) by mouth at bedtime. Indication: anxiety. Monitor for behavior manifested by (m/b) insomnia. On 5/31/2024, escitalopram oxalate 10 mg. Give 10 mg (1 tablet) by mouth at bedtime. Indication: depression m/b verbalize sadness. On 1/6/2025, mirtazapine 15 mg. Give 15 mg (1 tablet) by mouth at bedtime. Indication: depression m/b insomnia and oral intake less than 40 percent (% - a unit of measurement). On 3/20/2025, lorazepam 0.5 mg. Give 0.5 mg (1 tablets) by mouth at bedtime. Please hold if resident is sleepy. Indication: anxiety m/b insomnia. During a review of Resident 21's Plan of Care (POC), dated 11/30/2023, regarding medical conditions, the POC indicated the following interventions: escitalopram oxalate 10 mg by mouth at bedtime, mirtazapine 15 mg by mouth at bedtime, lorazepam 0.5 mg by mouth at bedtime, and gabapentin 600 mg by mouth at bedtime. During a concurrent interview and record review, on 4/10/2025, at 9:31 a.m., with Registered Nurse (RN) 2, Resident 21's Active Orders, Medication Administration Record (MAR), Consents, and POC were reviewed. RN 2 stated she cannot find the consents for psychotropic medications Lexapro, Remeron, Ativan, and Neurontin used for anxiety and sleep. RN 2 stated before administering the medications they need a physician's order, obtain an informed consent from the resident or resident representative discussing the risk and benefits of taking the medications, monitor for adverse effects (an unwanted and harmful result, often caused by a medication, treatment, or procedure) of the medication, and develop and implement a care plan on its use. RN 2 stated it was important to obtain a consent from the resident or representative before administering the medications to honor the resident or representative's right to informed consents and to afford them an opportunity to accept or decline the use of the medications. During an interview, on 4/11/2025, at 3:23 p.m., with the Director of Long-Term Care (DLTC), the DLTC stated the licensed staff should have ensured Resident 21 had a written consent for each psychotropic medications to ensure the resident's right to informed consent is honored. The DLTC stated there should be a physician's order, an informed consent indicating the resident was presented with the risk and benefit, monitoring for adverse effects, and a care plan on psychotropic medication use. During a review of the facility's recent policy and procedure (P&P) titled, Psychotherapeutic Medication/Monitoring/Informed Consent, last approved on 12/5/2024, the P&P indicated when psychotherapeutic drugs are used: 2. Residents will be monitored to determine the drug's effectiveness for the treatment of the stated condition and any adverse reaction. f. Documentation of obtaining informed consent (if new medication or higher dose of current medication). With the exception of antidepressants, written informed consent will be obtained from the resident of the resident's representative after disclosure of the following information: a. Possible nonpharmacologic approaches that could address the resident's needs. b. Whether the drug has a current boxed warning label along with a summary of, and information about how to find, the contraindications, warnings, and precautions required by the United States Food and Drug Administration (FDA). c. Whether the proposed drug is being prescribed for a purpose that has or has not been approved by the United States FDA. d. Possible interactions with other drugs the resident is receiving. e. How the facility and prescriber will monitor and respond to any adverse side effects and inform the resident of side effects. Before prescribing a psychotherapeutic drug: c. The consent requires the signature of the healthcare professional declaring the required material information has been provided. Medical Records: a. The signed written consent must be recorded in the resident's medical record. Renewals of Informed Consent: a. The written informed consent will be renewed every six months. 2. During a review of Resident 3's Face Sheet, the Face Sheet indicated the facility admitted the resident on 11/18/2024. During a review of Resident 3's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had moderate impaired cognition. The MDS indicated the resident was on a high-risk drug class antianxiety and antidepressant medications. The MDS indicated the resident had anxiety disorder, depression, and diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 3's Active Orders, dated 12/5/2024, the Active Orders indicated an order of escitalopram oxalate 20 mg. Give 20 mg (1 tablet) by mouth daily. Indication: depression m/b anxious behavior. During a review of Resident 3's POC regarding the use of psychotropic drug use, dated 11/18/2024, the POC indicated an intervention of escitalopram oxalate (Lexapro) 20 mg daily for depression. During a concurrent interview and record review, on 4/10/2025, at 10:39 a.m., with RN 2, Resident 3's Active Orders, MAR, Consents, and POC were reviewed. RN 2 stated she cannot find the consent for psychotropic medication Lexapro. RN 2 stated before administering the medications they need a physician's order, obtain an inform consent from the resident or resident representative discussing the risk and benefits of taking the medications, monitor for adverse effects of the medication, and develop and implement a care plan on its use. RN 2 stated it was important to obtain a consent from the resident or representative before administering the medications to honor the resident or representative's right to informed consents and to afford them an opportunity to accept or decline the use of the medications. During an interview, on 4/11/2025, at 3:23 p.m., with the DLTC, the DLTC stated the licensed staff should have ensured Resident 3 had a written consent for psychotropic medication to ensure their right to informed consent is honored. The DLTC stated there should be a physician's order, an informed consent indicating the resident was presented with the risk and benefit, monitoring for adverse effects, and a care plan on psychotropic medication use. During a review of the facility's recent P&P titled Psychotherapeutic Medication/Monitoring/Informed Consent, last approved on 12/5/2024, the P&P indicated when psychotherapeutic drugs are used: 2. Residents will be monitored to determine the drug's effectiveness for the treatment of the stated condition and any adverse reaction. f. Documentation of obtaining informed consent (if new medication or higher dose of current medication). With the exception of antidepressants written informed consent will be obtained from the resident of the resident's representative after disclosure of the following information: a. Possible nonpharmacologic approaches that could address the resident's needs. b. Whether the drug has a current boxed warning label along with a summary of, and information about how to find, the contraindications, warnings, and precautions required by the United States Food and Drug Administration (FDA). c. Whether the proposed drug is being prescribed for a purpose that has or has not been approved by the United States FDA. d. Possible interactions with other drugs the resident is receiving. e. How the facility and prescriber will monitor and respond to any adverse side effects and inform the resident of side effects. Before prescribing a psychotherapeutic drug: c. The consent requires the signature of the healthcare professional declaring the required material information has been provided. Medical Records: a. The signed written consent must be recorded in the resident's medical record. Renewals of Informed Consent: a.The written informed consent will be renewed every six months.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (CP - is a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting): 1. For two of three sampled residents (Residents 21 and 77) reviewed for care plans by failing to ensure identified problems were specific, grouped together, with individual goals and interventions. 2. For one of seven sampled residents (Resident 19) reviewed under the accidents care area by failing to ensure a comprehensive person-centered Care Plan for smoking was developed and implemented when the smoking CP did not include the use of an apron (a safety device that prevent burns from dropped ashes or smoking materials). These deficient practices had a potential for delay in the delivery of necessary care and services and miscommunication among healthcare providers. Findings: 1. During a review of Resident 21's Face Sheet, the Face Sheet indicated the facility admitted the resident on 11/30/2023. During a review of Resident 21's History and Physical (H&P), dated 11/26/2024, the H&P indicated the resident was awake, alert, pleasant, and cooperative. The H&P indicated the resident had dyslipidemia (means too many lipids [fats] in the blood), chronic recurrent pneumonia (two or more episodes of pneumonia in 12 months or three episodes altogether with radiographic clearance in between), and atrial fibrillation (a common heart condition where the heart's upper chambers [atria] beat irregularly, sometimes too fast, creating a quivering or fluttering sensation). During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool), dated 2/14/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had moderate impaired cognition (a noticeable but not severe decline in a person's ability to think, remember, and make decisions). The MDS indicated the resident had multiple active diagnoses. During a review of Resident 21's Plan of Care (POC), dated 11/30/2023, the POC indicated a list of all of Resident 21's medical conditions on the first column, and a list of goals on the second column. The list on the second column was not specific to the problems identified as there were multiple problems listed on the first column. The third column contained the interventions, with 89 interventions not organized according to identified problems. During a concurrent interview and record review, on 4/10/2025, at 9:07 a.m., with Registered Nurse (RN) 2, Resident 21's POC, dated 11/30/2023, was reviewed. RN 2 stated the POC written for Resident 21 was complicated to sort out. RN 2 stated the problems/medical diagnosis identified were all on the same column and the interventions were all mixed up with other identified problem interventions. RN 2 stated they have to scroll through multiple pages to check for interventions for a specific problem. RN 2 stated the POC should have one problem per care plan with specific goals and interventions. RN 2 stated the POC written for Resident 21 was disorganized and had the potential for delayed treatment and miscommunication with other healthcare providers. During an interview, on 4/11/2025, at 3:23 p.m., with the Director of Long-Term Care (DLTC), the DLTC stated the POC of Resident 21 should be organized in such a way that it can communicate the problem and interventions to healthcare workers effectively. The DLTC stated a POC should have one problem, with a goal, and interventions specific to the problem. The DLTC stated Resident 21's POC was disorganized, and it will take time for a healthcare worker to go through which interventions will be appropriate for a specific problem as it is mixed in with other problems of the resident which leads to delay of care. During a review of the facility's recent policy and procedure (P&P) titled Care Plan - Resident, last reviewed on 12/5/2024, the P&P indicated to ensure a coordinated and comprehensive written plan is developed based on the resident assessment and the individual needs and preferences of the resident. The care plan will include the start date, goals, interventions and target date for the next review. 2. During a review of Resident 77's Face Sheet, the Face Sheet indicated the facility admitted the resident on 12/27/2023. During a review of Resident 77's H&P, dated 12/17/2024, the H&P indicated the resident was alert and unable to converse. The H&P indicated the resident had Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), frontal lobe dementia (an umbrella term for a group of brain diseases that mainly affect the frontal and temporal lobes of the brain), and major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 77's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition (a person has significant difficulty with thinking, memory, and reasoning, to the point where they struggle with everyday activities and may be unable to live independently). The MDS indicated the resident had multiple active diagnoses. During a review of Resident 77's POC, dated 12/27/2023, indicated a list of all of Resident 77's medical conditions on the first column, and a list of goals on the second column. The list on the second column was not specific to the problems identified as there were multiple problems listed on the first column. The third column contained 28 interventions not organized according to identified problem. During a concurrent interview and record review, on 4/10/2025, at 9:07 a.m., with RN 2, Resident 77's POC, dated 12/27/2023, was reviewed. RN 2 stated Resident 77's POC was complicated to sort out. RN 2 stated the problems identified were all on the same column and the interventions were all mixed up with other identified problem interventions. RN 2 stated they have to scroll through multiple pages to check for interventions for a specific problem. RN 2 stated the POC should be one problem per care plan with specific goals and interventions. RN 2 stated the POC written for Resident 77 was disorganized and had the potential for delayed treatment and miscommunication with other healthcare providers. During an interview, on 4/11/2025, at 3:23 p.m., with the DLTC, the DLTC stated the POC of Resident 77 should be organized in such a way that it can communicate the problem and interventions to healthcare workers effectively. The DLTC stated a POC should have one problem, with a goal, and interventions specific to the problem. The DLTC stated the care plan of Resident 77 was disorganized and it will take time for a healthcare worker to go through which interventions will be appropriate for the problem as it is mixed in with other problems of the resident which leads to delay of care. During a review of the facility's recent P&P titled Care Plan- Resident, last reviewed on 12/5/2024, the P&P indicated to ensure a coordinated and comprehensive written plan is developed based on the resident assessment and the individual needs and preferences of the resident. The care plan will include the start date, goals, interventions, and target date for the next review. 44244 3. During a review of Resident 19's Face Sheet, the Face Sheet indicated the facility admitted the resident on 8/7/2024. During a record review of Resident 19's Patient Diagnosis Information, the Patient Diagnosis Information indicated the resident had diagnoses that included dementia, diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and hyperlipidemia (high cholesterol [a waxy substance that can build up in the blood resulting in stroke or heart issues]). During a review of Resident 19's MDS, dated [DATE], the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident required partial/moderate assistance for oral hygiene and dressing and required substantial/maximal assistance from staff for toileting, bathing, personal hygiene, and transferring from the bed to chair. During a review of Resident 19's Resident Smoking Assessment, dated 11/15/2024, the Resident Smoking Assessment indicated the resident expressed a desire to smoke small cigars again and was assessed by the interdisciplinary team (IDT). The IDT indicated the resident planned to smoke a few times a week with a caregiver present and Resident 19 would need to wear an apron. During a review of Resident 19's CP titled, Smokes Cigars, initiated 11/15/2025, the CP indicated a goal that the resident would comply with the smoking policy and would be assisted with lighting and extinguishing cigars. During a concurrent interview and record review, on 4/9/2025, at 3:58 p.m., with the Minimum Data Set Coordinator (MDSC), Resident 19's Care Plans and Resident Smoking Assessment, dated 11/15/2024, were reviewed. The MDSC stated Resident 19 expressed a desire to smoke after being admitted to the facility. The MDSC stated when a resident expresses a desire to smoke, an initial smoking assessment is completed by the Social Worker (SW) and a personalized CP is developed. The MDSC stated a smoking CP identifies resident specific interventions to ensure the resident complies with the smoking policy. The MDSC stated Resident 19's smoking assessment indicated the resident needs to wear a smoking apron, but Resident 19's CP did not include the use of a smoking apron. The MDSC stated it is important that Resident 19's CP include the intervention of wearing an apron because the CP is used to communicate the resident specific interventions with all the staff. During a concurrent interview and record review, on 4/10/2025, at 9:18 a.m., with the SW, Resident 19's Care Plans and Resident Smoking Assessment, dated 11/15/2024, were reviewed. The SW stated a smoking CP is completed for staff to be able to follow to keep a resident safe while smoking. The SW stated Resident 19 should wear a smoking apron while smoking. The SW stated a smoking CP should include the intervention of wearing an apron, but the SW forgot to add it to Resident 19's CP. The SW stated when the SW forgot to include the use of an apron in Resident 19's CP, there was a potential that the staff may take the resident out to smoke without an apron resulting in a burn injury to Resident 19. During an interview, on 4/11/2025, at 11:15 a.m., with the DLTC, the stated CPs are an individualized plan of care for each resident with different interventions used as guides for the appropriate care to provide. The DLTC stated the smoking apron is important for Resident 19's safety while smoking to prevent burns from falling ashes. The DLTC stated the apron is an intervention that should be in Resident 19's CP, but it was not. The DLTC stated when the use of an apron was not included in Resident 19's CP, the facility P&P were not followed and could have potentially resulted in burns to the resident. During a review of the facility provided P&P titled, Care Plan - Resident, last reviewed 10/2024, the P&P indicated the purpose of the P&P was to ensure a coordinated and comprehensive written plan is developed based on the resident assessment and the individual needs and preferences of the resident. The CP will be person-centered and reflect the needs of the resident. The CP will include the start date, goals, interventions and target date for the next review. During review of the facility provided P&P titled, Resident Smoking, last reviewed 3/6/2025, the P&P indicated any resident that smokes will be assessed to ensure resident is able to smoke safely and to determine if supervision is needed. The smoking assessment will be completed on admission, annually, and with change of condition.

Based on observation, interview, and record review, the facility failed to provide care in accordance with professional standards of practice by: 1. Failing to ensure residents' scheduled medications were administered as ordered at the scheduled time for two of five sampled residents (Resident 66 and Resident 19) who were reviewed under the Medication Administration facility task. 2. Failing to check a resident's gastrostomy tube (g-tube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach for people with swallowing problems) placement and patency before administering medications for one of five sampled residents (Resident 86) reviewed under Medication Administration facility task. 3. Failing to flush water in between medications for a resident when g-tube medications were administered for one of five sampled residents (Resident 86) reviewed under Medication Administration facility task. 4. Failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites for one (1) of 1 sampled resident (Resident 10) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) These deficient practices had the potential for Resident 86 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have); for Residents 66 and 19's health and well-being to be negatively impacted; and for Resident 10 to experience adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat), and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross reference: F755, F759, and F760 Findings: 1. During a review of Resident 66's Face Sheet (FS- front page of the chart that contains a summary of basic information about the resident), the FS indicated the facility admitted the resident on 8/18/2023. During a review of Resident 66's Clinical Record Abstract (CRA), the CRA indicated Resident 66 had diagnoses including dementia (a progressive state of decline in mental abilities), paraplegia (loss of movement and/or sensation, to some degree, of the legs), and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 66's Minimum Data Set (MDS-a resident assessment tool), dated 3/21/2025, the MDS indicated Resident 66 had adequate hearing, clear speech, had the ability to make self understood, and usually understand others. The MDS indicated Resident 66 required substantial assistance with eating and was dependent on staff on functional abilities in mobility. During a review of Resident 66's Orders (physician's orders), the Orders indicated: - carboxymethylcellulose sodium (Refresh Tears-eye drops) 0.5 percent (%-a unit of measurement), take two drops twice a day, indication for irritation or dry eye, dated 9/29/2023. - cetirizine hydrochloride (HCL) (Zyrtec-antihistamine helps relieve allergies), give 10 milligrams (mg-a unit of measurement), give 10 mg (1 tablet) by mouth daily, indication for pruritus (itching), dated 4/9/2024. - Eyelid cleanser (Ocusoft lid scrub), instill one pad into both eyes, twice a day, indication for blepharitis (inflammation of the eyelid), dated 12/6/2024. - lacosamide (Vimpat-antiseizure medication) give 150 mg, one tablet by mouth, twice a day, indication for seizure disorder, dated 8/31/2023. - levetiracetam (Keppra- antiseizure) 500 mg, give 750 mg (1.5 tablets) by mouth, twice a day, indication for seizure disorder, dated 2/8/2024. During a review of Resident 66's Medication Administration Record (MAR-a record of medications administered to residents), for April 2025, the MAR indicated the scheduled time for Resident 66's medications to be given at 9 a.m. included carboxymethylcellulose sodium, cetirizine hydrochloride, eyelid cleanser, lacosamide, and levetiracetam. During a concurrent observation and interview on 4/10/2025 at 7:27 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 prepared the following medications for Resident 66: lacosamide, one tablet (tab); levetiracetam 500 mg, 1.5 tabs; cetirizine 10 mg, one tab; carboxymethylcellulose eye drops; and eyelid cleanser. LVN 1 stated she has a total of 3.5 tablets and one eye drops to give. During an observation and interview on 4/10/2025 at 7:31 a.m. with LVN 1, at Resident 66's bedside, LVN 1 administered 3.5 tablets, and one eye drop medications to Resident 66. LVN 1 stated she completed medication administration for Resident 66. During a concurrent interview and record review on 4/10/2025 at 7:34 a.m. with LVN 1, reviewed Resident 66's MAR for 4/10/2025. LVN 1 stated she cannot sign Resident 66's MAR with the actual time she gave the medications because the system will not allow her until 8 a.m. LVN 1 stated the medications she gave were scheduled at 9 a.m. LVN 1 stated she will continue to pass (administer) medications. During an interview on 4/10/2025 at 7:45 a.m. with LVN 1, LVN 1 stated she has notified Residents 66's nurse practitioner weeks before (does not recall exact date) with regard to the resident's preference to administer the medications earlier than the scheduled time. LVN 1 stated they (licensed nurses) have one hour before and one after from the scheduled time to give the medications. LVN 1 stated she was informed by the nurse practitioner and/or physician (does not recall exactly who) that if the resident continues to request to receive the medications earlier than the scheduled time then the timing will be changed. LVN 1 stated she gave the medications earlier because when Resident 66 was up in the chair, it was difficult to administer the eye drops compared to when the resident is was still on bed. LVN 1 stated she also asked Resident 66 if he would like to receive his medications before the scheduled time and Resident 66 stated he would like to take his medications if they were ready. LVN 1 stated she gives the medications to Resident 66 outside the scheduled time about three times a week but not all the time. During an interview on 4/11/2025 at 11:26 a.m. with the Employee Health Manager ([NAME]), the [NAME] stated medications should be administered at the scheduled time and can be administered one hour before or one hour after the scheduled time. The [NAME] stated LVN 1 should have documented the reason for giving medication early for Resident 66. During an interview on 4/11/2025 at 1:18 p.m. with the Director of Pharmacy (DP), the DP stated their MARs have a built-in one hour before and one hour after (time frames to record medication administration). The DP stated if the medication nurse was unable to sign the MAR of Resident 66, they (licensed nurses) would need to check with the provider (resident's physician) if it is okay to give outside the scheduled time. The DP stated the MAR has specified window of when medications can be given because they do not want to give medications too early or too late. The DP stated she expects the medication nurse (licensed nurse) to notify the provider directly or to let the pharmacy know so they (licensed nurses) can place the order. The DP stated the medication nurse should not give the medication outside of the prescribed time because it is deviating from the current order. The DP stated all medications administered should be documented on the MAR and reflect the actual time it was given. During an interview on 4/11/2025 at 5:17 p.m. with the Director of Long-Term Care (DLTC), the DLTC stated medications should be given at the scheduled time. The DLTC stated when medications are not given at the scheduled time, Resident 66 may not get the full effect and may have potential drug interactions. The DLTC stated the medication nurse is expected to clarify with the provider regarding the timing of the medication of Resident 66 and document the communication with the provider. During a review of the facility's P&P titled, General Administrative, last reviewed 3/2024, the P&P indicated the purpose its policy to provide a safe and efficient medication distribution system which shall include the evaluation, selection, purchase, storage, control, dispensing and administration of all drugs, chemicals and pharmaceuticals used throughout the Motion Picture and Television Fund Hospital (MPTF) organization. The P&P indicated that All medications administered to patients must be first ordered by a physician on the MPTF medical staff or an individual who has been granted clinical privileges. Each dose of medication shall be accurately recorded in the patient's medical record. During a review of the facility's P&P titled, Medication Administration, last reviewed 12/5/2024, the P&P indicated Medication shall be accurately and safely administered to MPTF patients/resident by authorized personnel. The procedure P&P indicated the licensed nurses to Sign the eMAR after administration or non-administration of all medications. The P&P indicated the six (6) Rights of Safe Medication Administration are Right Medication, Right Dose, Right Patient/Resident, Right Route, Right Time, and Right Documentation. The P&P indicated the physician's order must include the date and time of the order, name of medication, dose, frequency, route, indication, duration, if appliable, and diagnosis. 2. During a review of Resident 19's FS, the FS indicated the facility admitted the resident on 8/7/2024. During a review of Resident 19's CRA, the CRA indicated Resident 19 had diagnoses including dementia, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and constipation (a problem with passing stool). During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19 had minimal difficulty hearing, clear speech, had the ability to make self understood and understand others. The MDS indicated Resident 19 required staff assistance with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and mobility. During a review of Resident 19's Orders, the Orders indicated the following: - donepezil HCL (Aricept-used to treat dementia), give 5 mg, one tablet by mouth daily, indication for dementia, dated 8/7/2024. - gabapentin (Neurontin- nerve pain medication), give 100 mg, one capsule by mouth, twice a day, indication for depression m/b refusing and resistance to care, dated 12/24/2024. - metformin extended release (Glucophage Extended Release- medication that helps lower high blood sugar) 500 mg, give 1000 mg (two tablets) by mouth, twice a day, indication for diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), dated 8/7/2024. - pantoprazole (Protonix- decreases amount of acid produced in the stomach) 40 mg, give 40 mg, one tablet by mouth, daily, indication for gastroesophageal reflux disease (GERD- a condition in which the stomach contents move up into the esophagus), dated 8/7/2024. - polyethylene glycol 3350 (Miralax- used to treat constipation) 15 grams (g-a unit of measurement)/dose, give 17 g (one powder) by mouth daily, mix with eight (8) ounces (oz- a unit of measurement) of liquid or juice, indication for constipation, dated 8/7/2024. - solifenacin succinate (Vesicare- used to treat overactive bladder [OAB- a problem with bladder (organ that stores urine before leaving the body) function that causes the sudden need to urinate]) 5 mg, give 5 mg (one tablet) by mouth, daily, indication for OAB, dated 2/21/2025. During a review of Resident 19's MAR, for April 2025, the MAR indicated the scheduled time for Resident 19's medications to be given at 9 a.m. on 4/10/2025 included donepezil HCL, gabapentin, metformin extended release, pantoprazole, polyethylene glycol 3350, and solifenacin. During a concurrent observation and interview on 4/10/2025 at 7:37 a.m. with LVN 1, LVN 1 prepared Resident 19's including medications: pantoprazole 40 mg, one tab; metformin 500 mg, two tabs; gabapentin 100 mg, one capsule; solifenacin 5 mg, one tab; donepezil 5 mg, one tab; polyethylene glycol 17 g. LVN 1 stated she will administer a total of eight medications with seven tablets and one powder. LVN 1 stated she will separate buspirone and gabapentin into a separate medication cup because Resident 19 usually does not want to take all the medications. During a concurrent interview and record review on 4/10/2025 at 7:44 a.m. with LVN 1, reviewed Resident 19's MAR for 4/10/2025. LVN 1 stated she cannot sign at 7:44 a.m. the medications administered because the electronic MAR will not save the date and time she gave the medications. LVN 1 stated she will have to wait until 8 a.m. to sign Resident 19's medications. During an interview on 4/10/2025 at 7:45 a.m. with LVN 1, LVN 1 stated she has notified Resident 19's nurse practitioner weeks before (does not recall exact date) with regard to the resident's preference to administer the medications earlier than the scheduled time. LVN 1 stated they (licensed nurse) have one hour before and one after from the scheduled time to give the medications. LVN 1 stated she was informed by the nurse practitioner and/or physician (does not recall exactly who) that if the resident continues to request to receive the medications earlier than the scheduled time then the timing will be changed. During an interview on 4/11/2025 at 11:26 a.m. with the [NAME], the [NAME] stated Resident 19's medications should be administered at the scheduled time and can be administered one hour before or one hour after the scheduled time. The [NAME] stated LVN 1 should have documented the reason for giving medication early. During an interview on 4/11/2025 at 1:18 p.m. with the DP, the DP stated their (facility) MARs have a built-in one hour before and one hour after time frames to record medication administration. The DP stated if the medication nurse was unable to sign Resident 19's MAR, they (licensed nurses) would need to check with the provider (resident's physician) if it is okay to give outside the scheduled time. The DP stated the MAR has specified window of when medications can be given because they do not want to give medications too early or too late. The DP stated she expects the medication nurse (licensed nurse) to notify the provider directly or to let the pharmacy know so they (licensed nurses) can place the order. The DP stated the medication nurse should not give the medication outside of the prescribed time because it is deviating from the current order. The DP stated all medications administered should be documented on the MAR and reflect the actual time it was given. During an interview on 4/11/2025 at 5:17 p.m. with the DLTC, the DLTC stated Resident 19's medications should have been given at the scheduled time. The DLTC stated when medications are not given at the scheduled time the resident may not get the full effect and may have potential drug interactions.The DLTC stated the medication nurse is expected to clarify with the provider regarding the timing of the medication and document the communication with the provider. During a review of the facility's P&P titled, General Administrative, last reviewed 3/2024, the P&P indicated the purpose its policy to provide a safe and efficient medication distribution system which shall include the evaluation, selection, purchase, storage, control, dispensing and administration of all drugs, chemicals and pharmaceuticals used throughout the Motion Picture and Television Fund Hospital (MPTF) organization. The P&P indicated that All medications administered to patients must be first ordered by a physician on the MPTF medical staff or an individual who has been granted clinical privileges. Each dose of medication shall be accurately recorded in the patient's medical record. During a review of the facility's P&P titled, Medication Administration, last reviewed 12/5/2024, the P&P indicated Medication shall be accurately and safely administered to MPTF patients/resident by authorized personnel. The procedure P&P indicated the licensed nurses to Sign the eMAR after administration or non-administration of all medications. The P&P indicated the six (6) Rights of Safe Medication Administration are Right Medication, Right Dose, Right Patient/Resident, Right Route, Right Time, and Right Documentation. The P&P indicated the physician's order must include the date and time of the order, name of medication, dose, frequency, route, indication, duration, if appliable, and diagnosis. 3. During a review of Resident 86's FS, the FS indicated the facility admitted Resident 86 on 3/5/2025. During a review of Resident 86's CRA, the CRA indicated Resident 86 had diagnoses including epilepsy (a condition that affects the brain and causes frequent seizures, muscle spasm (a sudden, involuntary movement in one or more muscles), neuralgia (a sharp, shocking pain that follows the path of a nerve and is due to irritation or damage to the nerve), and neuritis (inflammation of a nerve). During a review of Resident 86's MDS, dated [DATE], the MDS indicated Resident 86 had unclear speech, adequate hearing, rarely/never made self understood, and rarely/never understands others. The MDS indicated Resident 86 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 86 required assistance from staff with ADLs and mobility. The MDS indicated the resident had a feeding tube (a flexible tube inserted into the stomach or intestines to deliver liquid nutrition) while a resident of the facility. During a review of Resident 86's Orders, the Orders indicated: - gabapentin 300 mg, give 300 mg (one tablet) via g-tube three times a day, administer through the percutaneous endoscopic gastrostomy (PEG- a procedure for placing a feeding tube directly into the stomach through the abdominal wall, bypassing the mouth and esophagus) tube, indication for neuralgia and neuritis, dated 3/5/2025. - quetiapine fumarate (Seroquel- drug used to manage abnormal condition of the mind described as involved a loss of contact with reality) 100 mg, give 100 mg (one tablet) via g-tube three times a day via PEG tube, indications for encephalopathy (a disease that affects the function or structure of the brain) secondary to hypoxic brain injury (low levels of oxygen in the brain causing irreversible damage) m/b agitation, dated 3/6/2025. - baclofen 10 mg, give 15 mg (1.5 tablets) via g-tube, three times a day, indication for muscle spasticity of cerebral (brain) origin, dated 4/6/2025. During a review of Resident 86's MAR, for April 2025, the MAR indicated the scheduled time for Resident 86's medications to be given at 2 p.m. included gabapentin, quetiapine, and baclofen. During a concurrent observation and interview on 4/10/2025 at 1 p.m. with LVN 1, LVN 1 prepared Resident 86's medications: quetiapine 100 mg, one tab; gabapentin 300 mg, one capsule; baclofen 10 mg, 1.5 tablets. LVN 1 stated she will administer three medications, total 3.5 tablets to give. LVN 1 crushed each tablets separately in a plastic pouch and poured separately into each medication cup. Observed LVN 1 poured five to 10 ml of water into each medication cup and stirred the medications. During an observation on 4/10/2025 at 1:10 p.m. with LVN 1, at Resident 86's bedside, LVN 1 informed Resident 86 that she (LVN 1) prepared the resident's medications to administer. LVN 1 located Resident 86's g-tube and checked g-tube residual (the amount aspirated from the stomach following administration of enteral feed) which was zero (0) ml. LVN 1 flushed Resident 86's g-tube with 30 ml of water by gravity. LVN 1 administered all three medications with no flushing of water in between medications then flushed with 30 ml of water afterwards. LVN 1 stated she had completed medication pass for Resident 86. During an interview on 4/10/2025 at 1:24 p.m. with LVN 1, LVN 1 stated she prepared Resident 86's medications then she went inside Resident 86's room. LVN 1 stated she checked Resident 86's g-tube residual and there was none. LVN 1 stated she flushed the g-tube with 30 ml and gave the medications then flushed the g-tube another 30 ml afterwards. LVN 1 stated she did not check for patency during the medication pass because in the morning before the night shift nurse left, she (LVN 1) checked Resident 86's g-tube and it was patent. LVN 1 stated she uses a stethoscope to check for patency. LVN 1 stated her supervisor has told her that she did not need to check for patency every medication pass (medication administration). LVN 1 stated she checks for g-tube patency once per day at the beginning of her shift. LVN 1 stated she did not flush the g-tube in between medications because she follows the physician's order which was to flush the g-tube before and after medication administration. LVN 1 stated there was no order to flush the g-tube in between medications. During a concurrent interview and record review on 4/10/2025 at 2:15 p.m. with the DLTC, reviewed the facility's policy and procedure (P&P) titled, Tube Feeding Maintenance and Medication Administration, last reviewed 12/5/2024. The DLTC stated the P&P for g-tube medication administration is to check placement, patency, and residual before every scheduled medication administration time. The DLTC stated the P&P indicated #10 administer prepared medication separately (Do not mix medication) and flush with 15 ml to 30 ml (unless otherwise ordered) of water between each med (prevent air from entering the tube and follow feeding procedure). The DLTC stated medication nurses are expected to flush 15 to 30 ml between every medication unless there is an order to administer specific amount of water to flush. The DLTC stated if there is no physician's order; the standard of practice applicable to residents including Resident 86 is to flush 15 ml to 30 ml of water between medications. During a concurrent interview and record review on 4/10/2025 at 2:47 p.m. with LVN 1, reviewed Resident 86's MAR. LVN 1 stated there was a physician's order to flush Resident 86's g-tube with 30 ml of water before and after medication administration which she did. LVN 1 stated she did not give water flush in between medications because there was no order to flush in between medications. During a concurrent interview and record review on 4/10/2025 at 2:55 p.m. with LVN 1, reviewed the facility's P&P titled, Tube Feeding Maintenance and Medication Administration, last reviewed 12/5/2024. LVN 1 stated she did not follow their P&P to flush in between medications and did not check Resident 86's g-tube placement and patency at every scheduled medication administration. LVN 1 stated the [NAME] provided the instructions that there is no need to check for g-tube placement and patency at every scheduled medication administration, and that checking for g-tube placement and patency once at the beginning of the shift or the first scheduled medication during her shift was good. During an interview on 4/11/2025 at 11:26 a.m. with the [NAME], the [NAME] stated the standard of practice for g-tube administration is to check for placement, patency, residual, flush with water before medication administration, in between medications, and after medication administration. The [NAME] stated she did not provide instruction to LVN 1 to only checking placement and patency at the beginning of the shift during the first scheduled medication. The [NAME] stated their policy is to check for placement, patency, and residual done before administering every scheduled medication to be administered. The [NAME] stated flushing in between medications is done as to not mix the medications. The [NAME] stated when flushing in between medications is not done, then it is the same as mixing the medications in the same cup. The [NAME] stated LVN 1 should have followed their policy when LVN 1 administered medications to Resident 86. During an interview on 4/11/2025 at 1:25 p.m. with the DP, the DP stated medications given through the g-tube should not be mixed and should be flushed in between medications to maintain g-tube patency and to ensure Resident 86 received the whole dose. The DP stated there is a potential for medication interactions and clogging of the g-tube. During an interview on 4/11/2025 at 5:17 p.m. with the DLTC, the DLTC stated it is important for the medication nurse to flush in between medications because they would not know what the drug interaction for Resident 86 and this is to ensure the patency of the g-tube and that the resident receives the medications as ordered. The DLTC stated the purpose of checking for patency and placement is to ensure the g-tube is in the right place. The DLTC stated when this is not done the resident could potentially not receive the medications or the medication could go to a different area of the body and would not be properly absorbed. During a review of the facility's P&P titled, Tube Feeding Maintenance and Medication Administration, last reviewed 12/5/2024, the P&P indicated the purpose of the policy is to provide medication administration when unable to take orally and to monitor for signs and symptoms of infection, irritation at the stoma (a surgically created opening on the abdomen) site. The P&P indicated procedure for medication administration: 1. Check doctor's order. 2. Wash hands and prepare equipment. 3. Identify patient and explain procedure. 4. Position patient; semi-Fowler's position. 5. [NAME] (put on) gloves and check feeding tube for placement, patency, and residual. 6. For GT/JT placement check: air auscultation (a method used to listen to the sounds of the body by using a stethoscope [medical device), stomach secretions, aspiration . 7. Check gastric residual before giving medication (unless otherwise ordered). 8. If residual is greater than 100 ml, hold medication for one hour and repeat check . 9. Flush tube with 30 ml of water prior to administering medication unless physician orders different amount for flush. 10. Administer prepared medication separately (Do not mix medication) and flush with 15 ml to 30 ml (unless otherwise ordered) of water between each med (Prevent air from entering the tube and follow feeding procedure). 11. After medication is administered, instill 30 mls of water to clear the tube or as GNP/ General Nurse Practitioner (GNP)/Physician order indicates. During a review of the facility's P&P titled, General Administrative, last reviewed 3/2024, the P&P indicated the purpose its policy to provide a safe and efficient medication distribution system which shall include the evaluation, selection, purchase, storage, control, dispensing and administration of all drugs, chemicals and pharmaceuticals used throughout the Motion Picture and Television Fund Hospital (MPTF) organization. During a review of the facility's P&P titled, Medication Administration, last reviewed 12/5/2024, the P&P indicated Medication shall be accurately and safely administered to MPTF patients/resident by authorized personnel. 43988 4. During a review of Resident 10's Face Sheet, the Face Sheet indicated the facility admitted the resident on 6/30/2021 with diagnoses including type 2 diabetes mellitus (DM 2-a disorder characterized by difficulty in blood sugar control and poor wound healing), anxiety disorder (mental health condition characterized by excessive and persistent worry, fear, and unease that can interfere with daily life), and chronic pain syndrome. During a review of Resident 10's History and Physical (H&P) dated 9/27/2024, the H&P indicated Resident 10 was alert and oriented to full name, exact date, and location. During a review of Resident 10's MDS, dated [DATE], the indicated Resident 10 had an intact cognition (mental action or process of acquiring knowledge and understanding) and required substantial/maximal assistance to total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS further indicated Resident 10 received insulin. During a review of Resident 10's physician's order, the physician's order dated 10/2/2024 indicated liraglutide (Victoza - a long-acting insulin) 0.6 milligrams (mg - a unit of measurement) per 0.1 milliliter (ml - a unit of measurement), inject 1.8 mg (0.3 ml) subcutaneously daily at eight (8) a.m. for DM 2. During a review of Resident 10's care plan (CP) titled Medical Condition: related to DM2, initiated on 6/30/2021, the CP indicated to administer liraglutide (Victoza) as one of the interventions to prevent complications or problems with medical conditions. During a concurrent interview and record review on 4/11/2025 at 8:57 am., reviewed Resident 10's physician's order, subcutaneous administration sites for Victoza from 1/8/2025 to 4/11/2025, and the MDS with Registered Nurse (RN) 1. RN 1 stated Resident 10 received insulin, had a physician's order for Victoza, and were administered as follows: - 3/19/2025 9:26 a.m. left middle mid-thigh - 3/20/2025 9:10 a.m. left middle mid-thigh - 1/27/2025 9:21 a.m. right lower back of arm - 1/28/2025 8:43 a.m. right lower back of arm - 1/5/2025 8:59 a.m. right lower quadrant - 1/6/2025 8:22 a.m. right lower quadrant RN 2 stated administration sites for insulin should be rotated per standards of practice and manufacturer's guideline to prevent hardening or lumps in the skin. RN 2 stated the location of administration sites for Resident 10's insulin was not rotated. RN 2 stated Resident 10's administration sites should have been rotated to prevent pain, redness, irritation, and lumps on the resident's skin which can affect the absorption of the insulin. During an interview on 4/11/2025 at 4 p.m. with the Director of Long-Term Care (DLTC), the DLTC stated the nurses are supposed to rotate insulin administration sites according to standards of practice, and as indicated in the manufacturer's guideline. The DLTC stated the location of administration sites for Resident 10's insulin was not rotated. The DLTC stated Resident 10's administration sites for the Victoza should have been rotated to prevent adverse effects such as bruising, skin irritation, skin pits, lipodystrophy and amyloidosis which can affect absorption of the insulin. During a review of the facility-provided manufacturer's guideline for Victoza dated 11/2024, the manufacturer's guideline indicated: - Inject Victoza SQ in the abdomen, thigh, or upper arm. - Rotate injection sites within the same region in order to reduce the risk of cutaneous amyloidosis.

Based on observation, interview and record review, the facility failed to provide adequate supervision and implement an intervention, standby assistance when ambulating, for one of two sampled residents (Resident 1). The new intervention was developed after Resident 1's second fall at the facility, on 10/14/17. The facility's failure to provide adequate supervision and standby assistance when ambulating, resulted in the third fall for Resident 1, on 10/27/17, as Resident 1 ambulated from the dining room, unsupervised and without assistance. Resident 1 sustained a [MEDICAL CONDITION] hip that required surgical repair. Findings: On 11/6/17, an unannounced visit was conducted at the facility to investigate a facility-reported incident (FRI) regarding Resident 1's fall that occurred on 10/27/17, at 4:16 PM. A review of Resident 1's medical record indicated Resident 1 was originally admitted to the facility on [DATE], and readmitted on [DATE], following hospitalization for surgical repair of a fractured left hip that was the result of a fall experienced on 8/1/17. Resident 1's [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/24/17, indicated Resident 1's cognitive skills for decision making ability were moderately impaired, decisions were poor and cues/supervision were required. Resident 1 required one person to physically assist while walking in the corridor. A review of Resident 1's, History and Physical, dated 2/16/17, indicated the resident's gait and balance had deteriorated and the resident had increased falls with increasing frailty. The plan indicated Resident 1 would require supervision and assistance with activities of daily living (ADLs), with transfers and gait. A review of a care plan titled, Falls, initiated on 2/16/17, indicated Resident 1 was at risk for falls, and the goal was to be free from falls or injury daily. A review of a revised care plan titled, Short Term: Fall witnessed by CNA, initiated on 10/14/17, indicated a new intervention was in place for Resident 1, after the second fall. The intervention was reinforcement for safety precautions to be maintained, at all times. Resident 1 required standby by assistance during ambulation. On 11/6/17, at 4:07 PM, 17 residents were observed sitting in the dining room. There were no staff observed in the dining room. There were two doors located at opposite ends of the dining room. LVN 1 was observed just outside the left door of the dining room, in the hallway, preparing medications. Resident 1 was not observed in the dining room. Resident 1 was hospitalized . On 11/6/17, at 12:05 PM, the director of long-term care (DLTC) was interviewed. The DLTC stated Resident 1 fell on her buttocks, on 10/27/17, suffered a fracture, and was in the hospital, for surgical repair of the right hip. On 11/6/17, at 2:56 PM, the DLTC stated staff were on standby for ambulation only if residents were unable to ambulate by themselves. The DLTC stated that standby meant close observation of residents. The facility usually provided close observation of residents in the dining room, when one certified nurse assistant (CNA) leaves, another CNA would take over the observation. On 11/16/17, at 3:30 PM, the DLTC was asked to provide documentation of the staffing assignment for the evening shift (3-11 PM), for the following dates, 10/14/17, 10/27/17, and 11/6/17, to verify that staff were assigned to supervise residents in the dining room. The DLTC stated there was no schedule or assignment for the hours from 3-11 PM. The DLTC stated the assignments did not include documentation for supervision of the dining room from 3-11 PM. On 11/6/17, at 4:28 PM, the licensed vocational nurse (LVN 1) was interviewed. LVN 1 stated she witnessed Resident 1 fall on 10/27/17. LVN 1 stated the incident occurred prior to dinner, while she was in the hallway, preparing medications for residents. LVN 1 was standing outside the opposite door of the dining room, from which Resident 1 exited. LVN 1 stated there were no CNAs supervising the residents in the dining room, at that time. The CNAs were in the resident's rooms, getting them ready for dinner. LVN 1 stated that LVN 2, who was the nurse assigned to Resident 1, was assisting a CNA in a resident's room. LVN 1 stated there were no other staff present, in the vicinity or in the dining room. LVN 1 stated Resident 1 was sitting in the dining room and walked out through the opposite door, from where LVN 1 was standing. LVN 1 stated Resident 1 walked, unassisted, into the hallway and tried to grab on to the handrail on the wall. Resident 1 was unsuccessful. LVN 1 stated Resident 1's turned, and Resident 1 fell on the floor. LVN 1 stated she was not able to reach Resident 1 before the fall. LVN 1 stated there was no one to assist with ambulation at that time. On 2/26/18, at 11:18 AM, the director of risk management (DRM) was interviewed. DRM stated that Resident 1 fell for the third time on 10/27/17. DRM stated Resident 1 required surgical repair for a left [MEDICAL CONDITION] from the first fall on 8/1/17. DRM stated Resident 1 did not sustain injury from the second fall on 10/14/17. A review of Resident 1's nurse's notes, dated 8/1/17, at 10:20 PM, indicated Resident 1's first fall occurred at approximately 3 PM. Resident 1 was sitting in the dining room, at approximately 3:15 PM. Resident 1 stood up, walked towards the door of the dining room, where she fell and landed in the hallway. A review of a Resident 1's care plan titled, 'Falls, initiated on 2/16/17, indicated a new intervention was added on 8/1/17, after Resident 1's first fall. The intervention was to take Resident 1 to the restroom after lunch. A review of a document titled, Long-Term Care Note, dated 9/19/17, indicated Resident 1 sustained a fall early in (MONTH) and was diagnosed with [REDACTED]. Resident 1 underwent surgical repair and returned to the facility. A review of Resident 1's nurse's notes, dated 10/14/17 at 8:17 PM, indicated Resident 1's second fall occurred. While the CNA was providing care, Resident 1 was standing at the sink in her room, lost her balance and landed on her buttocks. The resident was able to ambulate with assistance after the incident. A review of a document titled, Fall Risk Assessment, dated 10/14/17, indicated a score of 17, which meant Resident 1 was at HIGH RISK for a fall. A review of a revised care plan titled, Short Term: Fall witnessed by CNA, initiated on 10/14/17, indicated a new intervention was in place for Resident 1, after the second fall, to reinforce with new staff members to maintain safety precautions at all times, i.e. standby assistance when ambulating. A nursing note, dated 10/27/17 at 9:43 PM, indicated Resident 1's third fall occurred at 4:15 PM. Resident 1 was sitting in the dining room, got up, walked to the hallway, then LVN 1 noticed Resident 1 tried to hold on to the hallway handrails, but could not. Resident 1, then lost her balance and fell backwards and landed on her buttocks. Resident 1 was able to move all extremities, however, the patient indicated she had pain to her right hip. Resident 1 was examined by a nurse practitioner and stat (immediate) x-rays were ordered on both the hips and pelvis. The x-rays were completed and the results were pending. A review of Resident 1's radiology results, dated 10/27/17, at 10:18 PM, indicated there was a right sub-capital fracture with modest displacement (a broken bone to the hip area that has snapped in two or more parts). A nursing note, dated 10/28/17 at 1:50 PM, indicated the incident had been reported to the California Department of Public Health. Resident 1 had been transferred to an acute hospital for evaluation and follow up treatment. A review Resident of 1's nurse's notes, dated 10/31/17, at 1:19 PM, indicated the interdisciplinary team (IDT) met to discuss Residents 1's fall and the interventions to prevent the fall. The IDT recommended to increase supervision and to avoid and prevent falls. A review of the facility's policy and procedure titled, Falls, dated 8/2016, indicated fall risk interventions for residents who are at high risk for falls (16 points and above represents high risk) included close supervision during the day and to conduct hourly rounds as necessary.

Based on record reviews and interviews, the facility failed to provide a safe environment and adequate supervision to Resident 1, who had dementia with history of falls, from exiting the door to a flight of the stairs. Resident 1 had previously fallen down the same flight of stairs in [DATE] without injuries. On [DATE], Resident 1 wheeled herself out the second floor through the West exit door to the stairwell. Resident 1 fell out of the wheelchair between the first and second floors and sustained a burst fracture (a vertebra, spine bone, is crushed in all directions) of her neck and a severe lumbar fracture. Surgery was not medically recommended, and subsequently, the resident expired seven days later on [DATE]. According to the death certificate, the immediate cause of death was " sequelae of fall. " Findings: On [DATE] at 8:15 a.m., an unannounced visit was made to the facility to investigate the incident of Resident 1 ' s fall down a flight of stairs while in her wheelchair. On [DATE] at 10:45 a.m., a review of Resident 1's face sheet record indicated the resident was a [AGE] year old female who was admitted to the facility on [DATE] with admitting [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), full assessment and care screening tool, dated [DATE], indicated the resident had short and long-term memory problems, poor safety awareness, and moderately impaired cognitive skills for daily decision-making that required cues/supervision. The MDS indicated the resident required total assistance from staff for transfer and locomotion. The resident was unable to stand and her sitting balance was unsteady. Resident 1 ' s primary mode of locomotion was a wheelchair. Section J4 (accidents) indicated the resident fell in the past 31 to 180 days. The RAP Summary dated [DATE], indicated the resident had cognitive loss due to Alzheimer ' s dementia and the plan was to provide a safe environment daily. (Resident assessment protocols (RAPs) are a component of MDS. RAPs are a record of 18 medical concerns which, when triggered on an MDS, indicate that a nursing home patient requires additional medical attention.) A review of the Social Services notes, dated [DATE] and [DATE], indicated Resident 1 self-propels in a wheelchair around the unit and has episodes of leaving the unit with some success (AWOL type behavior, leaving the unit without staff knowing). A review of the Long-Term Care Notes, dated [DATE], indicated Resident 1 demonstrating some delusions of elopement-type behavior. A review of the Social Services Annual notes dated [DATE] at 2:35 p.m., indicated " Resident 1 presents in her wheelchair as confused and disoriented, alert to her name only. " A review of the IDT notes dated [DATE] at 11:07 a.m., indicated " Resident 1 was seen by a geriatric psychiatrist on [DATE] for increased sundowning (aberrant behaviors that occur in the late afternoon or evening; i.e., agitation, depression, rapid mood changes, restlessness and wandering); started on routine Seroquel for agitation. A review of the Social Services ' room change ' notes dated [DATE] at 2:56 p.m., indicated Resident 1 ' s niece was reminded that the resident was scheduled to move on [DATE] from a one story building to the second floor of a two story building, where she had previously fallen down a flight of stairs in [DATE]. A review of the "Falls/Increased risk for injury" care plan updated on [DATE] identified " Resident 1 to be at an increased risk for injury due to osteoporosis, Alzheimer ' s disease, extensive assist with transfers, use of antidepressant/antianxiety/antihypertensive meds, unsteady sitting balance, poor safety judgment, and falls asleep in wheelchair. The goal was to have no falls/injuries daily. The staff ' s plan of approaches included: bed in low position; call bell within reach at all times while in room; anticipate and meet needs; bed alarm when in bed; monitor frequently; monitor for leaning while in wheelchair and position at table when leaning or when she tends to fall asleep; resident likes to sit near or at nurses station when she is up in her wheelchair. " A review of the facility ' s Occurrence Screening Falls Investigation Report, dated [DATE] at 2:45 p.m., indicated the resident had a history of [REDACTED]. The investigation report indicated the resident wandered down the hallway and sustained a fall on [DATE], (time not found); a wheelchair alarm was heard in the south corridor, staff went immediately and found the resident near the elevator on the floor next to her wheelchair. The investigation report indicated the resident did not sustain any injuries and was assisted back to her wheelchair. A short term care plan titled " Actual Fall " , dated [DATE] indicated " One of the staff ' s care plan approaches was to update the long term falls care plan with recommendations from the fall committee. " A review of the long term falls care plan was made with Employee C, Director of Quality Resources. Employee C indicated the fall committee met on [DATE], to review and evaluate Resident 1 ' s medications and change of behaviors regarding the fall on [DATE]; Employee C stated there were no recommendations from the fall committee documented, as the resident was still in the hospital. There was no updated documentation to the long term care plan after the [DATE] fall addressing the " resident ' s safety regarding wandering behavior " in trying to wheel self out of the building that morning. A review of the Certified Nursing Attendant (CNA) Long Term Care (LTC) Daily Nursing Record, dated [DATE] at 3:55 p.m., indicated at 2:45 p.m. CNA 1 found Resident 1 on the landing of the stairwell that goes up to the second floor, west side of the building. Resident 1 ' s wheelchair was lodged at the third step down from the second floor. Resident 1 was found face up, yelling and complaining of neck pain. CNA 1 told Resident 1 to stay still; CNA 1 ran up the stairs, opened the door to the second floor and yelled for help. LVN 5 (2W) and LVN 1 (2E) responded immediately to the location of the incident. CNA 1 paged the Rapid Response Team (RRT) and the Nursing Supervisor. Within a few minutes, the RRT was there; the physician assessed the resident, decided not to move her and had " 911 " called. A review of the facility ' s Occurrence Screening Falls Investigation report, dated [DATE] 10 at 2:45 p.m., indicated Respiratory Therapist (RT 2) who cared for Resident 1 during the day was interviewed. RT 2 stated he had given the resident a respiratory treatment earlier that morning. He stated that after the treatment, the resident appeared more anxious than normal, but he did not report this to the charge nurse. A review of the facility ' s Investigative Report, initiated on [DATE] and completed on [DATE], indicated on [DATE] at 2:10 p.m., Employee J, Activities Staff, received report from RT 1 that Resident 1 was observed in the hallway, outside of the activities room, wandering toward ' J wing ' and found near the exit door. Employee J decided to return Resident 1 to the unit, due to her wandering toward the exit door, at approximately 2:15 p.m. He brought the resident to the table next to the north end of the nurses ' station on 2E where he observed LVN 1 talking to a resident and her son; he did not speak to LVN 1 to inform her of Resident 1 ' s wandering towards the exit door on the first floor, but knew they were close enough to be aware that Resident 1 had returned to the unit. A review of the facility ' s Investigative Report, initiated on [DATE] and completed on [DATE], indicated there was no documentation of assessment of Resident 1 ' s previous wandering behavior prior to her move from the Pavilion (one story building) to 2E (a two story building) in [DATE]; there was no documentation of assessment of Resident 1 ' s wandering behavior after the move to 2E; and, there was no documentation of concerns or of informing the physician or nurse practitioner regarding Resident 1 ' s wandering behavior in days prior to the fall on [DATE]. A review of the acute care hospital Physician Documentation record indicated Resident 1 was brought to the hospital on [DATE] at 3:53 p.m., after a fall from one flight of stairs with complaint of pain in head, neck, and back. A review of the computed tomography (CT, a machine that uses X-rays to make detailed pictures of structures inside the body) scan reports, dated [DATE] at 4:46 p.m., indicated a burst fracture (a vertebra, spine bone, is crushed in all directions) of the C1 (the first spine bone closest to the skull) vertebral body and a fracture slightly displaced posteriorly (back) on the body of C2 (the second spine bone, C1 and C2 forms the joint connecting the skull and spine); a greater than 75% vertebral body compression fracture of L1 vertebral body with angulation at that level (more than 75% of the front portion of the first lower back bone was collapsed and twisted); and, a non displaced fracture of the left tenth rib. A review of the Consultation report, written by Physician 3, Neurosurgical consult, dated [DATE] at 10 a.m., indicated after consult with Physician 8, a collective decision was made to place the resident in a Minerva brace (a cervical and upper thoracic orthosis to provide good orthotic control of the neck) and a C-collar (cervical collar is used to stabilize the head and neck). A review of the physician's order [REDACTED]. " A review of the Progress Note, written by Physician 5, Palliative Care Specialist, dated [DATE] at 3:09 p.m., indicated the resident was deemed to not be a surgical candidate by Physician 1 and Physician 3, Neurosurgery/Trauma Surgery, due to the extent of her injuries, other health co-morbidities, and her age. According to the hospital record, there was no documentation of falls while Resident 1 was in the hospital from [DATE] to [DATE]. In addition, there was no evidence of any events that occurred which may have exacerbated the resident ' s [DIAGNOSES REDACTED]. A review of the skilled nursing facility ' s Registration Record indicated Resident 1 was readmitted on [DATE] at 3:26 p.m., with [DIAGNOSES REDACTED]. A Minerva brace was in place. A review of a Progress Note/Clinic Note, written by Physician B, dated [DATE], indicated " The resident has not been able to eat much since her return. Dehydration, therefore, appears to be an imminent danger. " Physician B spoke with resident ' s niece to discuss possible options of continued palliative care and use of a feeding tube to meet the resident ' s nutritional needs. After discussion, it was decided to insert a feeding tube to provide the resident an opportunity at being given an appropriate degree of nutrition. A review of the physician progress notes [REDACTED]. When Physician A arrived, Resident 1 had agonal respirations (an abnormal pattern of breathing characterized by gasping, labored breathing, accompanied by strange vocalizations and [DIAGNOSES REDACTED]), hands warm, lips cyanotic (bluish) and no response to pain; dying but not pulseless nor apneic. Resident 1 was a " do not resuscitate/do not intubate " (DNR/DNI); no code was called. At 5:44 a.m., Resident 1 now apneic (not breathing), pulseless and without heart tones, was pronounced dead by Physician A. A review of the Certificate of Death indicated the immediate cause of death was " Sequelae of Fall. " On [DATE] at 12:15 p.m., during an interview, Employee B stated after a review of Resident 1 ' s medical record: " There was no care plan that addressed the wheelchair alarm use; there was no documentation of assessment or care plan regarding Resident 1 ' s wandering behavior prior to her move from the Pavilion unit to 2E on [DATE]; there was no documentation regarding Resident 1 ' s wandering behavior in days prior to the fall on [DATE] informing the physician or nurse practitioner; there was no documentation of any report from RT 2, to nursing staff regarding Resident 1 ' s breathing treatment the morning of the accident and how the RT 2 felt the resident was more anxious than normal after the breathing treatment; and, there was no documentation of any report from Employee J, Activity Staff, regarding the reason he brought Resident 1 back to the unit that afternoon. " The facility failed to provide a safe environment and adequate supervision to Resident 1, who had dementia with history of falls, from exiting the door to a flight of the stairs. Resident 1 had previously fallen down the same flight of stairs in [DATE] without injuries. On [DATE], Resident 1 wheeled herself out the second floor through the West exit door to the stairwell. Resident 1 fell out of the wheelchair between the first and second floors and sustained a burst fracture of her neck and a severe lumbar fracture. Surgery was not medically recommended, and subsequently, the resident expired seven days later on [DATE]. The above violation presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result and was a direct proximate cause of the death of the patient.