Every finding on record at Murrieta Health and Rehabilitation Center

Based on interview, and record review, the facility failed to implement their policy and procedure on abuse, for one of three residents (Resident 1), when:1. Resident 1's allegation of physical abuse by Certified Nursing Assistant (CNA) on June 23, 2026, was not investigated timely; and2. The alleged CNA was not suspended pending investigation of an allegation of abuse and continued to have provide care and services to the residents.These failures resulted in the delay of providing safety and protection for Resident 1 and other vulnerable residents and placed them at risk for further abuse.Findings:On August 26, 2026, at 8:30 a.m., an unannounced visit was conducted at the facility to investigate an allegation of physical abuse.On August 26, 2026, a review of Resident 1's medical record was conducted. Resident 1 was admitted to the facility on [DATE], with diagnoses which included depression and malaise (general feeling of discomfort).A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated June 24, 2026, indicated Resident 1 had a BIMS (Brief Interview of Mental Status) score of 14 (cognitively intact).A review of Resident 1's Physicians Order, dated June 23, 2026, indicated, .Monitor for allegation of (name of alleged abuser) came into my room to slap me every shift.A review of Resident 1's Care Plan Report dated June 23, 2026, indicated, .Monitor for allegation of (name of alleged abuser) came into my room to slap me every shift. with interventions which included to care in pairs when providing assistance and provide consistent care givers as much as possible.On August 26, 2026, at 10:45 a.m., during concurrent interview and record review with the Director of Staff Development (DSD), the DSD stated the DON was aware of the allegation of abuse on June 23, 2026, by Resident 1, and she was not sure if it was reported or investigated. The DSD stated she did not report the allegation of abuse and should have been reported. The DSD stated there was no documentation in Resident 1's medical record regarding the allegation of physical abuse on June 23, 2026, and no further investigation of the allegation of physical abuse on June 23, 2026, to keep Resident 1 safe and to prevent further abuse.On August 26, 2026, at 11:20 a.m., during concurrent interview and record review with the alleged CNA. The alleged CNA stated she remained working on the following days after the allegation of abuse was reported by Resident 1, on June 23, 2026. The CNA further stated, nobody told her that she was suspended and she continued to work on the following dates:- June 23, 2026, from 10:25 p.m., to June 24, 2026, to 6:32 a.m. and;- June 24, 2026, from 10:23 p.m., to June 25, 2026, to 6:30 a.m.On August 26, 2026, at 12:30 p.m., during an interview with the Director of Nursing (DON), the DON stated any alleged abuse in the facility should have been investigated as soon as the allegation was made known by the facility. The DON stated the alleged CNA remained working after the allegation of abuse was reported and should have been suspended pending investigation. The DON further stated if any allegation of abuse was not reported and investigated, and the staff involved was not suspended pending investigation, there would be a potential for recurrence, or continuous abuse would happen to Resident 1.On August 26, 2026, at 1:15 p.m., the Administrator (ADM) was interviewed. The ADM stated any allegation of abuse in the facility should have been investigated and reported in a timely manner as soon it was identified. The ADM stated the alleged abuser staff should have been suspended pending investigation.A review of the facility's policy and procedure titled, Abuse Investigation and Reporting, dated July 2017, indicated, .If an incident or suspected incident of resident abuse.The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation.The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented.A review of the facility's policy and procedure titled, Abuse Prevention Program, dated August 2021, indicated, .Our Resident have the right to be free from abuse.As part of the resident abuse prevention, the administration will.protect our residents from abuse by anyone including.facility staff.Investigate and report any allegations of abuse within timeframes as required by federal requirements.Protect residents during abuse investigations.A review of the facility's policy and procedure titled, Protection of Residents During Abuse Investigations, dated April 2021, indicated, .Residents are protected from harm, retaliation, reprisal, discrimination or coercion during investigations of abuse.If the alleged perpetrator is an employee or staff member.are suspended until findings of the investigation are reviewed by the administrator.

Based on interview and record review, the facility failed to report an allegation of physical abuse to California Department of Public Health (CDPH) immediately or within two (2) hours after the allegation was made, for one of three residents (Resident 1).This failure had the potential to result in further abuse for Resident 1, affecting the resident's physical, emotional, and psychosocial well-being.Findings:On August 26, 2026, at 8:30 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse.On August 26, 2026, a review of Resident 1's medical record was conducted. Resident 1 was admitted to the facility on [DATE], with diagnoses which included depression and malaise.A review of Resident 1's Minimum Data Set, dated [DATE], indicated Resident 1 had a BIMS score of 14 (cognitively intact).A review of Resident 1's Physicians Order, dated June 23, 2026, indicated, .Monitor for allegation of (name of alleged abuser) came into my room to slap me every shift.A review of Resident 1's Care Plan Report dated June 23, 2026, indicated, .Monitor for allegation of (name of alleged abuser) came into my room to slap me every shift. with interventions which included to care in pairs when providing assistance and provide consistent care givers as much as possible.On August 26, 2026, at 12 p.m., during interview with the Director of Staff Development (DSD), the DSD stated the Director of Nursing (DON) was made aware of the allegation of physical abuse by alleged CNA towards Resident 1 , on June 23, 2026, and she was not sure if it was reported or investigated. The DSD stated she did not follow up and reported the allegation of abuse and should have been reported. The DSD stated any allegation of abuse should be reported immediately or within two hours (2) from the time the allegation was reported to the facility staff. The DSD further stated she did not report the allegation of abuse incident to CDPH or any outside agencies and she should have been reported immediately within two hours.On August 26, 2026, at 12:30 p.m., during an interview with the DON, the DON stated she was made aware of the allegation of physical abuse, on June 23, 2026, around 2 p.m. and no one reported the allegation of abuse. The DON stated the allegation of abuse was reported on August 4, 2026, around 6 p.m., (42 days from the time it was initially reported to DON on June 23, 2026, at 2 p.m.). The DON stated any alleged or suspicion of abuse should be reported to CDPH within two hours. The DON further stated the allegation of physical abuse should have been reported immediately or within 2 hours for resident safety.A review of the facility's policy and procedure titled, Reporting Suspicion of a Crime, revision dated July 2017, indicated, .The Administrator, Director of Nursing or any other designated individual will report (within the required time frames) any reasonable suspicion of crime against a resident to state Survey Agency and local law enforcement agency.A review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigation, dated September 2022, indicated All reports or resident abuse.are reported to local, state and federal agencies.and thoroughly investigated by facility management.the suspicion of abuse must be reported immediately to the administrator and to other officials according to state law.Immediately is defined as.within two hours of an allegation involving abuse.or within 24 hours of an allegation that does not involve abuse.

Based on interview and record review, the facility failed to ensure discharge plan was arranged and followed up, for one of three sampled residents (Resident 1).This failure had the potential for Resident 1 not to receive the necessary support and services to meet the resident's care needs.Findings:On July 13, 2026, at 9 a.m., an unannounced visit to the facility was conducted to investigate a complaint related to discharge.On July 13, 2026, Resident 1's medical record was reviewed. Resident 1's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included difficulty in walking and need for assistance with personal care.A review of Resident 1's Social Service Review, dated June 26, 2026, indicated, .Discharge plan resident and son agrees w/ (with) placement-(name of facility).A review of Resident 1's Minimum Data Set (MDS - a tool for assessment), dated June 28, 2026, indicated Resident 1 had a BIMS (Brief Interview for Mental Status - a tool used to assess cognition) indicated cognitively intact.A review of Resident 1's Discharge Instruction Form, dated July 11, 2026, indicated the resident was discharged to private residence.A review of Resident 1's Progress Notes, dated July 11, 2026, at 3:19 p.m., indicated, .Patients' (sic) son called and expressed concerns of discharge. Stated that he is not liable for her care. Patient is alert and oriented and responsible for herself.Patient was picked up by transportation services via w/c (wheelchair) and left with all her belongings.On July 13, 2026, at 11:43 a.m., an interview was conducted with Social Service Assistant (SSA). The SSA stated Resident 1's family member requested to find an assisted living that will give extra care to Resident 1. The SSA further stated there was no follow up with the discharge plan for Resident 1 to be discharged in an Assisted Living as initially planned with the resident and resident's family member. The SSA stated, I should have followed up and initiate calling the Assisted Living. I forgot and it was missed.On July 13, 2026, at 11:56 a.m., during concurrent interview and review of Resident 1's record with the Social Service Director (SSD), the SSD stated Resident 1's Social Service Assessment, dated June 26, 2026, indicated, .She's home with son in apartment-prior and initial plan was to find a place for her discharge and agreed with son to coordinate with (name of facility) . The SSD further stated the facility did not arrange Resident 1's placement to assisted living and it should have been followed.On July 13, 2026, at 12:25 p.m., during an interview with Director of Nursing (DON), the DON stated the request of Resident 1 and family member should have been arranged and should have been followed up. The DON further stated if discharge plan is not followed, Resident 1 may potentially be discharged without appropriate support and services necessary to meet ongoing care needs.A review of the facility's policy and procedure titled, Discharge Summary and Plan, dated October 2022, indicated, .When a resident's discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge.developed by the care planning/interdisciplinary team with assistance of the resident and his or her family and includes.where the individual plans to reside.arrangements that have been made for follow-up care and services.If the resident indicates an interest in returning to the community, he or she will be referred to local agencies and support services that can assist in accommodating the resident's post discharge preferences.

Based on interview and record review, the facility failed to ensure care and treatment was provided, for one of four residents reviewed (Resident 1), when the resident's left great toe skin condition was not evaluated and referred to the physician for further treatment.This failure resulted in a delay in the care and treatment of Resident 1's skin condition and had a potential risk for further complications such as infection.Findings:On February 25, 2026, at 11:35 a.m., an unannounced visit was conducted at the facility to investigate complaints on quality of care.On February 25, 2026, at 2:16 p.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated Resident 1 complained of her feet hurting while she and CNA 2 were pulling up Resident 1 in bed on February 10, 2026. CNA 1 stated they removed her socks and saw a blister (a painful skin condition where fluid fills a space between layers of skin) on Resident 1's left great toe, with the skin slightly lifted and was pink underneath, but was not bleeding nor weeping (having secretions). CNA 1 stated she notified the Treatment Nurse (TN), stating to the TN that (Resident 1's nickname) had a blister on her left great toe, to which the TN replied, I'm doing rounds anyway. CNA 1 further stated when she returned to work two days later, she received no report or update that anything was done about the blister from the time she reported it to the TN, and when Resident 1's daughter reported it to the charge nurse, she recalled she had already reported it to the TN a couple of days prior.On February 26, 2026, at12:08 p.m., Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal blood sugar), morbid obesity (severe obesity), and dementia (decline in cognitive function-memory, language, problem-solving, and thinking, severe enough to interfere with daily life).A review of Resident 1's Minimum Data Set (MDS - a clinical assessment tool), indicated Resident 1 had memory problems and cognitive difficulty in new situations.A review of Resident 1's Order Summary Report, included physician's orders to send Resident 1 out to the ER (emergency room) for evaluation of left foot with green and red discoloration and skin tear and build up of skin debris, date ordered February 14, 2026. A review of Resident 1's eINTERACT Change in Condition Evaluation, dated February 14, 2026, indicated, .change in condition is .skin wound or ulcer.things that make the condition or symptoms unchanged.lack of treatment.Summary.Family approached nursing station and asked about skin concerns to LT (left) foot. Entered residents (sic) room and noted LT foot with green and red skin discoloration to great LT toe and top of LT foot with skin tear and build up of skin debris Further review of Resident 1's record There was no indication the wound on Resident 1's left big toe was assessed and referred to the physician for appropriate treatment when it was first identified by CNA 1 and reported to the TN on February 10, 2026.A review of resident 1's care plans indicated there was no documented evidence a care plan was developed to address the left foot wound.On February 26, 2026, at 12:58 p.m. CNA 2 was interviewed. CNA 2 stated she assisted CNA 1 to pull Resident 1 up in bed and Resident 1 had complained of pain on her left foot, in the beginning of February. CNA 2 stated CNA 1 took of the sock and realized the wound was there, it was not open yet and it as dry and flakey. CNA 2 stated CNA 1 told Resident 1 she was going to notify the TN, and CNA 1 left Resident 1's sock off to air dry the foot, and because the socks were hurting the foot.On February 26, 2026, at 1:24 p.m., the Licensed Vocational Nurse was interviewed. The LVN stated in the evening of February 14, 2026, Resident 44's family member (FM) went up to the nurses' station really upset about the wound on Resident 44's foot that she was not aware of at that time. The LVN stated she took pictures of the foot to send to the doctor and advised Resident 44's FM she was going to check if anything had been ordered for it. The LVN stated she did not see any treatment orders for the left foot skin condition. The LVN stated there were three specific areas where there was excess skin debris that were green in color, and the top of the foot was flakey. Additionally, Resident 1's toenail was really concerning since the bed was reddened; the lateral (side) part of the foot looked like a wound with blackened area and she could not tell if it was dried blood or a scab; and the entire left great toe was flakey and had greenish skin debris. The LVN also stated the FM told her it was extending under the toes, and as the LVN raised Resident 1's toes, the FM tried to grab some skin debris and the LVN stopped the FM from doing. The LVN stated it was extending between the left great toe and 2nd toe along the web of the foot. The LVN stated there was no prior communication to her about the skin condition and there was no documentation about it in Resident 1's chart. The LVN stated after the physician was notified and gave orders, Resident 1 was sent out to the GACH ER for evaluation of the wound.A review of the Director of Nursing's (DON) interview notes, dated February 15, 2026, indicated an interview with the TN. The document indicated the TN last evaluated Resident 1's foot two weeks prior, Resident 1 had an on and off issue with dryness and flakiness, which was treated with A & D ointment (Vitamin A and D topical application), and the wound care nurse practitioner did not round on Resident 1 because the skin condition was related to diabetes and vascular (related to blood vessels) issues.On February 26, 2026, at 2:46 p.m., the DON was interviewed. The DON stated she was notified by the LVN of the FM's complaint about Resident 1's left foot. The DON stated she investigated the matter and found out that CNA 1 notified the TN prior to February 14, 2026. The DON stated during her interview with the TN on February 15, 2026, the TN stated she evaluated the wound 2 weeks prior, was using wound wash on the wound and patting it dry, and applied A & D ointment, and the treatments were supposed to be daily or twice a week. The DON stated the TN was doing re-evaluations every 21 days, and the re-assessment of the site and re-evaluation of the treatment orders should have been done at that time. The DON stated during a follow up interview with the TN on February 16, 2026, she discussed with the TN how the prompt appeared on Resident 1's electronic medical records for a wound re-evaluation. The DON stated when she asked the TN if she should have done a re-evaluation, the TN stated, I've been doing it for 20 yrs, I have it in my memory.A review of the facility's policy and procedure titled, Resident Examination and Assessment, dated February 2014, indicated, .The purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan.Skin.intactness.moisture.color.texture.and.presence of bruises, pressure sores, redness, edema, rashes.Notify the physician of any abnormalities sch as, but not limited to.wounds or rashes on the resident's skin. Report all other information in accordance with facility policy and professional standards of practice.A review of the facility's policy and procedure titled, Change in a Residents' Condition or Status, revised February 2021, indicated, .Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status.The nurse will notify the resident's attending physician or physician on call when there has been a(an).significant change in the resident's physical/emotional/mental condition.need to transfer the resident to a hospital/treatment center.The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on observation, interview, and facility record review, the facility failed to ensure the sanitary requirements were met in the kitchen when: -An opened bag of frozen ground meat had an opened date of 7/11/24.-An opened container of Italian seasoning had a use-by date of 2/25/26.-The wire racks in the walk-in refrigerator were observed with dust.-A table-mounted can opener was observed with a brown sticky substance.-A pizza cutter was observed with crusty debris.-Five clear plastic bowls, five metal baking trays, and three plastic storage containers were stored and stacked on top of each other while still wet.These failures had the potential to expose 131 of 132 highly susceptible residents who received food from the kitchen to food borne illnesses (any illness resulting from eating contaminated/spoiled foods) due to cross-contamination (the transfer of harmful substances or disease-causing microorganisms to food). Findings: 1. During a concurrent observation and interview on 3/2/26 at 7:48 AM with Dietary Aide (DA) 1 during the initial tour, the following items were observed:-An opened, unlabeled, and undated bag of frozen ground meat was found in a box labeled Casa Solana Carne de Chorizo Sausage Bulk with an open date of 7/11/24 in the walk-in freezer.-An opened container of Italian seasoning had a use-by date of 2/25/26.DA 1 verified the findings and stated the food items should have been thrown away to prevent food borne illness and cross-contamination.A review of the facility's policy and procedure titled, Food Receiving and Storage, revised November 2022, indicated .Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. Dry foods that are stored in bins are removed from original packaging, labeled and dated ('use by' date). All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date). Refrigerated food are labeled, dated and monitored so they are used by their 'use-by' date, frozen, or discarded.2. During a concurrent observation and interview on 3/2/26 at 7:48 AM with DA 1, during the initial tour, the following items were observed:-Five clear plastic bowls were stored and stacked on top of each other while still wet.-The wire racks in the walk-in refrigerator were observed with dust.-A table-mounted can opener was observed with a brown sticky substance.-A pizza cutter was observed with crusty debris.-Five metal baking trays were stored and stacked on top of each other while still wet.3. During an observation and interview on 3/2/26 at 8:30 AM with the Director of Dietary Services (DDS), the following items were observed:-Three plastic food storage containers were stored and stacked on top of each other while still wet.The DDS verified the above findings and stated the food equipment should have been properly cleaned, sanitized, and completely dried before storing to prevent cross-contamination and food related illnesses.A review of the 2022 United States (U.S.) Food Code, Section 4-601.11 .Equipment, Food-Contact Surfaces, Nonfood-Contact Surface, and Utensils, indicated .the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Nonfood-contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris .A review of the 2022 U.S. Food Code, Section 4-602.13 .Nonfood-Contact Surfaces, indicated nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.A review of the 2022 U.S. Food Code, Section 4-901.11 Equipment and Utensils, Air- Drying Required, indicated .items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow .

Based on observation, interview, and facility record review, the facility failed to ensure the residents' food brought by visitors were properly labeled and stored in the refrigerator. This failure had the potential to expose highly susceptible residents who stored their foods in the unit refrigerator to foodborne illnesses (any illness resulting from eating contaminated/spoiled foods) due to cross-contamination (the transfer of harmful substances or disease- causing microorganisms to food). Findings:During a concurrent observation and interview on 3/2/26 at 8:52 AM with the Assistant Director of Nursing (ADON), the following were observed in the resident refrigerators:-One jar of Mango Thokku (grated pickled mango) was unlabeled and undated.-One Ziplock bag of dough-like food item with brown chunks on top was unlabeled and undated.-One frozen Starbucks drink was unlabeled and undated.-One bag of frozen tamales was unlabeled and undated.-Two beverages containers containing brown liquid were unlabeled and undated.The ADON stated all foods placed in the resident refrigerators should be labeled and dated prior to being stored to prevent food- borne illnesses.A review of the facility's policy and procedure titled Food Receiving and Storage, revised November 2022, indicated .All foods belonging to residents are labeled with the resident's name, the item and the 'use by' date. Beverages are dated when opened and discarded after twenty- four (24) hours .Other opened containers are dated and sealed or covered during storage .

Based on observation, interview, and facility record review, the facility failed to dispose and store trash in a sanitary manner.This failure had the potential to increase the risk of pest infestation in the facility.Findings:During a concurrent observation and interview on 3/2/26 at 3:24 PM with Dietary Aide (DA) 3, four of the five outdoor garbage dumpsters were observed uncovered. DA 3 stated the dumpsters should be kept closed. During a follow up interview on 3/2/26 at 3:50 PM with the Director of Dietary Services (DDS), the DDS stated the garbage dumpsters should be kept covered to prevent attracting pests, which may spread illness and disease. A review of the 2022 United States (U.S.) Food Code, Section 5-501.113 Covering Receptacles, indicated Receptables and waste handling units for refuse, recyclables and returnables, shall be kept covered:. (B) With tight fitting lids or doors if kept outside the food establishment.

Based on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with physician orders and professional standards of practice when a medication error rate of 8.62% was identified, with five medication errors out of 58 medication administration opportunities, during medication administration observations for four of eight residents observed (Residents 38, 148, 168, and 169).These failures included administration of medications in inappropriate dosage forms, improper medication administration technique inconsistent with professional standards, and administration of medications outside physician-ordered parameters, which had the potential to compromise medication effectiveness, increase the risk of adverse drug effects, and result in potential adverse clinical outcomes including gastrointestinal (stomach and intestine) irritation, infection (such as oral thrush), and compromised medication therapy and resident safety.Findings: 1. During a medication administration observation for Resident 169 on 3/2/26 at 8:22 AM, Licensed Vocational Nurse (LVN) 3 prepared 12 oral medications by crushing nine tablets and opening three capsules and mixing them with chocolate pudding. The prepared pudding mixture included the following:- Potassium chloride (supplement) extended-release (ER - a medication formulation designed to release the drug slowly over an extended period) 20 milliequivalent (mEq - a unit of measurement) tablet. LVN 3 crushed the tablet and mixed it with other medications in chocolate pudding; and- Aspirin (used to prevent blood clots) enteric-coated (EC - a coating on the drug tablet to protect the stomach and to allow aspirin to pass through the stomach to the small intestine before dissolving) 81 milligram (mg - a unit of measurement) tablet. LVN 3 placed the whole tablet into the pudding mixture with other crushed medications.During a concurrent observation on 3/2/26 at 8:33 AM, LVN 3 administered the pudding mixture to Resident 169 by the spoonful. LVN 3 provided three spoonfuls of the mixture. Resident 169 chewed each spoonful before swallowing. The pudding mixture contained the aspirin enteric-coated tablet.A review of Resident 169's physician orders indicated the following orders:- Potassium chloride extended-release 20 mEq, Give 1 tablet by mouth one time a day for Supplement, dated 2/25/26.- Aspirin delayed-release 81 mg, Give 1 tablet by mouth one time a day for clot ppx (prophylaxis - prevention) . dated 2/24/26.During a concurrent interview and record review on 3/3/26 at 10:17 AM with LVN 3, LVN 3 acknowledged the aspirin EC tablet could be chewed when mixed with pudding unless the resident was instructed to swallow it whole. LVN 3 stated she should have notified the physician to consider changing the order to a chewable aspirin or administer the aspirin EC tablet separately with water. LVN 3 also acknowledged the potassium chloride ER tablet should not have been crushed and stated crushing the tablet could cause the medication to be released immediately rather than slowly.During a concurrent interview on 3/3/26 at 4:22 PM with the Director of Nursing (DON), the DON stated nursing staff should have contacted the pharmacy to identify alternative formulations and notified the physician to obtain an appropriate order rather than crushing the extended-release potassium tablet and adding the aspirin EC tablet with the pudding.2. During a medication administration observation for Resident 38 on 3/2/26 at 8:38 AM, LVN 3 prepared five oral medications including potassium chloride ER 20 mEq tablet.During a concurrent observation on 3/2/26 at 8:49 AM, LVN 3 crushed the potassium chloride ER tablet with other medications and mixed the crushed medications with chocolate pudding.During a concurrent observation on 3/2/26 at 8:50 AM, LVN 3 administered the pudding mixture containing the crushed medications to Resident 38.A review of Resident 38's physician order, dated 9/1/23, indicated Potassium Oral Tablet (Potassium) 20 mEq .Give by mouth one time a day for supplement .Give with 8 oz (ounce - a unit of measurement) water.During a concurrent interview on 3/3/26 at 10:20 AM with LVN 3, LVN 3 confirmed the potassium chloride ER tablet was crushed and mixed with pudding. LVN 3 acknowledged she should not have crushed the medication and stated crushing the tablet could cause the medication to be released immediately rather than slowly over time.During a concurrent interview on 3/3/26 at 4:22 PM with the DON, the DON stated nursing staff should have contacted the pharmacy for alternative formulations and notified the physician to obtain an appropriate order rather than crushing the extended-release potassium tablet.A review of the manufacturer's package inserts (document included in the package of a medication with information about drug and its use) for potassium chloride ER tablets indicated .To take each dose without crushing, chewing or sucking the tablets. If those patients are having difficulty swallowing whole tablets, they may try one of the following alternate methods of administration: a. Break the tablet in half and take each half separately with a glass of water. b. Prepare an aqueous (water) suspension as follows: 1. Place the whole tablet(s) in approximately 1/2 glass of water (4 fluid ounces). 2. Allow approximately 2 minutes for the tablet(s) to disintegrate. 3. Stir for about half a minute after the tablet(s) has disintegrated. 4. Swirl the suspension and consume the entire contents of the glass immediately by drinking or by the use of a straw. 5. Add another one fluid ounce of water, swirl, and consume immediately. 6. Then, add an additional one fluid ounce of water, swirl, and consume immediately.3. During a medication administration observation on 3/2/26 at 9:05 AM, LVN 3 prepared 14 medications for Resident 148, including Pulmicort (budesonide inhalation powder, an inhaled corticosteroid used to reduce airway inflammation) Flexhaler (a breath-activated dry powder inhaler that releases medication when the resident inhales through the mouthpiece) 90 microgram (mcg - a unit of measurement), and Anoro Ellipta inhaler (a combination inhalation medication containing umeclidinium and vilanterol used to treat chronic obstructive pulmonary disease ([COPD], a lung disease causing difficulty breathing) 62.5 mcg/25 mcg.During a concurrent observation on 3/2/26 at 9:19 AM, Resident 148 self-administered one puff of Anoro Ellipta followed by one puff of Pulmicort. Immediately afterward, LVN 3 handed the resident oral medications with water, and the resident swallowed the medications without rinsing the mouth.A review of Resident 148's physician order, dated 2/1/26, indicated Pulmicort Flexhaler 90 mcg per actuation (one inhalation dose released from the inhaler when activated), 1 puff inhale orally every 12 hours for COPD [chronic obstructive pulmonary disease - a progressive lung disease which blocks air flow making breathing difficult].During a concurrent interview and record review on 3/3/26 at 10:26 AM with LVN 3, LVN 3 confirmed Resident 148 did not rinse the mouth and spit after the Pulmicort inhalation. LVN 3 stated she previously explained to Resident 148 that rinsing the mouth and spitting after inhalation of Pulmicort helped prevent oral thrush infection. LVN 3 acknowledged she did not document the refusal or notified the physician for further instruction.During a concurrent interview on 3/3/26 at 4:25 PM, the DON stated the manufacturer's instructions for Pulmicort should be followed, and nursing staff should notify the physician because a resident refusal required further administration steps.A review of the manufacturer's package inserts for Pulmicort Flexhaler, dated 7/2025, indicated .After inhalation, the patient should rinse the mouth with water without swallowing.Warnings and Precautions.In clinical studies, the development of localized infections of the mouth and pharynx with Candida albicans has occurred in patients treated with PULMICORT FLEXHALER.Patients should rinse the mouth after inhalation of PULMICORT FLEXHALER. 4. During a medication administration observation on 3/2/26 at 9:33 AM, LVN 5 asked Resident 168 what pain level the resident was currently experiencing. Resident 168 stated the pain level was 3 (mild pain, on a 0-10 pain scale, where 0 indicates no pain and 10 indicates severe pain) and requested stronger medication before the scheduled physical therapy. LVN 5 prepared and administered oxycodone-acetaminophen 5-325 mg (generic for Percocet, a narcotic pain medication used to treat moderate to severe pain) to Resident 168.During a record review on 3/2/26 at 3:43 PM, Resident 168's physician orders indicated the following orders on 2/19/26:-Oxycodone-acetaminophen 5-325 mg, Give 1 tablet by mouth every 4 hours as needed for moderate pain (4-6) .-Acetaminophen (pain medication) 325 mg, Give 1 tablet by mouth every 4 hours as needed for mild pain 1-3 .A review of Resident 168's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for March 2026, indicated Resident 168's pain level was documented as 3 prior to the administration of Percocet on 3/2/26.During an interview on 3/2/26 at 4:15 PM with LVN 5, LVN 5 stated Resident 168 refused acetaminophen and requested a stronger pain medication prior to physical therapy. LVN 5 further stated she wrote made a progress note documenting the resident's request.During a concurrent interview and record review on 3/3/26 at 12:51 PM with LVN 5, LVN 5 acknowledged the physician's order was not followed and stated she should have reassessed the resident's pain and notified the physician for clarification of the order.During a concurrent interview on 3/3/26 at 4:30 PM with the DON, the DON confirmed the Percocet was administered when the resident's documented pain level was 3 and stated nursing staff should follow physician-ordered pain parameters or contact the physician for clarification.A review of the facility's policy and procedures titled Administering Medications, dated April 2019, indicated .Medications are administered in accordance with prescriber orders.If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident.the person preparing or administering the mediation will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns.The individual administering the medication checks he label THREE (3) times to verify.right medication, right dosage.before giving the medication.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when:The Maintenance Assistant (MA) did not perform hand hygiene before entering and after leaving a room on Enhanced Barrier Precautions ([EBP] - an infection control prevention designed to reduce the transmission of multi-drug-resistant organisms (MDROs) in healthcare settings, particularly nursing homes).An Activity Assistant (AA) did not perform hand hygiene before entering and after leaving a room on EBP.A Physical Therapy Assistant (PTA) did not perform hand hygiene and did not wear proper personal protective equipment ([PPE] - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) before and after providing care to Resident 46, who was on EBP.Resident 46's respiratory supplies had no label.Resident 74's respiratory supplies had no label.A Licensed Vocational Nurse (LVN) 3 did not clean and disinfect shared medical equipment, blood pressure (BP - the force of blood pushing against the walls of the blood vessels as the heart pumps) cuff (a reusable inflatable medical device placed around the arm to measure blood pressure), stethoscope (a medical listening device used to listen to sounds inside the body), and pulse oximeter (a reusable finger device placed on the finger to measure the pulse rate and oxygen level in the blood) between each use for Residents 38, 148, and 169, in accordance with the facility's infection control policy.These failures had the potential for cross-contamination and spread of infection which can adversely affect the health and wellbeing of 132 medically compromised residents. 1. During an observation on 3/2/26 at 9:19 AM, room [ROOM NUMBER] had a signage posted next to the entry door that indicated, STOP .ENHANCED BARRIER PRECAUTIONS .EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and gown for the following High-Contact Resident Care Activities. Dressing, Bathing,/Showering, Transferring . During an observation on 3/2/26 at 9:21 AM, in the hallway of station 4, the MA entered and left room [ROOM NUMBER] without performing any hand hygiene. During an interview on 3/2/26 at 9:25 AM with the MA, the MA acknowledged he did not perform hand hygiene before entering and after leaving the room. He also stated that it was important to wash hands or perform hand hygiene to prevent the spread of germs to staff and other people. 2. During an observation on 3/2/26 at 9:31 AM, room [ROOM NUMBER] had a signage posted next to the entry door that indicated, STOP .ENHANCED BARRIER PRECAUTIONS .EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring . During a concurrent observation and interview on 3/2/26 at 9:32 AM, in the hallway of station 4, the AA was observed distributing the The Daily Chronicles (a daily record of events) to residents inside the room. The AA entered and left room [ROOM NUMBER] without performing any hand hygiene. The AA acknowledged that there was an EBP signage posted and that the expectations were for staff to follow them. The AA stated that it was important to follow precautions to prevent the spread of germs and protect staff and residents. During an interview on 3/4/26 at 4:02 PM with the Infection Preventionist (IP), the IP stated staff were expected to follow EBP and emphasized that staff should perform hand hygiene before entering and after leaving the resident's room, whether they were on EBP or not. She added that it was unacceptable for staff not to practice hand hygiene, as it was a standard precaution. The IP stated that it was very important to prevent the spread of infection. During an interview on 3/4/26 at 4:17 PM with the Registered Nurse (RN ) 1, RN 1 stated that the staff was expected to follow EBP and use the proper PPE. RN 1 added that these were important to prevent the transmission of infections. 3. During an observation on 3/5/26 at 8:46 AM, room [ROOM NUMBER] had a signage posted next to the entry door that indicated, STOP .ENHANCED BARRIER PRECAUTIONS .EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and gown for the following High-Contact Resident Care Activities. Dressing, Bathing,/Showering, Transferring . During an observation on 3/5/26 at 8:48 AM, in front of room [ROOM NUMBER], the PTA entered the room and donned gloves without performing hand hygiene. The PTA put on Resident 164's socks and gait belt and then assisted the resident to transfer from the bed to the walker without wearing a gown. The PTA then removed her gloves and left the room with the resident without performing any hand hygiene. During an interview on 3/5/26 at 8:52 AM with the PTA, the PTA acknowledged that she should have performed hand hygiene and worn gown while providing care to the resident. During a concurrent interview and record review on 3/5/26 at 11:34 AM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Handwashing/Hand Hygiene, revised October 2023, Enhanced Barrier Precautions dated August 2022 and Policies and Practices-Infection Control revised April 2025 were reviewed. The DON stated that the staff was expected to wear the proper PPE and follow EBP. The DON verified that based on the observations made by the surveyor, the facility did not follow its P&P. A review of the facility's P&P titled Handwashing/Hand Hygiene, revised October 2023, indicated .This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections .Administrative Practices to Promote Hand Hygiene.2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.Indications for Hand Hygiene: 1. Hand hygiene is indicated: a. Immediately before touching a resident;.d. after touching a resident; e. after touching the resident's environment; .g. immediately after glove removal.5. The use of gloves does not replace hand washing/hand hygiene.Procedure: Applying and Removing Gloves: 1. Perform hand hygiene before applying non-sterile gloves. A review of the facility's P&P titled Enhanced Barrier Precautions, dated August 2022, indicated . Enhanced barrier precautions (EBP) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents .Policy Interpretation and Implementation .2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing.c. transferring.6. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk.10. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. A review of the facility's P&P titled Policies and Practices- Infection Control, revised April 2025, indicated . This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy Interpretation and Implementation: 1. This facility's infection control policies and practices apply equally to all personnel, consultants, contractors.2. The objectives of our infection control policies and practices are to: a. prevent, detect, investigate, and control infections in the facility;.c. establish guidelines for implementing isolation precautions, including standard and transmission-based precautions. 4. During an initial tour observation on 3/2/26 at 8:35 AM, inside room [ROOM NUMBER], a plastic respiratory bag containing nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) tubing, nebulizer mask (a flexible respiratory supply, covering both the nose and mouth used to deliver liquid medication directly into the lungs as a fine mist), and nebulizer tubing were observed at resident's bedside. All the respiratory supplies and bag had no label. During a concurrent observation and interview on 3/2/26 at 8:55 AM, inside room [ROOM NUMBER], Licensed Vocational Nurse (LVN) 1 stated that Resident 46 was out of the facility for an appointment. LVN 1 acknowledged that the respiratory bag was unlabeled, and the nasal cannula, nebulizer mask, and tubing were also undated. LVN 1 stated that the expectations were for these supplies to be changed at least weekly and should be labeled with resident's name and date. A review of Resident 46's admission Record, (a document showing a summary of the resident's information), dated 3/5/26, indicated the resident was admitted to the facility on [DATE], with diagnoses that included chronic congestive heart failure ([CHF] -a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), pneumonia (an infection/inflammation in the lungs), and resistance to multiple antimicrobial drugs (antibiotics). A review of Resident 46's Order Summary Report, dated 3/5/26, indicated Resident 46 had the following orders: -Change Oxygen Nasal Cannula Q [every] wk [week] on Wednesday and PRN [as needed] (with name and date label) every night shift every Wed.-Oxygen at 2liter/min via Nasal Cannula continuously every shift.-IPRAT-ALBUT (Ipratropium- Albuterol) 0.5-3 (2.5) MG [(mg) - metric unit of measurement, used for medication dosage and/or amount) /3 ML ([ml] - metric unit of measurement for volume of a liquid) 1 vial inhale orally via nebulizer four times a day for SOB [shortness of breath]. During an interview on 3/4/26 at 12:33 PM with RN 1, RN 1 stated that respiratory supplies needed to be changed weekly, on Wednesdays. RN 1 also stated that staff were expected to label these supplies with the resident's name, date, and time. RN1 added that it was unacceptable to change and not label them as it was the facility's policy. RN 1 stated it was important for staff to know when the supplies were last changed, how long they were used, and when they needed to be changed. During an interview on 3/4/26 at 3:56 PM with the IP, the IP stated staff were expected to change and label respiratory supplies every week on Wednesdays. The IP added these were important for infection control and it was a respiratory care standard. During an interview on 3/5/26 at 11:41 AM with the DON, the DON stated she expected the staff to label the respiratory bag with the resident's name and date. The DON also added that the nasal cannula and nebulizer tubing should be labeled as well. The DON further stated that it was unacceptable to leave these respiratory supplies unlabeled. 5. During an observation on 3/1/26 at 8:58 AM, in Resident 74's room, Resident 74's nasal cannula and humidifier solution container did not have any labels or dates on them. During a concurrent observation and interview on 3/1/26 at 9:02 AM with RN 2, in Resident 74's room, RN 2 confirmed the nasal cannula and humidifier solution container were not labeled and dated. During an interview on 3/4/26 at 10:20 AM with the Director of Staff Development (DSD), the DSD stated that the facility taught all nurses to label and date the nasal cannula and humidifier solution containers. During an interview on 3/4/26 at 3:40 PM with the DON, the DON confirmed that the facility's official practice was to label and date all humidifier solutions and nasal cannula tubing. A review of Resident 74's Order Summary Report, dated 3/4/26, indicated Resident 74 had the following orders:-Change O2 humidifier Q Wk_on_WED and PRN when consumed (w/name & date label) every night shift every Wed.-Change Oxygen Nasal Cannula Q Wk on_WED_and PRN (w/name & date label) every night shift every Wed. 6a. During a medication administration observation on 3/2/26 at 8:17 AM for Resident 169, LVN 3 used a BP cuff, stethoscope, and pulse oximeter to obtain Resident 169's blood pressure and pulse in the resident's room. After obtaining Resident 169's blood pressure and pulse, LVN 3 placed the used BP cuff and pulse oximeter on the medication cart surface and placed the stethoscope over the sharps container attached to the side of the medication cart without cleaning or disinfecting the equipment. b. During another medication administration observation on 3/2/26 at 8:38 AM, LVN 3 used the same BP cuff, stethoscope, and pulse oximeter that had not been previously cleaned or disinfected to obtain Resident 38's blood pressure in the resident's room. After obtaining Resident 38's blood pressure and pulse, LVN 3 placed the used BP cuff and stethoscope into the bottom drawer of the medication cart and placed the pulse oximeter into its cover bag located on the medication cart surface, without cleaning or disinfecting the equipment. c. During another medication administration observation on 3/2/26 at 9:05 AM, LVN 3 used the same BP cuff, stethoscope, and pulse oximeter that had not been previously cleaned or disinfected to obtain Resident 148's blood pressure in the resident's room. During an interview on 3/3/26 at 10:26 AM with LVN 3, LVN 3 acknowledged the BP cuff, stethoscope, and pulse oximeter were not cleaned or disinfected between each use for Residents 38, 148, and 169. LVN 3 stated the BP cuff, stethoscope, and pulse oximeter were shared equipment and should have been cleaned and disinfected before and after each use with wipes in the purple cap container (Sani-Cloth germicidal [disinfectant that kills germs such as bacteria and viruses] disposable wipes) available in the medication cart for infection control. During an interview on 3/3/26 at 4:22 PM with the DON, the DON stated any shared medical equipment, including the BP cuff, stethoscope, and pulse oximeter must be cleaned and disinfected with disinfectant wipes before and after each use for infection control. A review of the facility's P&P titled, Cleaning and Disinfecting of Resident-Care Items and Equipment, dated September 2022, indicated .Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Centers for Disease Control and Prevention - a nationally recognized disease control and prevention organization) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration – a government agency for workplace safety) Bloodborne Pathogens (disease-causing germs, like viruses or bacteria in human blood and other body fluids that can cause disease in people) Standard.c. Non-critical items are those that come in contact with intact skin. Non-critical resident-care items include bedpans, blood pressure cuffs.Non-critical items require cleaning followed by either low- or intermediate-level disinfection following manufacturer's instructions. Disinfection is performed with an EPA [Environmental Protection Agency – U.S. federal government agency regulating and approving disinfectants used to kill germs]-registered disinfectant labeled for use in healthcare settings.Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment) .

Based on interview and record review, the facility failed to provide written information concerning the right to formulate an Advance Directive (a written document specifying an individual's medical care wishes) for three of 26 sampled residents (Residents 3, 7, and 88).This failure could pose significant risks that may negatively affect the residents' quality of life and medical care, leading to medical interventions that do not align with the residents' preferences.Findings:1. A review of Resident 3's admission Record, (a document showing a summary of the resident's information) dated 3/4/26, indicated Resident 3 was readmitted to the facility on [DATE].A review of Resident 3's Physician Orders for Life-Sustaining Treatment, ([POLST] - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) dated 12/7/23, indicated that Resident 3 had no Advance Directive.A review of Resident 3's medical records revealed no Advanced Healthcare Directive Acknowledgment Form (a form that serves as proof to healthcare providers that the Advance Directive is authentic and valid, allowing them to follow resident wishes regarding medical care, end-of-life decisions, and the appointment of a healthcare agent) was completed.2. A review of Resident 7's admission Record, dated 3/4/26, indicated Resident 7 was readmitted to the facility on [DATE]. A review of Resident 7's POLST, dated 1/12/23, indicated that Resident 7 had no Advance Directive.A review of Resident 7's medical records revealed no Advanced Healthcare Directive Acknowledgment Form.3. A review of Resident 88's admission Record, dated 3/4/26, indicated Resident 88 was readmitted to the facility on [DATE].A review of Resident 88's POLST, dated 10/2/24, indicated that Resident 7 had no Advance Directive.A review of Resident 88's medical records revealed no Advanced Healthcare Directive Acknowledgment Form was completed.During a concurrent interview and record review on 3/3/26 at 10:38 AM, with the Social Services Director (SSD), Residents 3, 7, and 88's medical records were reviewed. The SSD confirmed that there was no Advanced Healthcare Directive Acknowledgment Form provided to the residents or their representatives concerning their rights to formulate an Advance Directive. The SSD stated that the Advanced Healthcare Directive Acknowledgment Form should be completed and discussed with the residents or their family members upon admission.During an interview on 3/4/26 at 4:06 PM, with the Director of Nursing (DON), the DON stated that an Advanced Healthcare Directive Acknowledgment Form should be completed upon admission for all residents. The DON emphasized that the importance of formulating an Advance Directive was to honor the rights and wishes of the residents.A review of the facility's policy and procedure titled Advance Directives, revised September 2022, indicated .The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy.1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives.

Based on interview and record review, the facility failed to ensure accuracy of the Preadmission Screening and Resident Review ([PASRR] - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) Level 1 Screening assessment for one of 26 sampled residents (Resident 3).This failure resulted in the missed identification of a serious mental illness that could potentially lead to improper placement or failure to provide appropriate specialized treatment for the resident.Findings:A review of Resident 3's admission Record, (a document showing a summary of the resident's information) dated 3/4/26, indicated Resident 3 was readmitted to the facility on [DATE]. Resident 3's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought).A review of Resident 3's CUSTODIAL CARE Re-admission, dated 10/1/24, indicated Resident 3 was .being treated for an unspecified psychiatric condition with Zyprexa (olanzapine [a medication primarily used to treat schizophrenia]). Under the plan, the document indicated that Resident 3 had unspecified schizophrenia presently managed with medication and indicated continuation of Zyprexa. A review of Resident 3's Order Summary Report, dated 3/5/26, indicated orders for olanzapine 20 milligram ([mg] - metric unit of measurement, used for medication dosage and/or amount) by mouth at bedtime for schizophrenia manifested by paranoid delusions (irrational thoughts and beliefs become so fixed that nothing can convince a person that what they think or feel is not true) and to monitor for psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) every shift for olanzapine use. A review of Resident 3's Preadmission Screening and Resident Review (PASRR) Level 1 Screening, dated 7/10/24, 6/26/23, and 5/31/23, indicated the answer No for the questions asking whether Resident 3 had a diagnosed serious mental illness such as schizophrenia/schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) or symptoms of psychosis and psychotropic medication (a prescription drug to treat mental health conditions). During a concurrent interview and record review on 3/3/26 at 10:51 AM, with the Minimum Data Set ([MDS] - a standardized assessment tool) Supervisor (MDS-S), Resident 3's Preadmission Screening and Resident Review (PASRR) Level 1 Screening, dated 7/10/24, 6/26/23, and 5/31/23 were reviewed. The MDS-S confirmed that Resident 3's PASRR Level 1 Screenings were not accurately completed. The MDS-S verified that Resident 3 had a serious mental illness and was on psychotropic medication. The MDS-S emphasized the importance of accurate assessment for residents to receive appropriate treatment.During an interview on 3/4/26 at 4:06 PM with the Director of Nursing (DON), the DON stated that residents should be screened for PASRR Level 1 upon admission by the admission staff, and the assessment should be updated as needed by the MDS nurse. The DON confirmed that the PASRR Level 1 Screening should have an accurate assessment to trigger Level 2 Screening when needed.A review of the facility's policy and procedure titled admission Criteria, revised March 2019, indicated .Our facility admits only residents whose medical and nursing care needs can be met. 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process.

Based on observation, interview, and record review, the facility failed to ensure one of 26 sampled residents (Resident 73) who received necessary assistive devices to support eating and maintain independence, had a required physician's order for their use.This failure had the potential to affect the resident's safety, dignity, and ability to receive individualized care.Findings:During an observation on 3/2/26 at 12:21 PM in the dining room, Resident 73 was observed sitting in a wheelchair being assisted by staff with lunch. Resident 73 was observed with a plate guard (a curved, plastic, or metal barrier that clips onto the edge of a standard plate used to assist residents while eating) and adaptive utensils (specially designed eating tools used to help individuals who have difficulty feeding themselves due to physical, cognitive, or neuromuscular limitations).A review of Resident 73's admission Record (a document showing a summary of the resident's information), dated 3/4/26, indicated Resident 73 was initially admitted to the facility on [DATE], with diagnoses including displaced fracture of sixth cervical vertebra (one of the seven bones in the neck), muscle wasting and atrophy (weakening, shrinking, and loss of muscle), and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities).A review of Resident 73's Order Summary Report, dated as of 3/4/26, failed to show a physician's order for the use of the plate guard and adaptive eating utensils.During a concurrent interview and record review on 3/5/26 at 4:05 PM with the Director of Nursing (DON), Resident 73's medical record was reviewed. The DON verified the resident did not have a physician's order for the use of the plate guard and adaptive eating utensils. The DON stated the hospice will usually communicate with the facility's staff regarding any new and current orders, and then the staff will update the residents' orders in the system. The DON stated that obtaining a physician's order was important to ensure the residents receive the appropriate services and to allow staff to reassess the need for adaptive equipment in the future.

Based on observation, interview, and record review, the facility failed to ensure IV (Intravenous- fluids given directly into the blood stream) therapy was provided consistently in accordance with the professional standards of practice, physician orders, and comprehensive person-centered care plans for two of four sampled residents (Residents 2 and 59) when:-There was no documented evidence indicating that Resident 2's IV antibiotic was administered on 2/4/26 and 2/5/26 as ordered.-There was no documented evidence that Resident 2's PICC line (Peripherally Inserted Central Catheter - a thin flexible tube inserted to a large vein in the upper arm used to deliver medications for long term treatments) was flushed with normal saline on 2/4/26 and 2/5/26 as ordered. -Resident 2's PICC line dressing had no label.-Resident 59's PICC line dressing was not changed as ordered. Cross reference to F842, Example#1.These failures had the potential to put Residents 2 and 59 at risk for infections and complications that may negatively affect their overall health and well-being.Findings:1a. During an initial tour observation on 3/2/26 at 10:16 AM, inside the resident's room, Resident 2 was awake, alert, and lying on his bed while watching TV. Resident 2's IV antibiotic was infusing via the PICC line on his right upper arm.A review of Resident 2's admission Record, (a document showing a summary of the resident's information) dated 3/3/26, indicated the resident was admitted to the facility on [DATE], with diagnoses that included streptococcal sepsis (a life-threatening bacterial blood infection) and abscess of liver (pus in the liver).A review of Resident 2's physician order, dated 2/2/26 at 09:18 AM, indicated an order to discontinue the following order:-Piperacillin-Tazobactam-NaCl [a type of antibiotic] Intravenous Solution Reconstituted 4-0.5GM/100ML [gram (a metric unit of measurement for mass/weight)/milliliter (a unit of measurement)] (Piperacillin Sodium-Tazobactam Sodium-Sodium Chloride) Use 4.5 gram intravenously every 12 hours for strep septicemia/abscess (a serious bloodstream infection caused by streptococcus bacteria) until 2/5/26 23:59. The order indicated the reason for discontinuation was to change the dose to 3.375 grams IV every 12 hours until 2/5/26 and to infuse the medication over four hours.A review of Resident 2's IV Administration Record, (legal document used to track intravenous medications) dated 2/1/2026 to 2/28/2026, indicated to administer the updated order for Piperacillin-Tazobactam-NaCl 3.375 grams IV every 12 hours starting on 2/2/26 at 9:00 PM. However, there was no documented evidence indicating the medication was administered on 2/4/25 and 2/5/26 at 9:00 PM, as the boxes in the IV Administration Record were left blank.A review of the facility's policy & procedure (P&P) titled GENERAL POLICIES FOR IV THERAPY, dated March 2014, indicated .M. Documentation of IV therapy should include but is not limited to:.IV medication administration.b. A review of Resident 2's Order Summary Report dated as of 3/3/26, indicated orders to Flush PICC line (specify) lumen with 10 ml of normal saline [a salt water solution] every 12 hours for maintenance and Flush PICC line (specify) lumen with 10 ml saline before and after IV medications every 12 hours.A review of Resident 2's IV Administration Record, dated 2/1/2026 to 2/28/2026, indicated to Flush PICC line (specify) lumen with 10 ml of normal saline every 12 hours for maintenance and to Flush PICC line (specify) lumen with 10 ml saline before and after IV medications every 12 hours starting on 1/29/26 at 9:00 PM. However, there was no documented evidence indicating the medications were administered on 2/4/25 and 2/5/26 at 9:00 PM, as the boxes in the IV Administration Record were left blank.During an interview on 3/5/26 at 9:10 AM with Registered Nurse (RN) 2, RN 2 stated that staff were expected to flush the PICC line with normal saline first, administer the antibiotic, and then flush the line again with normal saline. RN 2 also stated staff were expected to document after medication administration to indicate that the task was done.During a concurrent interview and record review on 3/5/26 at 9:34 AM with RN 2, RN 2 reviewed Resident 2's medical record via PCC (PointClickCare- cloud-based electronic health record) and confirmed there was no documented evidence that the staff flushed Resident 2's PICC line and administered the antibiotic on 2/4/26 and 2/5/26 at 9PM.During a concurrent interview and record review on 3/5/26 at 9:46 AM, with the Assistant Director of Nursing (ADON), the ADON reviewed Resident 2's medical record via PCC and stated that she did not see any documentation indicating that the staff flushed Resident 2's PICC line and administered the antibiotic on 2/4/26 and 2/5/26 at 9PM.During a concurrent interview and record review on 3/5/26 at 11:48 AM with the Director of Nursing (DON), the DON reviewed Resident 2's medical record via PCC. The DON verified Resident 2's PICC line flush was missed and there was no documented evidence that Resident 2's antibiotic was administered on 2/4/26 and 2/5/26 at 9 PM.A review of Resident 2's Care Plan Report, indicated the following care plan problems:- Resident requires Enhanced Barrier Precautions ([EBP] - an infection control prevention designed to reduce the transmission of multi-drug-resistant organisms [MDROs] in healthcare settings, particularly nursing homes) related to PICC Line right upper arm on IV Antibiotic therapy for abdominal abscess, Septicemia.Interventions: IV ABX (antibiotic) AS ORDERED .- Altered hepatic function r/t (related to) Liver Abscess [pus in the liver], Liver Cirrhosis [liver disease] with Ascites [buildup of fluids in the abdomen].Interventions .Administer medications as ordered.c. During an initial tour observation on 3/2/26 at 10:16 AM, inside the resident's room, Resident 2 was awake, alert, and lying on his bed while watching TV. Resident 2's IV antibiotic was infusing via PICC line on his right upper arm. The PICC line dressing had no label.During a concurrent observation and interview on 3/2/26 at 11:59 AM with RN 2, RN 2 confirmed that Resident 2's PICC line dressing had no label. RN 2 stated that staff were expected to label the dressing with the date, time, and staff initials. RN 2 added that this was important, so staff knew when to change the dressing and for infection control purposes.A review of Resident 2's Order Summary Report, dated as of 3/3/26, indicated Resident 2 had the following orders: Antimicrobial disc [small, absorbent pad that inhibit bacterial growth] will be utilized for all central/midline sites and changed every 7 days with dressing change. One time a day every Sun. with a start date of 2/1/26 and Change PICC line dressing, Stat-lock [adhesive-based medical device designed to securely hold PICC line in place] every day shift every Sun [Sunday] if gauze dressing is used change every 48 hours. with a start date of 2/1/26. 2. During a concurrent observation and interview on 3/2/26 at 11:28 AM with RN 2, RN 2 read the label of Resident 59's PICC line dressing and confirmed the date written was 2/16/26. RN 2 added that the dressing was normally changed every seven days. Resident 59's dressing change was seven days overdue.A review of Resident 59's admission Record, dated 3/3/26, indicated the resident was readmitted to the facility on [DATE], with diagnoses that included cutaneous abscess of abdominal wall (localized collection of pus caused by bacterial infections, surgical complications, or trauma), malignant neoplasm of the prostate (prostate cancer), and acute osteomyelitis (a serious bone infection causing severe pain, inflammation, fever, and potential bone death).A review of Resident 59's Order Summary Report, dated as of 3/3/26, indicated Resident 59 had the following orders: Antimicrobial disc will be utilized for all central/midline sites and changed every 7 days with dressing change. one time a day every 7 day(s) . with a start date of 2/18/26 and .Change PICC line dressing, Stat-lock every day shift every 7 day(s) if gauze dressing is used change every 48 hours. with a start date of 2/18/26.A review of Resident 59's Progress Notes, dated 2/18/2026, indicated .dressing dated 2/16/26 due on 2/23/26. and Antimicrobial disc will be utilized for all central/midline sites and changed every 7 days with dressing change. One time a day every 7 day(s) .During an interview on 3/5/26 at 10:00 AM with the ADON, the ADON stated that staff were expected to change PICC line dressings every week, on Sundays. The ADON also stated that staff should label the dressing with date and initials every dressing change. The ADON added that this was important for IV site monitoring and infection prevention.During a concurrent interview and record review on 3/5/26 at 11:58 AM with the DON, the DON reviewed Resident 59's medical record via PCC. The DON stated Resident 59's PICC line dressing dated 2/16/26 was from the hospital, and there was no documented evidence that it was changed on 2/23/26. The DON stated Resident 59's PICC line dressing had not been changed since admission.During a follow-up interview on 3/5/26 at 12:10 PM with the DON, the DON stated that staff were expected to follow the facility's P&P for PICC line dressing change.A review of Resident 59's Care Plan Report, indicated .The resident has infection of the Osteomyelitis [inflammation of the bone or bone marrow, usually due to infection] of Pubic Symphysis [the location where the two halves of the pelvic bones meet in front of the body].Anterior abdominal wall abscess.Interventions . Administer IV antibiotic medication as ordered .Change IV dressing per order.A review of the facility's Registered Nurse Supervisor's Job Description, indicated POSITION SUMMARY: The purpose of your job description is to supervise the day-to-day activities of the facility during your shift in accordance with current federal, state, and local standards that govern the facility, and as directed by your management. The Registered Nurse Supervisor.will be committed to always doing the right thing. ESSENTIAL DUTIES AND RESPONSIBILITIES.Monitoring nursing staff to ensure they are complying with resident's care plan.Passing out medications when needed.Abiding with all facility policies and procedures.Following Infection and Control policies.A review of the facility's P&P titled Central Venous Catheter and Dressing Changes, revised March 2022, indicated .The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. General Guidelines: 1. Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised.3. Change the dressing if it becomes damp, loosened or visibly soiled and: a. at least every 7 days for TSM (Transparent Semi-permeable membrane), b. at least every 2 days for sterile gauze dressing.c. immediately if the dressing or site appear compromised.Procedure to apply sterile dressing:.7. Apply sterile dressing.e. Label with initials, date and time. Documentation: 1. The following information should be recorded in the resident's medical record: a. Date and time dressing was changed.f. signature and title of the person recording the data.

Based on observation, interview and record review, the facility failed to ensure an oxygen administration order was obtained for one of five sampled residents investigated for oxygen treatment (Resident 166).This failure could result in Resident 166 experiencing oxygen toxicity (lung damage caused by breathing excessive oxygen at high pressure) due to the administration of excessive or inappropriate supplemental oxygen, potentially leading to respiratory failure (when lungs cannot properly transfer oxygen into blood causing severe breathing difficulty).Findings:During a concurrent observation and interview on 3/2/26 at 10:37 AM with Resident 166, Resident 166 was in bed, alert, and verbally responsive. Resident 166 was receiving oxygen at a rate of four liters per minute through a nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen). Resident 166 stated that the previous oxygen administration rate was only two liters per minute, but it was likely that the facility staff received an order to increase the rate.During a concurrent interview and record review on 3/2/26 at 1:40 PM with Licensed Vocational Nurse (LVN) 3, Resident 166's active orders were reviewed. LVN 3 verified that Resident 166's order for oxygen administration was at two liters per minute at bedtime, and Resident 166 had no orders for oxygen administration during daytime and/or as needed. LVN 3 stated that the attending physician should be notified to obtain an oxygen administration order during daytime and/or as needed and adjust the parameters accordingly.During an interview on 3/4/26 at 3:47 PM with Registered Nurse (RN) 1, RN 1 emphasized the importance of obtaining a physician's order for oxygen administration, noting that excessive administration of oxygen could potentially result in hyperventilation (rapid or deep breathing) for the resident.During an interview on 3/4/26 at 4:06 PM with the Director of Nursing (DON), the DON stated that oxygen administration required a physician's order and should be followed within the scope of practice.A review of Resident 166's admission Record (a document showing a summary of the resident's information), dated 3/2/26, indicated Resident 166 was readmitted to the facility on [DATE], with diagnoses which included asthma (a long term chronic condition that makes it difficult to breathe because the lungs airways become swollen and narrowed) and obstructive sleep apnea (a serious disorder where breathing repeatedly stops and starts during sleep because throat muscles relax and causing the airway to collapse).A review of the facility's policy and procedure titled Oxygen Administration, revised October 2010, indicated .The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation.1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Based on observation, interview, and record review, the facility failed to ensure accurate accountability of controlled substances (controlled substance [CS] - medications with high potential for abuse and addiction) when:The Controlled Drug Records ([CDR] - a medication count sheet, an inventory record used to document the receipt, use, and count of controlled substances) for one out of nine randomly selected residents (Resident 56) did not reconcile with the Medication Administration Record ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident).These failures resulted in inaccurate accountability of controlled substances, which had the potential for diversion (medication taken by someone other than for whom it is prescribed) or misuse of controlled substances and had the potential to compromise the residents' medication therapy and safety.Findings:During an inspection of Medication Cart 2A at Nursing Station 200 on 3/3/26 at 11:43 AM, a blister card for oxycodone-acetaminophen (generic for Percocet, a controlled narcotic mediation for pain) 5-325 mg (milligram - a unit of measurement) labeled for Resident 56 was concurrently reviewed with Licensed Vocational Nurse (LVN) 6.A review of Resident 56's physician order, dated 12/11/25, indicated an order for oxycodone-acetaminophen 5-325 mg, give 1 tablet by mouth every 4 hours as needed for severe pain 7-10 (pain scale).A review of Resident 56's CDR and January 2026 MAR indicated the nursing staff removed and signed out one tablet of oxycodone-acetaminophen 5-325 mg on 1/14/26 at 6:40 AM and 1/24/26 at 7:10 AM, but there was no corresponding documentation of administrations and pain assessments on the MAR.During a concurrent interview and record review on 3/3/26 at 11:43 AM with LVN 6, LVN 6 confirmed the discrepancy and stated the CS administration was required to be documented on both the CDR and the MAR.During a concurrent interview and record review on 3/3/26 at 4:16 PM with the Director of Nursing (DON) in the DON's office, the DON confirmed discrepancies between the CDR and the MAR for Resident 56, including documented CS removals without corresponding MAR documentation of administration. The DON stated her expectation for the nursing staff was to document the CS removal on the CDR and medication administration on the MAR.A review of the facility's policy and procedures titled, Administering Medications, dated April 2019, indicated .As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered.e. any complaints or symptoms for which the drug was administered .f. any results achieved and when those results were observed; and g. the signature and the title of the person administering the drug.

Based on observation, interview, and facility record review, the facility failed to ensure the kitchen staff had the appropriate skill set to safely perform the daily operations of the Food and Nutrition Services Department.Dietary Aide (DA) 2 was unable to correctly explain the procedures to test the chemical concentration measured in parts per million (ppm - a unit of measurement) of the quaternary sanitizing solution (a chemical solution used to kill germs on surfaces) to sanitize food contact surfaces.This failure had the potential to expose 131 of 132 highly susceptible residents who received food from the kitchen to foodborne illnesses (any illness resulting from eating contaminated/spoiled foods) due to cross- contamination (the transfer of harmful substances or disease- causing microorganisms to food). During an observation and interview on 3/2/26 at 3:30 PM with DA 2, DA 2 was asked to demonstrate how to check the sanitizing solution. DA 2 stated she was not sure.A review of DA 2's personnel files indicated DA 2's date of hire was 3/18/25. During a concurrent interview and record review on 3/2/26 at 3:50 PM with the Director of Dietary Services (DDS), the DDS stated staff were supposed to dip the test strip into the sanitizing solution for ten seconds, then match the color to the chart. The DDS added that the solution should be between 200-400 ppm. When asked to review the competency skills for DA 2, the DDS stated he was unable to locate DA 2's competency skills check. The DDS stated the competency skills check should have been completed within three months after hire. The DDS stated it was important to check that the quaternary sanitizer was within range to effectively sanitize and prevent foodborne illnesses.A review of the facility' s policy and procedures titled Sanitization, dated November 2022, indicated the service area wiping cloths are cleaned and dried or placed in a chemical sanitizing solution of appropriate concentration.

Based on observation, interview, and record review, the facility failed to ensure complete, accurate, and consistent documentation for two of 26 sampled residents' (Residents 59 and 60) medical records when:Resident 59's medical record did not accurately reflect the resident's PICC line (Peripherally Inserted Central Catheter - a thin flexible tube inserted to a large vein in the upper arm used to deliver medications for long term treatments) dressing change. 2. Resident 60's activity records were not accurately and consistently completed. These failures had the potential for these two residents to receive inconsistent care coordination and unmet care needs. Findings:1. During an initial tour observation on 3/2/26 at 9:38 AM, in the resident's room, Resident 59 was awake, verbally responsive, and comfortably lying on his bed. Resident 59 had a PICC line dressing on his right upper arm dated 2/16/26. During a concurrent observation and interview on 3/2/26 at 11:28 AM with Registered Nurse (RN) 2, RN 2 read the label of Resident 59's PICC line dressing and confirmed the date written was 2/16/26. RN 2 added that the dressing was normally changed every seven days. Resident 59's dressing change was seven days overdue. A review of Resident 59's admission Record, (a document showing a summary of the resident's information) dated 3/3/26, indicated the resident was readmitted to the facility on [DATE], with diagnoses that included cutaneous abscess of abdominal wall (localized collection of pus caused by bacterial infections, surgical complications, or trauma), malignant neoplasm of the prostate (prostate cancer), and acute osteomyelitis (a serious bone infection causing severe pain, inflammation, fever, and potential bone death). A review of Resident 59's Order Summary Report, dated as of 3/3/26, indicated Resident 59 had the following orders: Antimicrobial disc [small, absorbent pad that inhibit bacterial growth] will be utilized for all central/midline sites and changed every 7 days with dressing change. one time a day every 7 day(s) . with a start date of 2/18/26 and .Change PICC line dressing, Stat-lock [adhesive-based medical device designed to securely hold PICC line in place] every day shift every 7 day(s) if gauze dressing is used change every 48 hours. with a start date of 2/18/26. A review of Resident 59's IV Administration Record, (a legal document used to track intravenous medications) dated 2/1/2026 to 2/28/2026, indicated the following items were completed and signed off by staff on 2/18/26 and 2/25/26: -Antimicrobial disc will be utilized for all central/midline sites and changed every 7 days with dressing change. one time a day every 7 day(s) which started on 2/18/26 at 9:00 AM.-Change PICC line dressing, Stat-lock every day shift every 7 day(s) if gauze dressing is used change every 48 hours which started on 02/18/2026 at 7:00 AM. A review of Resident 59's Progress Notes, dated 2/18/2026, indicated .dressing dated 2/16/26 due on 2/23/26. and Antimicrobial disc will be utilized for all central/midline sites and changed every 7 days with dressing change. One time a day every 7 day(s) . During a concurrent interview and record review on 3/5/26 at 11:58 AM, with the Director of Nursing (DON), the DON reviewed Resident 59's medical record via PCC (PointClickCare - a cloud-based electronic health record). The DON stated Resident 59's PICC line dressing dated 2/16/26 was from the hospital, and there was no documented evidence that it was changed on 2/23/26. The DON also stated that the IV Administration Record that indicated the dressing was changed on 2/25/26 was inaccurate and Resident 59's PICC line dressing had not been changed since admission. The DON reviewed the facility's policy and procedure (P&P) titled Charting and Documentation, revised July 2017, and stated the policy was not followed. A review of the facility's P&P titled, Charting and Documentation revised July 2017, indicated . All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record shall facilitate communication between interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation:.2. The following information is to be documented in the resident medical record:.c. Treatments or services performed; 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.7. Documentation of procedures and treatments will include care-specific details, including: a. the date and time, the procedure/treatment was provided; b. the name and title of the individual(s) who provided the care;.e. whether the resident refused the procedure/treatment;.g. the signature and title of the individual documenting. 2. During an observation on 3/3/26 at 10:41 AM, in the resident's room, Resident 60 was resting in bed with her eyes closed while the television was on in English. A review of Resident 60's admission Record, dated 3/4/26, indicated the resident was initially admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and generalized anxiety disorder. A review of Resident 60's Care Plan Report indicated a care plan problem including The resident has daily preferences and/or activity preferences. Resident is visited daily and is on a one-to-one room visit with sensory motor stimuli to touch and small conversation. Interventions included that the resident prefers to choose their own bedtime. During a concurrent interview and record review on 3/3/26 at 4:09 PM with the Activities Director (AD), Resident 60's Event Calendar Report for February 2026 was reviewed. Resident 60's Event Calendar Report for February 2026 indicated on 2/18, 2/24 and 2/25/26, no activities were documented. The AD stated Resident 60 was visited daily. The AD verified the dates did not contain entries to show activities were provided to Resident 60. The AD stated it was important to log the activities provided to ensure all residents were receiving activities that were not only important for their cognition, but also for their psychosocial well-being. Additionally, the AD stated it helped to keep track of activities the residents liked and preferred. A review of the facility's P&P titled Room Visit Program Independent Activities, (undated), indicated .Room visit program and independent activities are recorded on the Activity Attendance Record form.Room visit records are kept in the activity office as part of the attendance record keeping system. This includes the date of the visit, the activity provided and the resident's response .

Based on observation, interview, and record review, the facility failed to keep the resident call light system (a device that residents can press to ask staff for help) in good working order for two of 26 sampled residents (Residents 13 and 171). This failure had the potential to delay staff response to resident needs and compromise resident safety.Findings:During a concurrent observation and interview on 3/2/26 at 8:59 AM with Certified Nursing Assistant (CNA) 1, CNA 1 tested the call light system in Resident 13 and Resident 171's rooms. Both call light systems did not show a light or were audible at the nursing station. CNA 1 verified that the call light system for both residents was not working.During a concurrent follow-up observation and interview on 3/2/26 at 11:59 AM with CNA 1, CNA 1 tested the call light system in Resident 13 and Resident 171's rooms again. Both call light systems still did not show a light or were audible at the nursing station. CNA 1 verified that the call light system for both residents were still not working.During an interview on 3/2/26 at 12:12 PM with CNA 1, CNA 1 was asked about the facility's process when the call light system malfunctioned. CNA 1 stated the facility placed a call bell at the bedside table, so the residents can alert the staff if needed. CNA 1 stated she already placed a request to notify maintenance of the issue.During an interview on 3/4/26 at 10:54 AM with the Maintenance Assistant (MA), the MA confirmed he was aware of Resident 13 and 171's nonfunctioning call lights and stated that he had already fixed the issue. The MA stated he replaced the call light system on the wall and tested them to ensure they were functioning properly.A review of the facility's policy and procedure titled Call System, Residents, dated 9/2022, indicated .Residents are provided with a mean to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. 2. Call system communication may be audible or visual. The system may be wired or wireless.3. The resident call system remains functional at all times. If audible communication is used, the volume is maintained at an audible level that can be easily heard. If visual communication is used, the lights remain functional.

Based on interview and record review, the facility failed to ensure care and treatment was provided, for one of four residents reviewed (Resident A), when Resident A had high blood pressure.This failure had potential for a delay in the care and treatment to address Resident A's high blood pressure and could affect the resident's overall health condition.Findings:On January 27, 2026, at 9:15 a.m., an unannounced visit was conducted to investigate a quality-of-care issue.On January 27, 2026, Resident A's record was reviewed. Resident A's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included hypertension (high blood pressure).A review of Resident A's Order Summary Report, included a physician's order, dated November 18, 2024, which indicated, .Terazosin HCL (medicate to treat high blood pressure) Oral Capsule 1 (one) MG (milligram - unit of measurement).Give 1 (one) capsule by mouth at bedtime for systolic (the first (top/upper) number) of > (more than) 140.A review of Resident A's Minimum Data Set (MDS - a resident assessment tool), dated November 25, 2025, indicated Resident A had a BIMS (Brief Interview of Mental Status) score of 9 (impaired cognitive status).A review of Resident A's eINTERACT Change in Condition Evaluation, dated January 14, 2026, at 2:38 p.m., indicated, .Tachycardia (elevated heart rate), increased BP (blood pressure), decreased BP, c/o dizziness and shakiness.Resident had c/o (complaint of) feeling dizzy and shaky. VS (vital signs) were obtained to be as follows: at 0943am (9:43 a.m.) BP 157/122 mmHg (millimeter mercury - unit of measurement).Around afternoon 13:21 (1:31 p.m.) resident still c/o dizziness and shakiness with BP of 78/59 mmHg, Notified (name of physician) immediately with order to send out resident to ER for further evaluation.On January 27, 2026, at 2:39 p.m., during an interview conducted with the Registered Nurse (RN), she stated she was the licensed nurse in charge of Resident A when the resident was sent out to the hospital on January 14, 2026. The RN stated the following:-She was passing the morning medications for the residents in Station 2, and Resident A was complaining of dizziness and shakiness, and the resident's BP was obtained and indicated it was high at about 150/120 (could not recall the exact BP reading);-She notified the physician around 9:40 a.m., and received orders to monitor the resident and give supplemental oxygen, and obtain medical history from the resident. However, Resident A refused the oxygen.-She notified the physician around 1 p.m., that Resident A refused the oxygen, had history of stroke, and the BP taken was 78/59 with heart rate of 120 (normal range is 60 to 100 beats per minute). The physician ordered to send out Resident A to the acute hospital;-She stated she did not monitor or check Resident A's BP from 9 a.m. when the elevated BP was initially identified, not until 1 p.m., when the BP was low and had a high heart rate. She stated she should have closely monitored the resident's BP, frequently checked on the resident's status, and notified the physician timely.On January 27, 2026, at 4:15 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated the following:-The RN notified her of Resident A's high blood pressure after 10 a.m., and advised the RN to call the physician; and-She expected the licensed nurse (LN) to call the physician if the resident's BP was high and with accompanying symptoms such as shaking and dizziness, to obtain a PRN (as needed) medication to address the high BP. The LN should monitor the resident's BP at least every hour, follow up with the physician and send the resident to the acute hospital for further evaluation if appropriate.A review of the facility's policy and procedure titled, Blood Pressure, Measuring, dated September 2010, indicated, .The blood pressure is generally defined as Normal when the systolic pressure is in the range of 101 to 129 mm/Hg and the diastolic pressure (the lower/bottom number) is in the range of 61 to 84 mm/Hg.Hypertension is usually defined as blood pressure over 140/90 mm/Hg.Hypertension should be reported to the physician. If a resident has a hypertensive reading, staff should record several readings taken at different times of the day. Staff should note any pertinent medications and/or recent changes of condition when reporting to the physician.Hypotension is defined as blood pressure less than 100/60 mm/Hg.Hypotension should be reported to the physician.A review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, dated February 2021, indicated, .Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status.the nurse will notify the resident's attending physician or physician on call when there has been a(an).need to alter the resident's medical treatment significantly.A review of the facility's undated policy and procedure titled, Emergency Physician Care, indicated, .Should the resident's attending physician be unavailable, the nurse supervisor/charge nurse must first attempt to contact the physician's designated referral physician or practitioner.should the designated referral physician be unavailable to assist in the emergency, the on-call physician or medical director shall be contacted.

Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 1) was discharged to a facility that would be able to provide the care required by the resident. Resident 1 was discharged to an assisted living facility (ALF- a residential community providing housing, meals, and personalized support for older adults or people with disabilities who need help with daily activities [ADLs- activity of daily living] but not round the clock skilled nursing [high level medical care requiring the expertise of licensed professionals like registered nurses, licensed vocational nurses, and therapist]), which was unaware of the presence of the unstageable pressure injury ( a full thickness skin and tissue loss where the actual depth of the wound is completely obscured by slough [soft, yellowish, stringy, dead tissue] or eschar) on the right heel. This failure resulted in Resident 1 being transferred to a general acute care hospital (GACH), on the day Resident 1 was discharged from the skilled nursing facility (SNF) to the ALF, due to inability to provide the required care and services for Resident 1's pressure injury.Findings:On January 8, 2026, at 11:14 a.m., an unannounced visit to the facility on a complaint investigation was initiated.A review of Resident 1's face sheet indicated resident was admitted on [DATE], with diagnoses of pressure ulcer of right heel, unstageable; type 2 diabetes mellitus (a chronic condition that affects the way the body uses sugar. The body either resists the effects of insulin - a hormone that regulates the movement of sugar into the cells - or doesn't produce enough insulin to maintain normal sugar levels), wedge compression fracture of first lumbar vertebra (a common spinal injury where the front portion of the vertebral body collapses due to excessive force, while the back remains intact).A review of Resident 1's History and Physical, dated October 27, 2025, indicated resident was alert and oriented X (times) 3 (oriented to person, time, and place).On January 8, 2026, at 12:22 p.m., an interview was conducted with the SNF Case Manager (CM). The CM stated that Resident 1 was to be discharged to an ALF with home health, physical therapy, and wound care.On January 8, 2026, at ,1:49 p.m., an interview was conducted with the Treatment Nurse (TN 2). TN 2 stated that Resident 1 was admitted on [DATE], with a right heel unstageable wound, also described as a diabetic foot ulcer (DFU - an open, full-thickness wound or sore, typically located on the bottom of the foot, that occurs in individuals with diabetes). TN 2 stated that Resident 1 received daily wound cleansing with povidone-iodine (a stable chemical complex acting as a powerful, broad-spectrum topical antiseptic), and dressing changes.On January 8, 2026, at 4:45 p.m., an interview and record review was conducted with the CM. The CM confirmed that form 602 (a mandatory physician's report for seniors moving into state-licensed residential care facilities completed by a doctor to detail a resident's medical, mental, and physical capabilities, TB test results, and care needs) was completed on November 3, 2025, indicating, .Physical Health Status.m. History of Skin Condition or Breakdown was checked Yes R [right] heel w/o pressure injury was handwritten. The CM was unsure of the w/o abbreviation. The CM also confirmed this information was emailed to the ALF on December 18, 2025.On January 9, 2026, at 11:24 a.m., an interview and record review was conducted with the Registered Nurse (RN). The RN stated that discharge instructions should include the discharge location and documentation of any wounds. The RN confirmed that Resident 1's Discharge Instruction Form / Recapitulation of Stay V-2 dated December 22, 2025, indicated a discharge to a private residence but did not document Resident 1's right heel wound.On January 9, 2026, at 12:24 p.m., a telephone interview was conducted with the ALF Resident Service Director (RSD). The RSD stated that the ALF Executive Director visited the SNF to assess Resident 1. At the time, the right heel pressure injury had a dressing and the Executive Director did not see the extent of the pressure injury and the facility staff reported the wound was healing. The RSD stated the 602-form signed by the Nurse Practitioner indicated no pressure injury, however; on December 22, 2025, upon admission to the ALF, the facility assessed the resident's right heel wound as unstageable and the resident had to be transferred to the GACH due to their inability to care for it.On January 9, 2026, at 1:08 p.m., an interview was conducted with the Social Services Director (SSD). The SSD stated that usually the ALF would determine if the resident is appropriate for their facility. The SSD stated that an ALF can take a simple wound and typically do not take an unstageable wound.On January 9, 2026, at 2:03 p.m., a telephone interview was conducted with the Nurse Practitioner (NP). The NP stated that she recalled Resident 1 with a right heel wound. When the NP was asked about the w/o abbreviation and the NP confirmed the abbreviation meant without. The NP stated that she was unable to recall what kind of wound was present on the right heel and was unable to recall why she documented Resident 1's right heel as without pressure injury. The NP stated that Resident 1 was discharged from the skilled nursing facility to the ALF and was transferred to the GACH because the ALF could not manage the wound.A record review of Resident 1's Wound Assessment dated December 16, 2025, (six days prior to discharge to ALF), indicated .Wound type.Diabetic.Discussion/Relevant Interim History.RE-EVAL-R HEEL. Location R HEEL Post (cm) [centimeters] L [length] ulcer] . Prognosis . Non-Healable . Negative Progression . Additional Devitalized Tissue. Infection.Drainage: None . Odor: None . Wound Bed: .Eschar 100% . Sinus/Tunneling . No .Wound Margins (circle) . Regular .Treatment: Topical: Betadine Frequency: Daily .Evidence of Improvement . Stable .A record review of Resident 1's Order Summary Report, dated December 22, 2025, indicated, .Patient request discharge 12/22/25 to [name of ALF and address] w/ [with] Home Health nursing for evaluation and medication management/ PT [physical therapy] evaluation and treatment/ Wounds Care: Betadine 3.6 W [width] 3.1 D [depth] UTD [unable to determine] Wound Type DFU [diabetic foot Swab sticks 10% apply to right heel topically every day for pressure injury, cleanse with NS [normal saline], pat dry W/ [with] 4 X 4 gauze, paint with swab.A review of the facility policy and procedure titled, Discharge Summary and Plan, revised October 2022, indicated, When a resident's discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge .1. The discharge summary includes recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's .course of illness, treatment and/or therapy since entering the facility .medication therapy .3. Every resident is evaluated for his or her discharge needs and has an individualized post-discharged plan .The discharge plan is re-evaluated based on changes in the resident's condition or needs prior to discharge .

Based on interview and record review the facility failed to ensure that it provided care and services were provided in accordance with professional standards of practice for one of three sampled residents (Resident A) in a universe of 144 residents. This failure occurred when a certified nursing assistant (CNA 1) administered an Epsom salt foot soak treatment for [REDACTED]. The burn required wound treatment and the administration of an antibiotic to prevent infection. Findings: On February 27, 2020, at 9:07 a.m., an unannounced visit was conducted at the facility for the investigation of two complaints. Resident A's medical record was reviewed and indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident A's, History and Physicals, (H&P) dated, December 27, 2019, indicated, This resident has the capacity to understand and make decisions. A review of Resident A's, Minimum Data Set, (MDS- standardized assessment for the management of care) dated, January 3, 2020, indicated a BIMS, (brief interview for mental status- screening tool to assess mental capability) score of 13 out of 15 (scores of 13-15 indicates cognitively intact). Additional review of Resident A's medical record found a progress note dated, February 11, 2020, at 3:15 p.m., that indicated, resident stating her husband brought her Epsom salt & (sic) if someone could soak her feet this evening, stated someone from the night shift has been soaking her feet in it & (sic) feels it is helping her swelling. Made (sic) her aware we would have to contact md (doctor) & (sic) get orders. Resident was very adamant on her being able to receive the soak. MD made aware. MD okay'd (sic) order for soak. n/o (new order) noted & (sic) carried out . A review of Resident A's physician orders indicated an order dated, February 11, 2020, for Epsom salt soak to bilateral (both) feet every 8 hours as need for comfort. A review of a progress note for Resident A dated, February 15, 2020, at 3:32 p.m., authored by a licensed vocational nurse (LVN 1) indicated, pt (patient) has new coc (change of condition) for left plantar (sole of the foot) foot burn. New order for [MEDICATION NAME] (per the manufacturer- topical antimicrobial drug used for the prevention and treatment of [REDACTED]. Pt reported to am (morning) tx (treatment) nurse that PM (evening) CNA per pt request soaked (sic) her feet, water to (sic) hot. Review of a care plan for Resident A dated, February 15, 2020, indicated, left foot plantar burn from hot water foot soak. Review of a physician's order dated, February 15, 2020, for Resident A indicated, [MEDICATION NAME] Cream 1% Apply to left plantar foot typically one time a day for burn . Review of a physician's order for Resident A dated, February 17, 2020, indicated, Wound consult with (doctor's name) 02/19/2020. ind. (indication) plantar wound. Review of a care plan for Resident A dated, February 17, 2020, indicated, 2/17/2020 Resident requested for Epsom Salt soak to BLE (bilateral lower extremities) as ordered @ (at) around 1500 (3:00 p.m.), noted with left plantar foot burn, after the soak bath; tx (treatment) Nurse stated skin peeled from soak. Resident stated, water was hot. Further review of Resident A's record found that she had been sent to the hospital on February 18, 2020, for an unrelated issue. Review of Resident A's hospital, History & Physical, (H&P) dated, February 18, 2020, indicated, .Patient states she requested foot bath, nursing aide provided water which was way too hot and this brought her feet (sic) .Patient is being admitted secondary to significant burn. Given ceftezole (antibiotic) in the ER (emergency room ). A review of Resident A's hospital H&P, further indicated, Left foot burn .Full thickness burn (third degree burn which destroys the outermost layer of the skin and the second layer of skin) .needs preventive measures, keep foot clean .daily woundcare (sic). Continue antibiotics. On February 27, 2020, at 10:55 a.m., an interview and concurrent record review were conducted with LVN 1. LVN 1 stated that she had been asked to help another treatment nurse evaluate Resident A's left foot injury. LVN 1 stated that she had documented the situation in her progress note. A section of the progress note was read back to the LVN. At that time LVN 1 confirmed that the wound had occurred from the foot soak. LVN 1 also confirmed that she had documented that the resident had told her that the water was too hot. On February 27, 2020, at 11:12 a.m., an interview was conducted with the facility's Director of Staff Development (DSD). The DSD was asked when she had been informed of Resident A's foot injury. The DSD stated that she had found out on Monday morning February 17, 2020, in the stand-up meeting (meeting held with department heads to review events in a facility). The DSD stated that CNA 1 had provided Resident A with an Epsom salt foot soak treatment with, hot water. The DSD stated in her interview with CNA 1, he had told her that the water was too warm so he took the resident's water pitcher and added cool water to the basin. The DSD stated that CNA 1 should have asked the Charge Nurse to administer the salt soak. The DSD continued that the Epsom salt soak was a treatment and it should have been done by the Charge Nurse. The DSD further said that a treatment is not within the scope of practice of a CNA. The DSD stated that treatments were only to be performed by a nurse. On February 27, 2020, at 11:18 a.m., an interview was conducted with the facility's Administrator, (AD), Acting Director of Nursing (ADN) and Assistant Director of Nursing (ADON), regarding the facility's investigation of the injury to Resident A's left foot. In review of the incident with the department heads, the AD stated that CNA 1 had not been working within the scope of his practice by providing the foot soak treatment for [REDACTED]. On February 27, 2020, at 12:52 p.m., at the acute hospital an interview was conducted with Resident A. The resident was asked about her left foot injury. Resident A stated, that she had asked her evening male CNA for an Epsom salt soak for her feet. She stated that CNA 1 brought her a basin of water and said he had boiled the water. Resident A stated that CNA 1 had told her that when he had been a football player this is what they would do. Resident A stated that she had trusted him and, took his word for it. When asked the identity of the male CNA, the resident named CNA 1. Resident A stated that she could see the water, bubbling. Resident A was asked how the water was heated, and the resident stated that CNA 1 had put the water in the microwave. Resident A was asked if CNA 1 had tested the water prior to giving it to her. Resident A stated that, he did not test the water, Resident A further stated that, he just gave it to me. Resident A stated that she continued to, see the bubbles. She stated that the skin is thin on her feet. Resident A stated that the water was so hot and painful. Resident A stated that she put, just the bottom of her left foot in the water, but barely touched the water to the bottom of her right foot. Resident A stated that she never submerged her feet in the water. Resident A was asked if CNA 1 had stayed to observe her put her feet into the water. Resident A stated, No, and further stated that he had delivered the water and left me. Resident A stated that CNA 1, didn't stay there in the room with her. Resident A stated that she had not, realized that her foot had been cooked. On February 27, 2020, at 2:19 p.m., a phone interview was conducted with CNA 1. CNA 1 confirmed that he had provided care for Resident A. CNA 1 was asked if he had gotten the water for Resident A's salt soak. CNA 1 stated, Yes. CNA 1 stated that he had gotten the water for the basin in the sink at Nursing Station 4. When asked how he heated the water, CNA 1 stated that he, just got it hotter from the microwave. CNA 1 was asked how long he left the water in the microwave. He stated he had left the water in the microwave for, approximately a minute and a half. CNA 1 was asked if he had placed the plastic basin in the microwave. CNA 1 confirmed that he had put the plastic basin in the microwave. CNA 1 was then asked if he had checked the temperature of the water prior to giving it to Resident A. CNA 1 stated, Yes, I stuck my finger in there. CNA 1 was asked if he had used a thermometer to check the water temperature. CNA 1 stated, No and stated he just touched it myself. CNA 1 further stated it wasn't too hot. CNA 1 was asked if Resident A had complained that the water was too hot. CNA 1 stated that she had said that it, was hot. CNA 1 stated that he had taken Resident A's water pitcher and added cool water to the basin. CNA 1 stated that after he had provided the foot soak to Resident A, he left the room for half an hour and then came back. A review of a facility policy titled, Applying a Warm Compress or Soak, revised April 2013, indicated, Preparation: 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident. The policy indicated, General Guidelines .2. Check the resident's skin often for redness or discoloration .5. Listen to the resident's complaints. Report them to the Staff/Change Nurse. The policy further indicated, The following equipment and supplies will be necessary when applying a warm soak: 1. Soak basin, 2. Pitcher of warm water (105 degrees Fahrenheit), 3. Bath thermometer .If applying a warm soak .5. Fill the water pitcher with warm water (105 degrees) .10. Unless otherwise instructed, check the skin of the limb being soaked every five (5) minutes. (Note: if the skin appears to be reddened or discolored, cease the treatment .12. Unless otherwise instructed, soak the limb for twenty (20) minutes .

Based on interview and record review, the facility failed to ensure changes of condition were fully assessed in accordance with professional standards of practice for one of three sampled residents (Resident A) when Resident A: a. developed a left arm [MEDICAL CONDITION] ([MEDICAL CONDITION]-blood clot in the veins of the arm with potentially life threatening complications), and b. had an abnormally elevated WBC count (white blood cell-a type of blood test when elevated can be a sign of infection) and subsequent breathing problems. These failures increased the potential for harm for Resident A, for changes in Resident A's condition to go unrecognized and untreated, and may have contributed to the decline in Resident A's overall health. Findings: On (MONTH) 17, 2019, the Department received a complaint with an allegation that Resident A had abnormal breathing and pneumonia for at least two days at the facility before he was sent to the hospital, on (MONTH) 2, (YEAR). On (MONTH) 26, 2019, at 10:15 a.m., a visit was made to the facility for the investigation of one complaint. On (MONTH) 26, 2019, Resident A's facility record was reviewed. The record indicated Resident A was admitted to the facility on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. Resident A's History and Physical form, dated (MONTH) 16, (YEAR), indicated Resident A could make his needs known but could not make medical decisions. The Physician order [REDACTED].Full Treatment-primary goal of prolonging life by all medically effective means . The Admission Assessment nurse's notes, dated (MONTH) 14, (YEAR), at 11:05 p.m., indicated Resident A was noted to have the cardiac pacemaker in his left upper chest, normal breathing, scattered discolorations on his arms without swelling, and a left hip incision with surgical staples. a. The nurse's progress notes, dated (MONTH) 21, (YEAR), at 11:15 a.m., indicated Resident A had new onset of left arm swelling, and was ordered to have left arm venous doppler study (images taken of veins in arm to check for blood clot). The nurse's notes form titled, Change in Condition Evaluation (used to document residents' changes of condition and notification of the physician) dated (MONTH) 21, (YEAR), at 4:22 p.m., indicated, change .swelling to left forearm . The area of the nurse's notes used to document if the change in condition had gotten worse or better since it was first noted was marked, Unable to determine The area of the nurse's notes used to document the location and description of the left arm swelling had no documented indication of a measurement of Resident A's left arm, the specific location of the swelling, or any potential changes to Resident A's skin or movement of the left arm. The nurse's notes further indicated Resident A's blood pressure was taken using his left arm potentially causing an increase in the swelling, inaccurate blood pressure reading, or pain. Resident A's venous doppler ultrasound report, dated (MONTH) 22, (YEAR), at 11:30 a.m., indicated Resident A had, .thrombus (blood clot) in the left [MEDICATION NAME], brachial, and basilic veins .Prominent [MEDICAL CONDITION] involving left arm .(extensive blood clot in multiple large veins of the arm). Resident A's care plan, dated (MONTH) 21, (YEAR), indicated, left forearm swelling .Resident will have decrease (sic) swelling to left forearm in a week .Interventions .Assess VS Qshift (VS-vital signs, check temperature, blood pressure, heart rate, and respirations every shift), Notify Dr. if any further complications . There was no documented indication of specific nursing assessments implemented to evaluate Resident A's left arm [MEDICAL CONDITION] such as measurements of the left arm, color and temperature of the skin on the arm, presence of pain or decreased movement, or any standard precautions implemented such as avoiding blood pressure readings or blood draws on the left arm. There was no documented indication of nursing assessments implemented to check Resident A's heart sounds, lung sounds, and oxygen levels, for symptoms of potentially life threatening complications related to [MEDICAL CONDITION] including [MEDICAL CONDITIONS] (blood clot that travels from deep vein to heart or lungs). On (MONTH) 1, 2019, a follow-up visit was made to the facility to further investigate the complaint. On (MONTH) 1, 2019, at 1:45 p.m., the Director of Nurses (DON) was interviewed. When asked how the nurses assessed Resident A's left arm swelling, the DON stated the nurses monitored the swelling and did visual checks. The DON verified no measurements or further detailed assessments were done for the swelling in Resident A's left arm. On (MONTH) 28, 2019, at 10:40 a.m., Registered Nurse (RN) 1 was interviewed by telephone and stated [MEDICAL CONDITION] precautions and interventions included the following: measure the affected limb for increased swelling, elevate and avoid taking blood pressures on the limb, watch for increased swelling, blue skin discoloration, and pain; and, RN 1 acknowledged the resident with [MEDICAL CONDITION] would be at risk for [MEDICAL CONDITIONS]. b. On (MONTH) 26, 2019, Resident A's record was further reviewed. The CBC (Complete Blood Count-a type of blood test when high can be a sign of infection) results, dated (MONTH) 21, (YEAR), at 3:45 a.m., indicated Resident A's WBC count was 9.15 (normal range 4.00-10.0) and the test was to be repeated in one week. The next CBC result, dated (MONTH) 30, (YEAR), at 4:03 a.m., indicated Resident A's WBC count was abnormally high at 15.92 and [DIAGNOSES REDACTED]s (a type of blood cell) were abnormally high at 13.18. The nurse's progress notes, dated (MONTH) 30, (YEAR), at 3:04 p.m., indicated, .lab result in and seen by MD . There was no documented indication if Resident A was assessed for potential signs or symptoms of infection, or any additional tests such as chest X-ray or other blood tests were ordered by Resident A's healthcare provider or requested by nursing staff to determine the potential source of infection that caused Resident A's WBCs to be elevated by more than 6,000 WBCs above normal, since the previous test that was completed on (MONTH) 21, (YEAR). The following day's nurse's progress notes, dated (MONTH) 31, (YEAR), at 1:18 p.m., indicated, pt (Resident A) found wheezing . The nurse's notes Change of Condition Evaluation, form, dated (MONTH) 31, (YEAR), at 12:56 p.m., indicated Resident A had a change of condition, .change .wheezing .What time of day did this start .Morning . noted at 8:53 a.m., Resident A's blood pressure was again taken in the left arm, and Resident A's respiratory rate was last checked at 4:31 a.m. The nurse's notes indicated, .Since the change in condition occurred .the symptoms .Stayed the same . and .Describe respiratory changes: .No changes observed .Laboratory tests/Diagnostic Procedures .None to report . The nurse's notes indicated Resident A's provider was contacted at 12 p.m. (noon)., and recommended [MEDICATION NAME] (breathing treatment) every four hours as needed, and [MEDICATION NAME] (non-prescription medication for congestion) 600 mg (milligram-a unit of measure) twice a day. The nurse's notes indicated Resident A's oxygen saturation level was checked one time at 12:57 p.m., with a result of 94%, after the provider was called. There was no documentation to indicate if the Licensed Vocational Nurse (LVN) notified the provider of Resident A's elevated WBC count the day before, or requested the Registered Nurse on duty assess Resident A's heart and lung sounds for changes. The Medication Administration Record [REDACTED].inhale every 4 hours as needed for wheezing . starting (MONTH) 31, (YEAR) at 1:04 p.m. The nurse's notes, dated (MONTH) 31, (YEAR), at 6:18 p.m., through (MONTH) 1, (YEAR), were reviewed and indicated Resident A was given [MEDICATION NAME] three times during that time period and continued to have wheezing. There was no documented indication Resident A's heart and lungs sounds were re-assessed before or after the breathing treatments, his oxygen level was re-checked, the provider was notified his symptoms continued, or any additional tests were requested to determine the cause of his continued respiratory symptoms. The nurse's notes, dated (MONTH) 2, (YEAR), at 8:30 a.m., indicated, Resident was sent out to (name of acute care hospital) for further evaluation of SOB (shortness of breath) . (three days after the elevated WBC Count and two days after Resident A's wheezing were first noted). On (MONTH) 1, 2019, at 12:50 p.m., LVN 1 was interviewed and stated she helped transfer Resident A to the hospital on (MONTH) 2, (YEAR). LVN 1 stated the Certified Nursing Assistant (CNA) called LVN 1 to check Resident A and Resident A was struggling to breathe. LVN 1 stated Resident A had orders to give breathing treatments as needed starting on (MONTH) 31, (YEAR), and Resident A's cough and wheezing did not get better with the treatments. LVN 1 stated she called Resident A's family on (MONTH) 2, (YEAR), about Resident A's breathing problems, and the family requested Resident A be sent to the hospital. LVN 1 stated if a resident had wheezing, their oxygen level should be checked and then re-checked again in 15 minutes, and documented in the daily nurses notes. On (MONTH) 1, 2019, at 1:45 p.m., the DON was interviewed. The DON verified no additional testing was requested or done when Resident A had the elevated WBC count on (MONTH) 30, (YEAR) or started wheezing on (MONTH) 31, (YEAR). The DON stated the nurses were not assertive when they talked to Resident A's physician. On (MONTH) 28, 2019, at 10:40 a.m., RN 1 was interviewed by telephone and stated RN supervisors and charge nurses were responsible for reviewing lab results. RN 1 stated an elevated WBC count might indicate an infection and the nurse should check to see if the resident had prior lab results. She said if the test results were worse, the physician should order tests to find out the cause of the elevated WBCs. RN 1 stated the nurses should watch the resident for any signs of infection, and if a resident had an elevated WBC count and respiratory symptoms, the nurses should notify the physician, watch the resident's oxygen level and watch for an increased breathing rate. RN 1 stated the nurses should auscultate (listen to lung sounds) every shift and document the assessment in the nurse's progress notes. On (MONTH) 10, 2019, Resident A's Ambulance Transport Notes, dated (MONTH) 2, (YEAR), beginning at 8:13 a.m., were reviewed and indicated paramedics arrived at Resident A's bedside at 8:24 a.m., and Resident A was, .Pale .confused .Chest/Lungs Rhonchi on Right Rhonchi on Left (abnormal lung sounds) . and had a heart rate of 152 BPM (BPM-beats per minute, normal rate 60-100), respiratory rate of 48 per minute (normal rate16-20) and decreased oxygen level of 88%. Resident A's records from (name of hospital) were reviewed. The ED (Emergency Department) Physician's Report, dated (MONTH) 2, (YEAR), at 8:59 a.m., indicated Resident A's oxygen saturation level was 82%, and .worsening SOB (shortness of breath) since last night .respiratory distress .critical .audible coarse breath sounds from across the room .emergently intubated (breathing tube inserted into Resident A's windpipe) .purulent (pus-like) material at the cords (vocal cords). The CBC results, dated (MONTH) 2, (YEAR), at 9:20 a.m., indicated Resident A's WBC count was critically high at 30.4 (an increase of 15,000 WBCs since the previous test on (MONTH) 30, (YEAR)). The chest X-ray, dated (MONTH) 2, (YEAR), at 9:13 a.m., indicated Resident A had, .Right lower lobe infiltrate/pneumonia (respiratory infection in the right lung) . Resident A's hospital Discharge Summary/Death Note, dated (MONTH) 3, (YEAR), indicated Resident A had, Cardiopulmonary arrest .Severe septic shock (shock due to severe infection) .HAP (hospital acquired pneumonia) and passed away on (MONTH) 3, (YEAR) at 4:24 a.m., less than 24 hours after leaving the facility. The facility Policy and Procedure titled, Change in a Resident's Condition or Status, last revised (MONTH) (YEAR), was reviewed and indicated, .The nurse will notify the resident's Attending Physician (sic) or physician on call when there has been a .need to alter the resident's medical treatment significantly .A significant change of condition is a major decline .that Will not normally resolve itself without intervention by staff or implementing standard disease-related clinical interventions .Prior to notifying the .healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider .The nurse will record in the resident's medical record information relative to changes .If a significant change in the resident's .condition occurs, a comprehensive assessment .will be conducted .

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident A) in a universe of 138 residents received treatment and care to maintain the highest practicable level of physical well-being when Resident A was observed with emesis (vomit) that resembled brown coffee grounds (blood in vomit may appear bright red, black or dark brown like coffee grounds) and the physician was not immediately notified. This failure resulted in the delayed treatment of [REDACTED]. Resident A was transferred to the acute hospital via 911 (paramedic) ambulance at 8 p.m., arrived at the hospital at 8:40 p.m., and expired (died ) at 9:35 p.m., that same evening. Findings: On [DATE], at 11:29 a.m., an unannounced visit was made to the facility for the investigation of a complaint regarding quality of care. On [DATE], Resident A's facility record was reviewed. Resident A was an [AGE] year old male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident A's facility document titled, Order Summary Report, indicated an order dated [DATE], for [MEDICATION NAME] Sodium Solution (anticoagulant -blood thinner) 30MG (milligram)/0.3ML (milliliter) Inject 1 syringe subcutaneously (under the skin) one time a day for [MEDICAL CONDITION] ([MEDICAL CONDITION]- blood clot in a deep vein) [MEDICATION NAME](something done for prevention) for 2 weeks . Review of a facility care plan for Resident A dated [DATE], indicated, Focus: At risk for bleeding r/t (related to) ANTICOAGULANT THERAPY. The care plan listed an intervention to, .MONITOR FOR S/S (signs and symptoms) OF .BLEEDING .NOTIFY MD (doctor). A review of Resident A's facility, History and Physicals, (H&P) dated [DATE], indicated, This resident has the capacity to understand and make decisions. A facility progress note for Resident A titled, Health Status Note, dated, [DATE], at 3:00 p.m., authored by a licensed vocational nurse (LVN 1) was reviewed. In review of this note, there was no documentation found that indicated Resident A had been observed with coffee ground emesis during that shift (day shift was 7:00 a.m. - 3:00 p.m.). Nor was there documentation found in this note that indicated the physician for Resident A had been notified of the coffee ground emesis. Further review of Resident A's facility medical record found only one progress note entry from the day shift on [DATE], the only progress note found was the note listed above authored by LVN 1 at 3:00 p.m. Review of a Health Status Note, dated [DATE], at 7:45 p.m., authored by LVN 2 indicated, AT 7:30 PM SON CAME UP TO NURSE STATION AND STATED (sic) CAN SOMEONE CHECK ON HIS DAD AND WANTED TO KNOW WHAT WAS ON HIS DAD'S MOUTH. WENT IN TO ASSESS PATIENT AND NOTED PATIENT TO HAVE COFFEE GROUND EMESIS WITH FOUL SMELL .CALL (sic) DR. (name of doctor) WITH ORDER TO SEND PATIENT TO (name of hospital) ER (emergency room ) FOR EVAL. (evaluation) CALLED 911 AT 7:45 PM THEY CAME IN AT 8:00 PM . A review of Resident A's facility document titled, NEUROLOGICAL ASSESSMENT FLOWSHEET, dated [DATE], was conducted. The document listed a column titled, OBSERVATION (IE [MEDICAL CONDITION], VOMITING (sic) PARALYSIS). The column indicated the following: - At 1:30 p.m., a zero was listed in this column. - At 1:45 p.m., a zero was listed in this column. - At 2:00 p.m., a zero was listed in this column. - At 2:15 p.m., a zero was listed in this column. - At 2:45 p.m., a zero was listed in this column. - At 3:15 p.m., a zero was listed in this column. - At 4:15 p.m., a zero was listed in this column - At 5:15 p.m., a zero was listed in this column. Review of Resident A's facility document titled, Resident Transfer Record, dated [DATE], indicated the reason for transfer was coffee ground emesis. Review of Resident A's facility document titled, PHYSICIAN'S DISCHARGE SUMMARY, with a discharge date of [DATE], indicated, Transfer/Discharge was necessary due to .GI (Gastrointestinal) Bleeding, nausea/vomiting. Review of a facility progress note for Resident A titled, IDT Review, dated [DATE], indicated, .At approximately 3pm, CNA (Certified Nurse's Assistant) asked nurse to check on resident due to phlegm (mucous). Charge nurse found a small amount of liquid on the corner of the resident's mouth, and a quarter-sized amount of liquid on the resident's gown. CNA and charge nurse both report (sic) that liquid was dark in color, but did not appear to be blood. Charge nurse reported that it looked like he had spit out food; resident noted with chocolate .at bedside .No C(NAME) (change of condition) noted until approximately 7pm, when family member asked the evening charge nurse to assess the resident. Charge nurse noted foul-smelling, coffee-ground emesis in the resident's mouth . Review of Resident A's acute hospital records indicated the resident was admitted at 8:40 p.m., on [DATE], for GI bleeding. A review of Resident A's hospital documentation titled, Emergency Documentation, dated [DATE], indicated, History of Present Illness: The patient presents with vomiting. The onset was earlier today. The character of symptoms is bloody .Per family pt (patient) was found with dry blood on his chest . Further review of this record indicated, ER course: The patient arrives in the ER from a rehabilitation facility, he has severe respiratory distress (fluid collects in the lungs' air sacs making it difficult to breathe and depriving organs of oxygen) on arrival .He is pronounced expired (died ) at 9:35 PM . A review of Mayo Clinic's description of vomit with blood indicated, .Blood in vomit may be bright red, or it may appear black or dark brown like coffee grounds .vomiting blood usually represents something more serious and requires immediate medical attention .Seek immediate medical attention .It's important to quickly identify the underlying cause of the bleeding and prevent more-severe blood loss and other complications, including death . On [DATE], at 1:53 p.m , an interview was conducted with the Director of Nursing (DON). The DON was asked about the brown substance on Resident A's mouth that LVN 1 had identified earlier in the shift on [DATE]. The DON stated LVN 1had determined it was chocolate. The DON further stated that LVN 1 had called her and informed her about what she had observed on Resident A prior to her leaving on vacation. On [DATE], at 12:13 p.m., a phone interview was conducted with the day shift certified nurse's assistant (CNA 1). CNA 1 was asked if she provided care for Resident A on [DATE]. CNA 1 stated, Yes. CNA 1 further stated she also had had a CNA student (Student 1) that had trained with her that day. CNA 1 stated that she had observed brown vomit in the corners of Resident A's mouth, on his gown and on the floor when she had entered his room after he had been found on the floor. CNA 1 stated that LVN 1 had been there and had also observed the brown vomit on Resident A's gown and on the floor. CNA 1 stated that she had thought about why Resident A's vomit had been brown and stated nothing added up as to what he could have eaten that would have made the vomit that brown color. CNA 1 further stated Resident A had had a complaint of nausea after lunch that day. CNA 1 stated that she and Student 1 had informed LVN 1 about Resident A's nausea. CNA 1 stated that LVN 1 had told them to get him something to eat. CNA 1 stated that after Resident A had had just a few bites of a sandwich, he had thrown up brown vomit again. CNA 1 stated that they had informed LVN 1 about Resident A's brown vomit. CNA 1 stated that she had informed LVN 1 three times about Resident A's nausea and brown vomit. CNA 1 stated that she felt as if she had been bothering LVN 1 and that LVN 1 appeared to be getting frustrated with her and felt like she was a problem for LVN 1. On [DATE], at 2:23 p.m., a phone interview was conducted with LVN 1. LVN 1 was asked if she had provided care for Resident A on [DATE]. LVN 1 stated, Yes, I believe so. LVN 1 was asked if she had observed brown emesis on Resident A and the ground when the resident was found on the floor after he had had a fall. LVN 1 stated, Not at that time, no. LVN 1 was asked if CNA 1 had informed her that Resident A had thrown up brown emesis after he had eaten a sandwich. LVN 1 stated that she was not informed. LVN 1 further stated that she had not been aware of Resident A's brown emesis at all during her shift. LVN 1 further stated that she had not been informed by CNA 1 about Resident A's complaint of nausea either. LVN 1 stated that at change of shift the PM CNA (CNA 2) had informed her that Resident A had thrown up. LVN 1 stated that the resident just had had something in the corners of his mouth, brown drool. LVN 1 stated that there had been only a little spot on his gown. LVN 1 further stated that it was nothing alarming just food that the family had brought in for the resident. LVN 1 was asked if she had documented the brown drool. LVN 1 stated that she could not recall if she had documented it. LVN 1 further stated that she didn't really think it was anything. LVN 1 was asked if she had reported the brown drool to the PM LVN (LVN 2). LVN 1 stated that she didn't recall. On [DATE], at 4:42 p.m., a phone interview was conducted with a family member (FM) of Resident A. The FM was asked if the family had brought any chocolate or chocolate chip cookies in for the resident while he had been in the facility. The FM stated, No. The FM further stated that no chocolate had been given to the resident by the family. The FM stated that on the evening of [DATE], her husband had brought in ambrosia, apples and grapes for the resident but stated no chocolate. When asked if she had seen any chocolate in the resident's room on the evening of [DATE], the FM stated, No, she had not seen any chocolate in the resident's room. On [DATE], at 3:13 p.m., a phone interview was conducted with CNA 2. CNA 2 was asked if she had been the PM CNA for Resident A on [DATE]. CNA 2 stated, I was. CNA 2 stated that it had been just past three p.m. when LVN 1 had approached her and had asked her to change Resident A's gown and clean his mouth. CNA 2 stated that Resident A had looked like he had had brown coffee grounds in the corners of his mouth. CNA 2 stated that his mouth had been dirty and that she had had a hard time cleaning his mouth. CNA 2 stated that LVN 1 had told her to change Resident A's gown because he had thrown up. CNA 2 stated that LVN 1 had said it wasn't blood. CNA 2 stated that the emesis had looked like coffee grounds. On [DATE], at 8:57 a.m., a phone interview was conducted with LVN 2. LVN 2 was asked if she had provided care for Resident A on [DATE]. LVN 2 stated, Yes. LVN 2 was asked if she had been informed by LVN 1 that Resident A had had coffee ground emesis on the day shift. LVN 2 stated that she had not been informed that Resident A had had coffee ground emesis. LVN 2 stated that she had not been informed of the coffee ground emesis until she had been standing in Resident A's room with his family and CNA 2 had informed her that he had thrown up earlier that day. LVN 2 stated that she had been angry because this had been the first time she had heard that the resident had vomited. LVN 2 stated that had she been informed about the coffee ground emesis, she would have sent the resident out at the beginning of her shift. On [DATE], at 1:41 p.m., a phone interview was conducted with Student 1. Student 1 was asked if she had provided care for Resident A on [DATE]. Student 1 stated, Yes. Student 1 was asked if she had assisted CNA 1 on that day. Student 1 stated, Yes. Student 1 stated that she and CNA 1 had assisted Resident A eat a sandwich. Student 1 further stated that the resident had taken one bite and had thrown up what looked like coffee grounds. Student 1 stated that the vomit had had a really bad smell. Student 1 stated that they had informed LVN 1 about the brown coffee ground emesis. Student 1 stated that they had also informed LVN 1 about the bad smell of the emesis. Student 1 stated that LVN 1 had told them that the resident had been doing that for a while and that they had been working on trying to figure out the cause of it. On [DATE], at 10:31 a.m., an interview was conducted with the DON, the facility Administrator (AD) and the Corporate Clinical Resource Specialist (CCRS). The facility staff members were asked about the observations made by CNA 1 and Student 1 with regards to Resident A's coffee ground emesis on the day shift of [DATE]. The facility staff members were asked why the coffee ground emesis had not been reported to the physician nor had been documented in the resident's medical record. The DON stated it had been reported to her by LVN 1 that there had been no observation of coffee ground emesis. The DON further stated that LVN 1 had determined it was chocolate in the corners of the resident's mouth and on his gown. The DON stated that was why the physician had not been notified of a change of condition nor documented as such. The DON further stated that had a change of condition been identified, the physician should have been notified and documented in the medical record. Review of a facility policy and procedure titled, Change in a Resident's Condition or Status, with a revised date of [DATE], indicated, Our facility shall promptly notify the resident, his or her Attending Physician .of changes in the resident's medical/mental condition . The policy further indicated, .1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: .d. A significant change in the resident's physical/emotional/mental condition .2. A significant change of condition is a decline .in the resident's status that: a. Will not normally resolve itself without intervention by staff .

Based on interview and record review the facility failed to notify the physician and receive orders within the time indicated in the facility policy to address a significant change of condition for one resident (Resident A) in a universe of 126 residents. This failure caused the resident to suffer from unrelieved abdominal pain that required the resident to be transported to the emergency department of the acute hospital by paramedic ambulance for further evaluation and treatment, where the resident underwent [REDACTED]. Treatment generally requires immediate surgery), and peritonitis (inflammation of the lining that covers abdominal organs). Findings: On June 2, 2016, at 10:20 a.m., an unannounced visit was made to the facility for the investigation of a complaint. On June 2, 2016, Resident A's record was reviewed. Resident A was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident A's, History and Physical, (H&P) dated April 14, 2016, indicated, This resident has the capacity to understand and make decisions. A review of Resident A's Minimum Data Set (MDS- a comprehensive assessment tool) dated April 21, 2016, section titled, Brief Interview for Mental Status, (BIMS) score was 13. A BIMS score is a reflection of a resident's mental status. A score of 13-15 indicates the resident is cognitively intact. A review of Resident A 's document titled, Order Summary Report, indicated, MONITOR FOR PAIN LEVEL 0-10 (0 -pain free; 10 -unspeakable pain) every shift for pain, ordered April 15, 2016. Further review of the summary report found two orders for Tylenol (pain reliever) for Resident A. The first order indicated, Tylenol Tablet 325 MG (milligram, unit of measurement) ([MEDICATION NAME]) Give 1 tablet by mouth every 4 hours as needed FOR MILD PAIN . The second order indicated, Tylenol Tablet 325 MG ([MEDICATION NAME]) Give 2 tablets by mouth every 4 hours as needed FOR MODERATE PAIN . Both ordered April 15, 2016. No other orders for pain medication were located during record review for Resident A. Review of Resident A's care plans found a care plan with the focus, AT RISK FOR FURTHER EPISODES OF PAIN, initiated April 15, 2016. The care plan's interventions indicated, Assess level of pain based on pain management scale of 0-10, Attend to needs promptly .Monitor effectiveness of medication and refer to MD if ineffective .Refer to MD if management is ineffective . Further review of Resident A's record found nursing documentation titled, Health Status Note, dated May 4, 2016, at 4:04 a.m. The note indicated, .RESIDENT CONT (continued) TO C/O (complain of) PAIN TO STOMACH, PM SHIFT GAVE PAIN PRN (as needed) INEFFECTIVE, RESIDENT RESQUESTED (sic) SLEEPING AID, INEFFECTIVE, RESIDENT NOTED TO HAVE ABD (abdominal) DESTENTION (sic) .DR NOTIFIED @ 1245 AM, AWAITING CALL BACK WITH ANY ORDERS . Resident A's, Health Status Note, dated May 4, 2016, at 2:24 p.m., indicated, .RESIDENT WAS SENT OUT TO ER AT (hospital name) SECONDARY TO C/O UNRELIEVED ABD PAIN TO RLQ (right lower quadrant). PT WAS (sic) C/O PAIN SINCE LAST NIGHTER (sic) PER NOC (night) SHIFT NURSE AND WAS UNRELIEVED EVEN THOUGH PAIN EDS (sic) WERE ADMINISTERED AND WITH INTERVENTION. DR. (2 physician's names) WERE CALLED SEVERAL TIMES DURING MORNING SHIFT DUE TO PATIENTS SEVERE C/O PAIN WITH NO ANSWER .DOCTOR CALL BACK TO NURSES ST (station) APPROX 0940 AND GAVE ORDER TO SEND PT OUT TO ER 911 . On May 4, 2016, at 10:29 a.m., Resident A was transferred from the facility to the acute hospital via 9-1-1 ambulance for unrelieved abdominal pain that began the evening of May 3, 2016, and had increased to severe pain over approximately 12 hours. On June 2, 2016, at 1:28 p.m., an interview was conducted with a licensed vocational nurse (LVN 1) who works on the day shift (7a.m. - 3 p.m.). LVN 1 was asked about Resident A's medical condition. LVN 1 stated that the NOC (night) shift nurse had reported to her that the PM (3 p.m. -11 p.m.) shift and NOC (11 p.m. - 7 a.m.) shift nurses had both attempted to reach the resident's physician but had received no response regarding Resident A's abdominal pain. LVN 1 stated she evaluated the resident at approximately 7:45 a.m., on May 4, 2016. LVN 1 stated the resident had a complaint of pain at eight out of 10 on the pain scale. LVN 1 stated she had attempted to call the physician three times but received no response. LVN 1 stated the physician called back to the nurse's station after the third attempt and gave orders for the resident to be sent out. An interview was conducted on June 2, 2016, at 1:35 p.m., with a registered nurse unit supervisor (RNUS) who works on the day shift. The RNUS was asked what the facility's protocol for contacting a physician for a resident's change of condition. The RNUS stated a physician should be called three times with a wait of 15 minutes between each call. The RNUS further stated that after three attempts had been made to call the resident's physician and no contact was made, the facility Medical Director should then be called. On June 2, 2016, at 1:51 p.m., an interview was conducted with a certified nurse's assistant (CNA 1) who works on the day shift. CNA 1 was asked if she had provided care for Resident A the day of May 4, 2016. CNA 1 stated, Yes. CNA 1 stated the resident had continued to use his call light and complained to her about his abdominal pain. A phone interview was conducted on June 6, 2016, at 2:42 p.m., with CNA 2 who works on the NOC shift. CNA 2 was asked if she had provided care for Resident A the night of May 3, 2016. CNA 2 stated, Yes. CNA 2 stated the resident was in bad abdominal pain that night. CNA 2 further stated she thought that the resident should have been sent out to the hospital because of his pain. CNA 2 stated she had told the resident's LVN about his abdominal pain and had told another licensed nurse that evening. CNA 2 further stated the resident had used his call light approximately, 25 times, that night to report his abdominal pain. CNA 2 stated another CNA had also answered the resident's call lights because he had used it so often to ask for help for his pain. CNA 2 stated Resident A almost cried he was in so much pain. On June 9, 2016, at 3:04 p.m., a phone interview was conducted with the facility Administrator (AD), the Assistant Director of Nursing (ADON) and the Director of Staff Development (DSD). The AD was asked about the facility's policy for contacting a physician with a resident's change of condition. The AD stated if there was an acute change in a resident's condition the physician was to be notified. The AD further stated if the staff had not received a prompt response from the resident's physician, the Medical Director should be called. When asked what a prompt response would be, the AD stated 30 minutes or less. On June 13, 2016, at 8:57 a.m., a phone interview was conducted with LVN 2 who works the NOC shift. LVN 2 was asked about Resident A's medical condition on the night of May 3, 2016. LVN 2 stated she was, worried about the resident. When asked if she had notified the physician about the change of condition, LVN 2 stated she had called the physician two times within an hour but stated she had not heard back from the physician. No additional attempts were made to contact the physician or to contact the Medical Director. When asked about the facility's protocol for contacting the physician for a resident's change of condition, LVN 2 stated it had not been explained to her. LVN 2 was asked at what time she had called the physician. LVN 2 stated she could not remember exactly, but knew it had been earlier in her shift. (NOC shift is 11:00 p.m. to 7:00 a.m.) On June 15, 2016, at 10:40 a.m., a phone interview was conducted with a registered nurse supervisor (RNS) who works the NOC shift. The RNS was asked about Resident A. The RNS stated LVN 2 had come to her about Resident A's abdominal pain. The RNS stated she and LVN 2 had assessed the resident and the resident had abdominal distention. The RNS stated she told LVN 2 to call the physician to get orders. The RNS stated they did not wait to hear back from the physician and decided to do a nursing intervention and straight catheterized (hollow plastic tube inserted through the urinary opening to the bladder to drain excess urine) the resident. The RNS stated LVN 2 had told her that she had called the physician and had awaited orders. The RNS was asked if she had called the physician for Resident A's change of condition. The RNS stated, No. The RNS further stated Resident A was LVN 2's resident. The RNS stated LVN 2 was the resident's, Main nurse. The RNS was asked about the facility's protocol for contacting a physician for a resident's change of condition. The RNS stated the physician was to be called, two or three times. When asked if a physician should be notified of a resident's change of condition and ask the physician if new orders were needed for the resident's care the RNS stated, Supposed to be. Record review and interview with facility staff indicated no attempts were made to contact the Medical Director when the physician failed to respond in a timely manner. On June 6, 2016, Resident A's acute hospital emergency department record had been reviewed. A review of Resident A's hospital form titled, History and Physical, (H&P) dated May 5, 2016, indicated, Chief Complaint .ABD PAIN 10/10 LAST NIGHT . The History of Present Illness, of the same H&P indicated, .Patient was admitted with abdominal pain and he was found to have [MEDICATION NAME] rupture, (forcible tearing or bursting of a body organ inside the abdominal cavity which is an emergency condition that requires immediate medical attention), and he went to surgery yesterday .Currently patient is intubated (a breathing tube placed in the windpipe) on ventilator with sedation . In the hospital record section, Assessment/Plan, of the H&P for Resident A, it indicated, .Bowel perforation (a hole that develops through the wall small intestine or large bowel, allowing strong acidic gastric juices and undigested food to spill out into the abdominal cavity causing severe pain) : .Evaluated by general surgery, was taking (sic) emergently to OR (operating room) . Review of Resident A's hospital, Operative Report, dated May 4, 2016, indicated, .Postoperative Diagnosis: [REDACTED]. Review of the facility's policy and procedure titled, Acute Condition Changes-Clinical Protocol, revised December 2012, indicated, .6. The nursing staff will contact the Physician based on the urgency of the situation. For emergencies, they will call or page the Physician and request a prompt response (within approximately one-half hour or less). 7. The Attending Physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition or status. a. The staff will notify the Medical Director for additional guidance and consultation if they do not receive a timely or appropriate response .

Based on interview and record review the facility failed to provide necessary care and services to ensure one resident (Resident A) in a universe of 126 residents maintained the highest level of physical and psychosocial well-being. This failure caused the resident to suffer from severe, unrelieved abdominal pain for approximately 12 hours. The failure required the resident to be transported to an acute hospital by a paramedic ambulance for further evaluation and treatment where the resident underwent [REDACTED]. Treatment generally requires immediate surgery) and peritonitis (inflammation of the lining that covers the abdominal organs). Findings: On June 2, 2016, at 10:20 a.m., an unannounced visit was made to the facility for the investigation of a complaint. On June 2, 2016, Resident A's record was reviewed. Resident A was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident A's, History and Physical, (H&P) dated April 14, 2016, indicated, This resident has the capacity to understand and make decisions. A review of Resident A's Minimum Data Set (MDS- a comprehensive assessment tool) dated April 21, 2016, section titled, Brief Interview for Mental Status, (BIMS) score was 13. A BIMS score is a reflection of a resident's mental status. A score of 13-15 indicates the resident is cognitively intact. A review of Resident A's document titled, Order Summary Report, indicated, MONITOR FOR PAIN LEVEL 0-10 (0 -pain free; 10 -worst pain ever experienced) every shift for pain, ordered April 15, 2016. Further review of the summary report found two orders for Tylenol ([MEDICATION NAME] - a pain reliever) for Resident A. The first order indicated, Tylenol Tablet 325 MG (milligram, unit of measurement) Give 1 tablet by mouth every 4 hours as needed FOR MILD PAIN . The second order indicated, Tylenol Tablet 325 MG ([MEDICATION NAME]) Give 2 tablets by mouth every 4 hours as needed FOR MODERATE PAIN . Both were ordered April 15, 2016. No other orders for pain medication were found during record review for Resident A. Review of Resident A's care plans found a care plan with the focus, AT RISK FOR FURTHER EPISODES OF PAIN, initiated April 15, 2016. The care plan's interventions indicated, Assess level of pain based on pain management scale of 0-10, Attend to needs promptly .Monitor effectiveness of medication and refer to MD if ineffective .Refer to MD if management is ineffective. Review of Resident A's Medication Administration Record [REDACTED]. In the column designated for Tuesday May 3rd, the pain level was documented with zeros (no pain) for all three shifts. For the Wednesday May 4th column an, 8/10, was documented in the seven to three shift column only. (Day shift) Further review of Resident A's MAR found only one entry to indicate Tylenol was given to Resident A. The documentation indicated the ordered medication was administered to the resident on Wednesday May 4, 2016 on the day shift for a pain level of, 8/10. The back of this document indicated, Tylenol 325mg, had been given for, C/O (complaint of) pain. The pain level for this entry indicated a seven. The result of the medication administration was documented as, effective. An entry dated May 5, 2016, at 8:15 a.m., (The resident was discharged from the facility to the acute hospital on May 4, 2016 at approximately 10:30 a.m.) indicated, Tylenol 325mg (2 tablets), given for, C/O 10/10 ABD (abdominal) PAIN. The result was documented as, INEFFECTIVE; SENT OUT TO (name of hospital). No documentation was made by the LVN that indicated if the entry had been a late entry. Further review of Resident A's record found nursing documentation titled, Health Status Note, dated May 4, 2016, at 4:04 a.m. The note indicated, .RESIDENT CONT (continued) TO C/O PAIN TO STOMACH, PM SHIFT GAVE PAIN PRN (as needed) INEFFECTIVE, RESIDENT RESQUESTED (sic) SLEEPING AID, INEFFECTIVE, RESIDENT NOTED TO HAVE ABD DESTENTION (sic) .DR NOTIFIED @ 1245 AM, AWAITING CALL BACK WITH ANY ORDERS . Resident A's, physician's orders [REDACTED]. Resident A's, Health Status Note, dated May 4, 2016, at 2:24 p.m., indicated, .RESIDENT WAS SENT OUT TO ER AT (hospital name) SECONDARY TO C/O UNRELIEVED ABD PAIN TO RLQ. PT WAS (sic) C/O PAIN SINCE LAST NIGHTER (sic) PER NOC (night) SHIFT NURSE AND WAS UNRELIEVED EVEN THOUGH PAIN EDS (sic) WERE ADMINISTERED AND WITH INTERVENTION. DR. (2 physician's names) WERE CALLED SEVERAL TIMES DURING MORNING SHIFT DUE TO PATIENTS SEVERE C/O PAIN WITH NO ANSWER .DOCTOR CALL BACK TO NURSES ST (station) APPROX 0940 AND GAVE ORDER TO SEND PT OUT TO ER 911 . Resident A was transferred from the facility to the acute hospital for unrelieved abdominal pain that began the evening of May 3, 2016, and had increased to severe pain over approximately 12 hours when the resident was transported by ambulance at 10:29 a.m., on May 4, 2016. On June 6, 2016, Resident A's acute hospital emergency department record was reviewed. A review of Resident A's hospital, History and Physical, (H&P) dated May 5, 2016, indicated, .ABD PAIN 10/10 LAST NIGHT . Section, History of Present Illness, of the same H&P indicated, .Patient was admitted with abdominal pain and he was found to have [MEDICATION NAME] rupture (forcible tearing or bursting of an abdominal organ which is an emergency condition that requires immediate medical attention) and he went to surgery yesterday .Currently patient is intubated (a breathing tube placed in the windpipe) on ventilator with sedation . In section, Assessment/Plan, of the H&P for Resident A, it indicated, .Bowel perforation (a hole that develops through the wall of the small intestine or large intestine) Evaluated by general surgery, was taking (sic) emergently to OR (operating room) . Review of Resident A's hospital, Operative Report, dated May 4, 2016, indicated, .Postoperative Diagnosis: [REDACTED]. On June 2, 2016, at 1:28 p.m., an interview was conducted with a licensed vocational nurse (LVN 1) who works on the day shift (7a.m. - 3 p.m.). LVN 1 was asked about Resident A's medical condition. LVN 1 stated the NOC (night) shift nurse had reported to her that the PM (3 p.m. -11 p.m.) shift and NOC (11 p.m. - 7 a.m.) shift nurses had both attempted to reach the resident's physician but had received no response regarding Resident A's abdominal pain. LVN 1 stated she evaluated the resident at approximately 7:45 a.m., on May 4, 2016. LVN 1 stated the resident had a complaint of pain at eight out of 10 on the pain scale. LVN 1 stated she had attempted to call the physician three times but received no response. LVN 1 stated the physician called back to the nurse's station after the third attempt and gave orders for the resident to be sent out. On June 2, 2016, at 1:51 p.m., an interview was conducted with a certified nurse's assistant (CNA 1) who works on the day shift. CNA 1 was asked if she had provided care for Resident A the day of May 4, 2016. CNA 1 stated, Yes. CNA 1 stated the resident had continued to use his call light and complained to her about his abdominal pain. A phone interview was conducted on June 6, 2016, at 2:42 p.m., with CNA 2 who works on the NOC shift. CNA 2 was asked if she had provided care for Resident A the night of May 3, 2016. CNA 2 stated, Yes. CNA 2 stated the resident was in bad abdominal pain that night. CNA 2 further stated she thought that the resident should have been sent out to the hospital because of his pain. CNA 2 stated she had told the resident's LVN about his abdominal pain and had told another licensed nurse that evening. CNA 2 further stated the resident had used his call light approximately, 25 times, that night to report his abdominal pain. CNA 2 stated another CNA had also answered the resident's call lights because he had used it so often to ask for help for his pain. CNA 2 stated Resident A almost cried he was in so much pain On June 9, 2016, at 3:04 p.m., a phone interview was conducted with the facility Administrator (AD), the Assistant Director of Nursing (ADON) and the Director of Staff Development (DSD). The AD was asked for the facility policy on how a physician was to be contacted with a resident's change of condition. The AD stated if there was an acute change in a resident's condition the physician was to be notified. The AD stated if the staff had not received a prompt response from the physician, the Medical Director should be called. The AD stated 30 minutes or less would be considered a prompt response. On June 13, 2016, at 8:57 a.m., a phone interview was conducted with LVN 2 who works the NOC shift. LVN 2 was asked about Resident A's medical condition on the night of May 3, 2016. LVN 2 stated she was, worried about the resident. When asked if she had notified the resident's physician about the change of condition, LVN 2 stated she had called the physician two times within an hour but stated she had not heard back from the physician. No additional attempts were made to contact the physician or to contact the Medical Director. LVN 2 was asked at what time she had called the physician. LVN 2 stated she could not remember exactly, but knew it had been earlier in her shift. (NOC shift is 11:00 p.m. to 7:00 a.m.) On June 15, 2016, at 10:40 a.m., a phone interview was conducted with a registered nurse supervisor (RNS). The RNS was asked about Resident A. The RNS stated LVN 2 had come to her about Resident A's abdominal pain. The RNS stated she and LVN 2 had assessed the resident and the resident had abdominal distention. The RNS stated she told LVN 2 to call the physician to get orders. The RNS was asked if she had called the physician for Resident A's change of condition. The RNS stated, No. When asked if a physician should be notified of a resident's change of condition and ask if new orders were needed for the resident's care, the RNS stated, Supposed to be. Record review and interview with facility staff indicated no attempts were made to contact the Medical Director when Resident A's physician failed to respond in a timely manner. Review of the facility's policy and procedure titled, Acute Condition Changes-Clinical Protocol, revised December 2012, indicated: .6. The nursing staff will contact the Physician based on the urgency of the situation. For emergencies, they will call or page the Physician and request a prompt response (within approximately one-half hour or less). 7. The Attending Physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition or status. a. The staff will notify the Medical Director for additional guidance and consultation if they do not receive a timely or appropriate response .