Every finding on record at Pacific Gardens Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to meet professional standards of practice for eight of 21 sampled residents (Resident 1, Resident 55, Resident 72, Resident 102, Resident 127, Resident 150, Resident 155, and Resident 167) when:1. Resident 1's oxygen therapy (a colorless, odorless, tasteless gas essential to living organisms) was set at 2 liters per minute (L/min - a unit of measurement for oxygen flow rate) and not 1 L/min as indicated on the physician order (a set of instructions written by a doctor for clinicians to follow when caring for a resident).2. Resident 55's oxygen flow rate (the quantity of oxygen that is passing through a cross-section of a pipe in a specific period) was being delivered at 4 LPM (liters per minute - a unit of measurement) instead of the ordered 2 LPM.3. Resident 127 was administered 2.5 L/min of oxygen therapy through a nasal cannula (a thin, flexible tube with two prongs that fit into the nostrils and deliver oxygen) without a physician's order.These failure resulted in Resident 1, Resident 55 and Resident 127 not receiving oxygen therapy as ordered which had the potential to result in the administration of unnecessary supplemental oxygen which could lead to nasal dryness, shortness of breath, oxygen toxicity (lung damage that happens from breathing in too much extra oxygen therapy), respiratory distress (difficulty breathing) and serious medical conditions. 4. Resident 155 and Resident 72's oxygen concentrator's (electric, medical air-purifier machine that makes its own pure oxygen) air filter (removes dust, pollen, pet dander and other particles from the room air before the machine turns it into concentrated oxygen) was covered with white dusty looking lint. These failures had the potential to result in Resident 155 and Resident 72 to not receive the oxygen necessary to treat their condition which could lead to more serious respiratory distress. 5. Resident 167's blood sugar level was taken at 5 a.m. and insulin lispro (fast-acting injectable medication that lowers blood glucose (sugar)) was administered an hour before meal.This failure had the potential to result in hypoglycemic (condition where sugar levels in the blood drop too low) episode for Resident 167.6. Resident 102's calcium acetate (medication that helps treat high phosphorus levels in kidney patients) was not given with meals as indicated in the physician's order.This failure had the potential to lead to ineffective treatment of high phosphorus levels and significantly increased the risk of Resident 102 developing hyperphosphatemia (high phosphorus level) due to more phosphorus absorbed into the resident's bloodstream on an empty stomach.7. Resident 102's hydralazine order was implemented with unclear frequency (with meals).This failure had the potential to cause significant, dangerous hypotension (low blood pressure), unpredictable blood pressure spikes, and mismanagement of Resident 102's blood pressure.8. Resident 150's calcium lab result was not communicated to the physician, and there was no evidence of clinical follow-up or intervention.This failure had the potential to place the Resident 150 at risk for complications related to abnormal calcium levels. Findings:1. During an observation on 4/21/2026 at 6:10 a.m. in Resident 1's room, Resident 1 was observed in bed, dressed in a t-shirt, and wearing an oxygen nasal cannula (NC- a small plastic tube, which fits into the person's nostrils to provide supplemental oxygen) with the oxygen rate set at 2 L/min.During a review of Resident 1's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 4/23/26, the AR indicated Resident 1 was admitted to the facility from an acute care hospital on 1/30/25 with diagnoses of acute respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a waste gas] from the blood), obstructive sleep apnea (OSA - when you stop breathing during sleep because of a blockage in the windpipe), cerebral ischemia (insufficient blood flow to the brain resulting in damage to brain tissue), type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), acquired loss of right limb (surgical removal of finger, toe, hand, foot, arm or leg) below the knee.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 3/9/26, the MDS section C indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 10 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 1 was moderately impaired.During a concurrent interview and record review on 4/22/2026 at 2:03 p.m. with Charge Nurse (CRN) 1, Resident 1's Order Review (OR) list, undated was reviewed. The ORL indicated, .oxygen at 1 L/min [LPM] via NC continuous. CRN 1 stated Resident 1's physician orders were to administer oxygen at 1 L/min. CRN 1 stated Resident 1's oxygen rate should have been at 1 L/min and should not have been put at 2 L/min rate. CRN 1 stated oxygen was considered a medication and staff should have followed the physician's orders for resident safety. CRN1 stated if a resident had a complaint of shortness of breath (SOB - occurs when you do not get enough oxygen, difficulty breathing), the nurse completed a change in condition assessment and notified the physician. CRN 1 stated she had not had a complaint from staff or Resident 1 for SOB.During an interview on 4/24/2026 at 10:32 a.m. with the Director of Nursing (DON), the DON stated oxygen was considered a medication and staff needed a physician's order to administer oxygen. The DON stated staff should have followed physician orders. The DON stated staff could have overdosed the resident or gave the resident oxygen when they did not need it. The DON stated if the resident needed a higher rate of oxygen, staff should have assessed the resident to see why he needed a higher rate of oxygen and notified the physician to see if the resident's oxygen rate could have been increased. The DON stated it was not acceptable to give a resident oxygen at 2 L/min when the physician ordered oxygen for 1 L/min.During a review of the facility's P&P titled, Oxygen Administration, dated 2025, the P&P indicated, .oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences.oxygen is administered under orders of a physician.staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy.the resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as.equipment setting for the prescribed flow rates.monitoring for complications associated with the use of oxygen.2. During an observation on 4/24/26 at 12:25 p.m. in Resident 55's room during the initial tour, Resident 55 was sitting upright in a wheelchair with a nasal cannula (a small clear plastic tube that delivers oxygen through the nose) in place, connected to an oxygen concentrator (medical device that acts like a specialized air filter). Resident 55's oxygen flow rate was set to 4 LPM.During a review of Resident 55's admission Record (AR), dated 3/30/26, the AR indicated, Resident 55 was admitted to the facility with the diagnoses that included Acute Respiratory Failure with Hypoxia (the body is not getting enough oxygen), Chronic Obstructive Pulmonary Disease (COPD-a disease when lungs are damaged and clogged, making it hard to breathe), and Chronic Pulmonary Edema (fluid keeps building up in the lungs over time, making it harder to breathe). During a review of Resident 55's Order Review Report (ORR), dated 3/31/26, the ORR indicated, . Oxygen at 2LPM via [nasal cannula (NC)] continuous .During a concurrent observation and interview on 4/21/26 at 12:40 p.m. with Licensed Vocational Nurse (LVN) 5 in Resident 55's room, Resident 55 was receiving oxygen at 4 LPM. LVN 5 stated Resident 55's oxygen flow rate was set at 4 LPM. LVN 5 adjusted the oxygen flow rate to 2 LPM as prescribed by the physician. LVN 5 stated that only the Registered Nurse (RN) is authorized to adjust the oxygen flow rate and sometimes he forgets this due to having worked at the facility for 19 years. During an interview on 4/24/26 at 9 a.m. with the Director of Staff Development (DSD), the DSD stated staff nurses were expected to follow the physician's orders. The DSD stated that only the RN, and not LVN, is permitted to regulate oxygen flow rate or initiate oxygen flow therapy.During an interview on 4/24/26 at 10:05 a.m. with the Director of Nursing (DON), the DON stated that a new regulation regarding oxygen administration was introduced this year. The DON stated the facility conducted an in-service training on the new guidelines. The DON stated that the administration, initiation, and regulation of oxygen was limited to RN's, physicians and respiratory therapists. The DON stated LVN's were not permitted to perform these functions. During a review of the facility's policy and procedures (P&P) titled, Oxygen Administration, dated 2025, the P&P indicated, .Personnel authorized to initiate oxygen therapy include physicians, RNs, and respiratory therapists. LVN's are not authorized to administer or adjust oxygen flow/titrate oxygen.3. During an observation on 4/21/26 at 6:44 a.m. in Resident 127's room, Resident 127 was observed lying in bed with a nasal cannula in her nose. Resident 127's nasal cannula was observed connected to the oxygen concentrator (medical device that helps residents breathe). The oxygen concentrator was observed on the left side of the bed turned on at 2.5 L/min.During an observation on 4/21/26 at 1:13 p.m. in Resident 127's room, Resident 127 was observed lying in bed with a nasal cannula in her nose. Resident 127's nasal cannula was observed connected to the oxygen concentrator. The oxygen concentrator was observed on the left side of the bed turned on at 2.5 L/min.During a concurrent observation and interview on 4/22/26 at 8:00 a.m. with Registered Nurse (RN) 2, in Resident 127's room, Resident 127 was observed lying in bed with a nasal cannula in her nose. RN 2 stated Resident 127's nasal cannula was administering 2.5 L/min of oxygen therapy. RN 2 stated licensed nursing staff administered oxygen to Resident 127 and were responsible for ensuring oxygen therapy was administered per physician orders.During a concurrent interview and record review on 4/22/26 at 8:10 a.m. with RN 2, Resident 127's Order Summary Review, dated 4/22/26 was reviewed. RN 2 stated Resident 127 did not have an order for oxygen nasal cannula therapy. RN 2 stated oxygen was a medication and required a physician order to administer. RN 2 stated Resident 127 received 2.5 L/min nasal cannula oxygen therapy without a physician order. RN 2 stated it was outside of nursing scope of practice and professional standards to administer oxygen therapy without a physician's order in non-emergent situations. RN 2 stated she could not locate an order or documentation to indicate Resident 127 was administered oxygen therapy for an emergent situation. RN 2 stated Resident 127 was at risk of unnecessary oxygen therapy outside of physician prescribed treatments and plan of care.During an interview on 4/23/26 at 1:17 p.m. with RN 3, RN 3 stated oxygen was a medication and required a physician order to be administered. RN 3 stated it was not within nursing scope of practice to administer oxygen without a physician order. RN 3 stated administering oxygen without a physician's order placed residents at risk for oxygen toxicity (lung damage that happens from breathing in too much extra [supplemental] oxygen) which could lead to serious medical conditions. During an interview on 4/24/6 at 10:27 a.m. with the Director of Nursing (DON), the DON stated oxygen was a medication and a prescribed treatment which required a physician's order. The DON stated it was not within nursing scope of practice to administer medication, including oxygen therapy, without a physician's order. The DON stated a physician order for oxygen therapy was essential to ensure oxygen therapy was administered at the correct dose, or L/min, and duration to be safe and effective for Resident 127. The DON stated safe and effective oxygen therapy administration prevented oxygen toxicity and ensured appropriate equipment was used for resident specific needs. The DON stated facility policy and procedure, as well as standards of practice, were not followed when Resident 127 was administered 2.5 L/min of oxygen therapy through a nasal cannula with no physician order.During a review of Resident 127's Order Summary Report (OSR), dated 4/22/26, the OSR indicated Resident 127 did not have orders for oxygen therapy.During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, undated, the P&P indicated, .oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences.oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control.During a professional reference review retrieved from https://pubmed.ncbi.nlm.nih.gov/19377391/ titled, The use of medical orders in acute care oxygen therapy, dated 2009, the professional reference review indicated, . Oxygen is considered to be a drug requiring a medical prescription and is subject to any law that covers its use and prescription . authorized by a physician following legal written instruction to a qualified nurse .4. During a review of Resident 155's AR, dated 4/24/26, the AR indicated Resident 155 was admitted to the facility on [DATE] with diagnoses which included pulmonary fibrosis (scarring in the lung), heart failure (heart muscle becomes too weak or stiff to pump blood efficiently, failing to meet the body's needs for oxygen) and respiratory failure (lungs cannot adequately get oxygen into the blood or remove carbon dioxide from it).During a concurrent observation and interview on 4/21/26 at 6:07 a.m. during the initial tour in Resident 155's room, Resident 155 was lying in bed with oxygen via nasal cannula (NC- a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) connected to an oxygen concentrator. Oxygen concentrator filter was covered with white looking lint. Resident 155 stated nursing staff replaced her NC every week but was not sure about the filter.During a review of Resident 72's AR, dated 4/24/26, the AR indicated Resident 72 was admitted to the facility on [DATE] with diagnoses which included hypertension (HTN- high blood pressure), and atherosclerosis of coronary artery bypass graft without angina pectoris (new fatty buildup is narrowing the bypass graft [detouring vessel] that was surgically placed in the heart, but it is not currently causing chest pain or symptoms).During a concurrent observation and interview on 4/21/26 at 6:38 a.m. during initial tour of the facility in Resident 72's room, Resident 72 was sitting up in bed watching TV, oxygen via NC connected to oxygen concentrator. Resident 72's oxygen concentrator had a filter covered with white looking lint.During a concurrent observation and interview on 4/21/26 at 6:20 a.m. with CNA 7, CNA 7 observed Resident 155's oxygen concentrator's filter and stated, It is very dusty. CNA 7 stated he was not sure who was responsible for ensuring the filters were cleaned. CNA 7 stated it was not the CNAs responsibility to clean the filters, but they let the licensed nurses know if there was something wrong with the concentrators.During a concurrent observation and interview on 4/21/26 at 7:48 a.m. with the DSD, the DSD stated Resident 72 and Resident 155's oxygen concentrator filters were dirty and dusty. The DSD stated, Dirty/dusty filters could potentially lead to more respiratory issues. The DSD stated residents on oxygen were already compromised, dirty/dusty filters could make them sicker instead of getting better. The DSD stated central supply was responsible to ensure oxygen concentrator filters were cleaned or replaced. The DSD stated she was not sure how often oxygen concentrator filters were cleaned or changed.During a concurrent observation and interview on 4/21/26 at 12:16 p.m. with the IP, the IP observed Resident 72 and Resident 155's oxygen concentrator air filters and stated, Filters are dirty and has a lot of dust. The IP stated dirty and dusty air filters could not filter air appropriately and could make residents sicker. The IP stated central supply or housekeeping were responsible to clean the air filters of oxygen concentrators.During an interview on 4/23/26 at 8:09 a.m. with the Central Supply Person (CSP), the CSP stated oxygen concentrator filters were replaced every month. The CSP stated the company who owned the oxygen concentrators serviced the concentrators yearly. The CSP stated she was not sure when Residents' 72 and 155's oxygen air filters were replaced or checked. The CSP stated, Dirty air filters may lead to overheating and not function as well.During an interview on 4/24/26 at 11:45 a.m. with the DON, the DON stated central supply was responsible to clean and replace oxygen concentrator air filters. The DON stated she was not sure why Resident 72 and Resident 155's air filters were not cleaned or replaced. The DON stated residents would not get better with dirty air filters. The DON stated central supply staff should ensure they were checking oxygen concentrator air filters and replaced them as needed.During a review of facility's [brand name] Oxygen Concentrator Instruction Guide, dated 2022, the instruction guide indicated, .Cabinet Filter. wash with each inspection. Replace if needed. Service and maintenance should only be performed by appropriately trained. personnel and/or service centers. Check to be sure the cabinet air filter (if applicable) and the intake filter area in place. Replace cabinet air filter (when applicable) and follow the Cleaning and Disinfection Instruction. 5. During an observation on 4/21/26 at 6:03 a.m. with Registered Nurse (RN) 4, RN 4 was observed to have documentation of residents' blood sugars on a piece of paper and RN 4 documented administration of insulin lispro for Resident 167 on the electronic health record (EHR)During an interview on 4/21/26 at 7:01 a.m. with RN 4, RN 4 stated breakfast was served around 7 a.m. RN 4 stated insulin lispro should be given about 30 mins before food. RN 4 acknowledged Resident 167 had been administered insulin lispro at approximately 6:00 a.m. and stated Resident 167 could become hypoglycemic if there was long period between insulin given and food served. RN 4 stated the blood sugar for all residents was taken and recorded around 5 a.m. RN 4 stated there would be a difference between blood sugar of residents taken at 5 a.m. and at 6:30 a.m. RN 4 stated the expectation was for nurses to get the reading of resident's blood sugar and administer insulin right away. RN 4 stated breakfast had not been served at 7:08 a.m. RN 4 verified with the kitchen when breakfast would be served and stated breakfast would be served around 7:20 a.m., over 1 hour after Resident 167 had been administered insulin lispro.During a review of Resident 167's admission Record (a summary of important information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the admission record indicated Resident 167 was admitted to the facility on [DATE] with a diagnosis which included type 2 diabetes mellitus (chronic condition where the body does not use insulin properly or make enough insulin, leading to high blood sugar levels, hyperlipidemia (abnormally high fat levels, or lipids, in the blood), chronic kidney disease (a long-term condition where the kidneys are damaged and gradually lose their ability to filter waste, toxins, and excess water from the blood), and long term (current) use of Insulin.During a review of Resident 167's Order Summary Report (OSR), dated 4/8/26, the OSR indicated, Resident 167 had an active order for . Insulin lispro injection solution 100 UNIT/ML [milliliters- metric unit used to measure the volume of a liquid] .inject. Subcutaneously [inject into the fatty tissue] before meals and at bedtime for DM During an interview on 4/22/26 at 3:19 p.m. with the Director of Nursing (DON), the DON stated the expectation from nurses was for insulin lispro should be given when the resident breakfast was available because the medication was short acting and had quick onset. When informed Resident 167's blood sugar level reading was taken at 5 a.m., insulin lispro was administered at 6:30 a.m., and the kitchen expected breakfast for Resident 167 to be served around 7:20 a.m., the DON stated blood sugar should checked right before the insulin was administered and the insulin should be administered no more than 15 mins before meals because there would be a difference in Resident 167's blood sugar within a 30 mins interval and Resident 167 could become hypoglycemic.During a telephone interview on 4/24/26 at 10:14 a.m. with the Consultant Pharmacist (CRPH), the CRPH stated the insulin lispro should be administered 15 mins before the meal or immediately after the meal, so the resident does not become hypoglycemic. The CRPH stated blood sugar level reading should be timed around insulin administration because if Resident 167 was hypoglycemic, the medication would not be administered and physician would be notified.During a professional reference review retrieved from National Library of Medicine/National Institute of Health- Daily Med found at https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=2be14cbb-197a-4da8-82c8-2443594e7f6f, titled, INSULIN LISPRO injection, solution, no dated, the professional reference review indicated .2.2 Administration Instructions for the Approved Routes of Administration-Subcutaneous Injection-Administer the dose of Insulin Lispro within fifteen minutes before a meal or immediately after a meal by injection into the subcutaneous tissue of the abdominal wall, thigh, upper arm, or buttocks.During a review of the facility's Policy and Procedure (P&P) titled, Medication Administration, no date, the P&P indicated, .Policy: medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.12a. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action and common side effects.16. Management of a resident's insulin . will be in compliance with practitioner's orders ., blood glucose checks, and as per manufacturers instruction . for the insulin.6. During a review of Resident 102's AR, dated 4/23/26, the AR indicated, Resident 102 was admitted to the facility on [DATE], with diagnoses which included heart failure (a heart disorder which causes the heart to not pump the blood efficiently), type 2 diabetes mellitus, Hypertensive heart and chronic kidney disease with heart failure (long-term high blood pressure has caused damage to both the heart muscle and the kidneys), hypothyroidism (when the thyroid gland does not make enough thyroid hormone), hyperlipidemia, chronic kidney disease, acute kidney failure (the sudden loss of the kidneys' ability to filter waste products from the blood, often occurring within hours or days).During a review of Resident 102's Medication Administration Record (MAR), dated 4/23/26, the MAR indicated, Resident 102 had an active order on 3/27/26 for . Calcium acetate oral tablet 667 MG[milligrams- a measurement of weight of how much medicine is in the tablet] (calcium acetate (phosphate binder)) give 2 tablet by mouth with meals for phos [phosphate] binder During a concurrent observation and interview on 4/21/26 at 12:03 p.m., in Resident 102's room, Resident 102 was sitting on his chair watching Television. Resident 102 stated he had not eaten lunch; lunch was served at 1 p.m.During an interview on 4/21/26 at 12:28 p.m. with the RN 1, RN 1 stated Resident 102's calcium acetate was administered to the resident around 12 noon. RN 1 stated Resident 102 receives lunch meals between 12:30 p.m. and 1p.m. RN 1 stated Resident 102's morning calcium acetate medication was administered to the resident around 7 a.m., and breakfast was given late, after 8 a.m. RN 1 stated the medication would not be as effective if given too early before meal, and would be 100% effective when given with mealDuring an interview on 4/22/26 at 3:25 p.m. with the DON, the DON stated Resident 102 should get calcium acetate with meals. The DON stated Resident 102 needed the calcium acetate medication because of his renal disease. The DON stated it was important for calcium acetate to be given with meal so it can bind to the phosphate in the meal and the medication would work better.During a telephone interview on 4/24/26 at 10:14 a.m. with the CRPH, the CRPH stated the calcium acetate should be given with meals. The CRPH stated it was important to ensure the medication absorbed the phosphate in the mealDuring a professional reference review retrieved from National Library of Medicine/National Institute of Health- Daily Med found at https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=c095727d-d0cb-448a-9325-d7eac27728a3, titled, CALCIUM ACETATE 667 MG- calcium acetate tablet, coated, undated, the professional reference review indicated .1 INDICATIONS AND USAGE- Calcium Acetate Tablet is a phosphate binder indicated to reduce serum phosphorus in patients with end stage renal disease (ESRD). 2 DOSAGE AND ADMINISTRATION- The recommended initial dose of Calcium Acetate Tablets for the adult dialysis patient is 2 capsules with each meal .During a review of the facility's document provided on Calcium acetate, undated, the document indicated, . How to take- calcium acetate is taken orally with meals to maximize its phosphate binding effect. It is available in capsule or tablet form. The dosage is individualized based on blood phosphate levels and kidney function, and it is important to follow the prescribing doctor's instruction closely.During a review of the facility's P&P titled, Medication Administration, undated, the P&P indicated, . Policy: medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.17. Administer medication as ordered in accordance with manufacturer specifications. A provide appropriate amounts of food and fluid. Example guidelines for medication administration (unless otherwise ordered by physician), this list is not all inclusive- medication required administration on an empty stomach, medication requiring administration after food or with food .7. During a review of Resident 102's AR, dated 4/23/26, the AR indicated, Resident 102 was admitted to the facility on [DATE], with diagnoses which included heart failure, type 2 diabetes mellitus, Hypertensive heart and chronic kidney disease with heart failure, hyperlipidemia.During a review of Resident 102's MAR, dated 4/23/26, the MAR indicated, Resident 102 had an active order on 3/27/26 for . Hydralazine HCl oral tablet 100 MG . give one tablet by mouth with meals for HTN During an interview on 4/21/26 at 12:18 p.m. with RN 1, RN 1 stated Resident 102 was supposed to get hydralazine three times a day. When asked if Resident 102 did not eat his meal, will the medication be held, RN 1 stated the medication would still be administered. RN stated the medication is only held based on the blood pressure parameters and not based on the meal. When asked if the order should indicate 3 times a day and not with meals, RN 1 did not response and stated the medication would still be administered even if Resident 102 did not eat his meal.During an interview on 4/22/26 at 3:32 p.m. with the DON, the DON stated Resident 102's hydralazine order was not clear enough. The DON stated an order should have name, route, dosage and frequency. The DON stated the frequency should be stated in the body of the order. The DON stated the order would be clarified.During a telephone interview on 4/24/26 at 10:14 a.m. with the CRPH, the CRPH stated the expectation was for the medication to have frequency. The CRPH stated it was important to have frequency in the medication order, so the nurses know how to give the medication. The CRPH stated frequency should be part of the medication order, and all medication orders should have a frequencyDuring a review of the facility's P&P titled, Medication Administration, undated, the P&P indicated, . Policy: medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.10. Ensure that the six rights of medication administration are followed: a. right resident b. right drug c. right dosage d. right route e. right time f. right documentation .8. During a review of Resident 150's AR, dated 4/23/26, the AR indicated, Resident 150 was admitted to the facility on [DATE], with diagnoses which included hypothyroidism, Type 2 diabetes mellitus, hyperlipidemia, essential hypertension.During a review of Resident 150's Lab Result Report (LRR), dated 2/17/26, the LRR indicated, Resident 150's blood was drawn on 2/16/26 at 5:49 p.m. The calcium level was reported as 7.2, which was below the reference range of 8.3-10.6. This result indicated a low and out of range value.During a concurrent interview and record review on 4/21/26 at 12:14p.m. with RN 1, Resident 150's EMR, undated was reviewed. RN 1 stated the EMR indicated there was no progress note on the calcium labs. RN 1 stated if labs were low, the supervisor should be informed, the physician should be notified, and it should be documented in the progress notes.During a concurrent interview and record review on 4/22/26 at 3:04 p.m. with the DON, Resident 150's EMR, undated was reviewed. The DON stated the EMR indicated Resident 150's calcium level at 7.2 was low. The DON stated the expectation for abnormal lab level would be for the nurse to notify the physician and the physician would give orders as needed. The DON was unable to provide documentation the physician was notified of low calcium levels. The DON stated it was important for nurses to inform the physician about abnormal levels, because calcium helps keep the bone levels and help prevent fractures in case residents fall.During a telephone interview on 4/24/26 at 10:22 a.m. with the CRPH, the CRPH stated the expectation was there should be a progress note on the lab result, the physician would review the lab result and orders would be given as needed. The CRPH stated it was important to notify the physician of abnormal labs, because abnormal labs could have negative effect on Resident 150During a review of the facility's P&P titled, Diagnostic test result notification, dated 8/2025, the P&P indicated, . Policy: It is the policy of the facil

Based on interview and record review, the facility failed to have an adequate system for reconciling controlled drugs (substances that have an accepted medical use and have a potential for abuse and may also lead to physical or psychological dependence), when the facility did not have an effective system in place for the Director of Nursing (DON) to accurately account for all controlled substances awaiting destruction in the facility.This failure had the potential for diversion (the illegal transfer, therft, or misuse of prescription drugs), mismanagement, or unaccounted medication, and the potential not to meet the needs of the residents in the facility.Findings:During an interview on [DATE] at 2:35 p.m. with the DON, the DON stated when controlled medications are discontinued, nursing staff would give the controlled medications to the DON and sign in the controlled medication binder at the nurses' station. The DON stated the discontinued controlled medications would be stored in a locked cabinet in her office until destroyed by the facility's consultant pharmacist (CRPH), during which both her and CPRH would sign a printed log form, accounting for the number of controlled medications destroyed. The DON stated there was no other log indicating how many controlled medications were received from nurses and therefore could not track all the controlled medications received from nursing staff. The DON acknowledged it would be difficult to know if controlled medications were removed from the office cabinet and acknowledged the facility did not have an effective system in place for the reconciliation and destruction of controlled medication. The DON stated it was important to log and track control medications received from the nurses and awaiting destruction to make sure none were missing.During a telephone interview on [DATE] at 10:30 a.m. with the CRPH, the CRPH stated there should be a form of record indicating the quantity of controlled medications the DON received from nursing staff. The CRPH stated this was important for accountability and to make sure there was no theft /diversion of the controlled medication.During a review of the facility's Policy and Procedure (P&P) titled, Inventory Control of Controlled Substances, revised [DATE], the P&P indicated, .5. A facility representative should regularly check the inventory records to reconcile inventory. Facility should regularly reconcile: 5.1 current and discontinued inventory of controlled substances to the log used in facility's controlled medication inventory system; 5.2 current inventory to the controlled medication declining inventory record and to the resident's MAR; And 5.3 unused control substances held in storage awaiting destruction with the declining inventory record.

Based on observation, interview, and record review, the facility failed to ensure three of five sampled residents (Resident 3, Resident 79 and Resident 150), were free from unnecessary drugs when:1. Resident 3 was administered magnesium oxide (a mineral supplement used to treat low magnesium levels) medication and magnesium levels were not monitored.2. Resident 79 was administered amiodarone (medication used to treat and prevent severe, life-threatening irregular heartbeats (arrhythmia) by slowing down overactive electrical signals in the heart) and thyroid stimulating hormone (TSH- blood test that measures level of thyroid hormone) levels were not monitored.3. Resident 150 was administered levothyroxine (medication used to treat an underactive thyroid (hypothyroidism) by replacing the missing thyroid hormone) and TSH levels were not monitored.The failure to monitor essential labs work for these medications had the potential to result in adverse consequences and complications which could lead to serious medical condition for Residents 3, 79 and 150.Findings:1. During a review of Resident 3's admission Record (AR- document containing resident personal information), dated 4/24/26, the AR indicated, Resident 3 was admitted to the facility on [DATE], with diagnoses which included, hypomagnesemia (dangerously low level of magnesium in the blood), essential hypertension (high blood pressure), type 2 diabetes mellitus (chronic condition where the body does not use insulin properly or make enough insulin, leading to high blood sugar levels), hyperlipidemia(abnormally high fat levels, or lipids, in the blood.)During a review of Resident 3's Order Summary Report (OSR), dated 12/11/25, the OSR indicated, Resident 3 had an active order for . Magnesium oxide oral tablet 400 MG [milligrams- a measurement of weight of how much medicine is in the tablet] .Give 1 tablet by mouth three times a day for hypomagnesemia During a review of Resident 3's Lab Result Report (LRR), dated 11/18/25, the LRR indicated, Resident 3's blood was drawn on 11/17/25 at 7:14 a.m. The magnesium level was reported as 1.3, which was above the reference range of 1.6-2.6. This result indicated a low and out of range value.During an interview on 4/23/26 at 11:25 a.m. with Registered Nurse (RN) 1, RN 1 stated when a resident is started on magnesium, there should be testing for magnesium levels, usually after 3 months. RN 1 stated that once there was a change in magnesium level, the physician was notified and there would be an order for labs to be completed. RN 1 stated there were no orders for magnesium labs, and no labs were drawn after Resident 3 started taking magnesium oxide.During a review of Resident 3's Medication Administration Record (MAR) dated, 3/26 and 4/26, Resident 3's MAR indicated Resident 3 was administered magnesium oxide 400 mg tablet three times daily.During a concurrent interview and record review on 4/24/26 at 9:45 a.m. with the Director of Nursing (DON), Resident 3's LRR, dated 11/18/26 was reviewed. The DON stated there were no labs completed for Resident 3 to check his magnesium levels after 11/18/26. The DON stated the expectation was for the nurse or pharmacy to recommend a lab follow up to the physician. The DON stated Resident 3's magnesium levels should have been checked since Resident 3 was started on the medication.During a telephone interview on 4/24/26 at 10:26 a.m. with the Consultant Pharmacist (CRPH), the CRPH stated the expectation was there should be a follow up with labs to check if Resident 3's magnesium levels were normal, high or still low.During a professional reference review retrieved from National Library of Medicine/National Institute of Health- Daily Med found at https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=7ccd3733-c3af-4a11-8500-0f99194c1472, titled, AMIODARONE HYDROCHLORIDE tablet, no dated, the professional reference review indicated .Amiodarone hydrochloride tablets can cause either hypothyroidism (reported in up to 10% of patients) or hyperthyroidism (occurring in about 2% of patients). Monitor thyroid function prior to treatment and periodically thereafter, particularly in elderly patients, and in any patient with a history of thyroid nodules, goiter, or other thyroid dysfunction.2. During a review of Resident 79's AR, dated 4/23/26, the AR indicated, Resident 79 was admitted to the facility on [DATE], with diagnoses which included chronic diastolic congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), unspecified atrial fibrillation(condition where an irregular and often very rapid heart rhythm occurs in the heart), supraventricular tachycardia (where the heart suddenly beats much faster than normal).During a review of Resident 79's OSR, dated 3/27/26, the OSR indicated, Resident 79 had an active order for . Amiodarone HCl oral tablet 200 MG. Give 1 tablet by mouth one time a day for CHF.During a concurrent interview and record review on 4/22/26 at 3:13 p.m. with the DON, Resident 79's OSR, dated 3/28/26 was reviewed. The DON stated Resident 79 was admitted [DATE] and started amiodarone on 3/28/26. The DON stated TSH labs should have been done when Resident 79 was started on amiodarone. The DON stated it was important to monitor the TSH lab so the medication can be adjusted if needed.During a professional reference review retrieved from National Library of Medicine/National Institute of Health- Daily Med found at https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=7ccd3733-c3af-4a11-8500-0f99194c1472, titled, AMIODARONE HYDROCHLORIDE tablet, no dated, the professional reference review indicated .Amiodarone hydrochloride tablets can cause either hypothyroidism (reported in up to 10% of patients) or hyperthyroidism (occurring in about 2% of patients). Monitor thyroid function prior to treatment and periodically thereafter, particularly in elderly patients, and in any patient with a history of thyroid nodules, goiter, or other thyroid dysfunction.3. During a review of Resident 150's AR, dated 4/23/26, the AR indicated, Resident 150 was admitted to the facility on [DATE], with diagnoses which included hypothyroidism (when the thyroid gland does not make enough thyroid hormone), Type 2 diabetes mellitus, hyperlipidemia, essential hypertension.During a review of Resident 150's OSR, dated 7/21/24, the OSR indicated, Resident 150 had an active order for . Levothyroxine sodium tablets 100 MCG. Give 1 tablet by mouth one time a day for hypothyroidism.During a concurrent interview and review on 4/21/26 at 12:04 p.m. with RN 1, Resident 150's Electronic Health Record (EHR), undated was reviewed. RN 1 stated the EHR indicated no labs were completed for TSH monitoring. RN 1 stated Resident 150 had an order for levothyroxine medication to be administered every morning. RN 1 stated Resident 150 was on hospice (specialized, comfort-focused care for individuals with terminal illness).During a review of Resident 150's LRR, dated 2/17/26, the LRR indicated, Resident 150's blood was drawn on 2/16/26 at 5:49 p.m. and there was no TSH level reported.During an interview on 4/22/26 at 3:09 p.m. with the DON, the DON stated Resident 150 was a hospice resident and if labs are done, the facility needed permission from hospice. The DON stated the expectation was for the TSH labs to be completed. The DON stated the therapeutic level should be monitored since Resident 150 was on levothyroxine. The DON stated it was important to monitor level so the medication can be adjusted.During a telephone interview on 4/24/26 at 10:23 a.m. with the CRPH, the CRPH stated there should be TSH baseline labs monitoring done and completed every six months. The CRPH stated it was important to have labs to check medication functions and side effects.During a professional reference review retrieved from National Library of Medicine/National Institute of Health- Daily Med found at https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=4ddcaec1-a58f-340b-9bc1-bbe048b8c885, titled, LEVOTHYROXINE SODIUM tablet, no dated, the professional reference review indicated .2.4 Monitoring TSH and/or Thyroxine (T4) Levels-Assess the adequacy of therapy by periodic assessment of laboratory tests and clinical evaluation. Persistent clinical and laboratory evidence of hypothyroidism despite an apparent adequate replacement dose of Levothyroxine Sodium Tablets may be evidence of inadequate absorption, poor compliance, drug interactions, or a combination of these factors. Adults. In adult patients with primary hypothyroidism, monitor serum TSH levels after an interval of 6 to 8 weeks after any change in dosage. In patients on a stable and appropriate replacement dosage, evaluate clinical and biochemical response every 6 to 12 months and whenever there is a change in the patient's clinical status.During a review of the facility's policy and procedure (P&P) titled, Diagnostic test result notification, dated 8/2025, the P&P indicated, . Policy: It is the policy of the facility to obtain laboratory and radiology services when ordered by a physician . and to promptly notify the ordering provider of test results. Procedure: 1. Laboratory and radiology services will be arranged and completed as ordered 2. Results of laboratory, radiology, and diagnosis tests outside the clinical reference ranges shall be promptly reported to the resident's attending physician . or as specified in the order. 3. Notification of test results will be documented in the resident's clinical records. 4. The results of lab . shall be made a part of the resident's medical records.During a review of the facility's P&P titled, Medication Administration, no date, the P&P indicated, . Refer to drug reference material if unfamiliar with the medication, including its mechanism of action and common side effects.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent for five residents (Resident 135, Resident 167, Resident 9, Resident 46 and Resident 117), when:1. Resident 135 was not administered their prescribed dose of levothyroxine (medication used to treat an underactive thyroid by replacing the missing thyroid hormone) and the medication was left with the resident.This failure had the potential to result in Resident 135's thyroid levels dropping, resulting in symptoms like cognitive decline (gradual loss of thinking skills), persistent fatigue (extreme tiredness or lack of energy) and weakness.2. Resident 167's oxycodone- acetaminophen tablet (prescription opioid medication used to treat moderate to severe pain) was administered without a pain assessment.This failure had the potential to lead to a life-threatening respiratory depression, excessive sedation, hypotension, severe constipation, nausea, or accidental overdose.3. Resident 9, Resident 46, and Resident 117's insulin (insulin lispro/ insulin aspart: fast-acting injectable medication that lowers blood glucose (sugar)) were administered an hour before their meal.This failure had the potential to result in hypoglycemic (condition where sugar levels in the blood drop too low) episodes for Resident 9, Resident 46, and Resident 117.The facility's medication error rate was 18.52 percent. There were 27 opportunities for errors.Findings:1. During an observation on 4/21/26 at 6:08 a.m. in Resident 135's room with Registered Nurse (RN) 4, RN 4 was observed trying to administer levothyroxine medication to Resident 135. Resident 135 stated she wanted to use the restroom. RN 4 was observed to have the left the medication with Resident 135 without administering the medication.During an interview on 4/21/26 at 6:22 a.m. with RN 4, RN 4 stated when nurses go into resident's room to administer medication, nurses were expected to monitor the residents and ensure the medications were consumed. RN 4 stated he did not see Resident 135 consume the levothyroxine medication.During a review of Resident 135's admission Record (AR- a summary of important information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 4/23/26, the AR indicated Resident 135 was admitted to the facility on [DATE] with a diagnosis which included hypothyroidism (when the thyroid gland does not make enough thyroid hormone), hyperlipidemia (abnormally high fat levels, or lipids, in the blood), and essential hypertension (high blood pressure).During a review of Resident 135's Order Summary Report (OSR), dated 4/5/26, the OSR indicated, Resident 135 had an active order for . Levothyroxine sodium tablets 125 [microgram (MCG)-unit of measure]. Give 1 tablet by mouth one time a day for hypothyroidism During an interview on 4/22/26 at 3:36 p.m. with the Director of Nursing (DON), the DON stated the expectation was for the nurse to wait for Resident 135 to take the medication. The DON stated, If a resident needed to use restroom, the nurse should take medication back and let the resident use the restroom. The DON stated it was important to witness Resident 135 taking medication and to ensure no other resident consumed the medication. The DON stated it was a safety issue and could lead to unnecessary medication.During a telephone interview on 4/24/26 at 10:28 a.m. with the Consultant Pharmacist (CRPH), the CRPH stated the expectation was nurses should not leave medications with the resident because they did not have sight of what was happening with the medication.During a review of the facility's Policy and Procedure (P&P) titled, Medication Administration, undated, the P&P indicated, .Policy: medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.12a.Refer to drug reference material if unfamiliar with the medication, including its mechanism of action and common side effects . 18. Observe resident consumption of medication.2. During an observation on 4/21/26 at 6:12 a.m. with RN 4 in Resident 167's room, Resident 167 stated she was in pain and wanted pain medication. RN 4 left Resident 167's room, prepared pain medication from the medication cart and administered the pain medication to Resident 167 without assessing Resident 167's pain level. During an interview on 4/21/26 at 6:24 a.m. with RN 4, RN 4 stated he did not ask for Resident 167's pain level prior to administering the pain medication. RN 4 stated Resident 167 had acetaminophen tablets (non-opioid medication used for pain relief and fever reduction) and oxycodone- acetaminophen tablets for pain. RN 4 stated it was important to ask for the pain level to know how bad the pain was and how effective the medication administered would be.During a review of Resident 167's AR, dated 4/23/26, the AR indicated Resident 167 was admitted to the facility on [DATE] with a diagnosis which included type 2 diabetes mellitus (DM-chronic condition where the body does not use insulin properly or make enough insulin, leading to high blood sugar levels), hyperlipidemia, chronic kidney disease (a long-term condition where the kidneys are damaged and gradually lose their ability to filter waste, toxins, and excess water from the blood), and history of falling.During a review of Resident 167's OSR, dated 4/06/26, the OSR indicated, Resident 167 had an active order for . oxycodone- acetaminophen tablets 10-325MG [milligrams- a measurement of weight of how much medicine is in the tablet] . Give 1 tablet by mouth every six hours as needed for moderate to severe pain (4 - 10 on pain scale) . During an interview on 4/22/26 at 4:05 p.m. with the DON, the DON stated before medication administration the nurse should ask the resident for their level of pain. The DON stated this was to ensure the right medication was given for severe pain or for moderate pain. The DON stated this failure could lead to ineffective medication, Resident 167 would not benefit from it, and the resident could still be in pain. The DON stated the resident could be lethargic, confused or sleepy if there was too much pain medication.During a telephone interview on 4/24/26 at 10:29 a.m. with the CRPH, the CRPH stated the nurse should have gotten a pain level before administering the pain medication, because there were different orders for pain level and if the pain level was zero, why would pain medication be administered.During a professional reference review retrieved from National Library of Medicine/National Institute of Health- Daily Med found at https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=88d97caf-bcf5-3cde-e053-2995a90acf4a, titled, OXYCODONE AND ACETAMINOPHEN tablet, undated, the professional reference review indicated .Titration [a technique where a solution of known concentration is used to determine the concentration of an unknown solution] and Maintenance of Therapy-Individually titrate oxycodone and acetaminophen tablets to a dose that provides adequate analgesia and minimizes adverse reactions. Continually reevaluate patients receiving oxycodone and acetaminophen tablets to assess the maintenance of pain control, signs and symptoms of opioid withdrawal, and other adverse reactions, as well as reassessing for the development of addiction, abuse, or misuse.During a review of the facility's P&P titled, Medication Administration, undated, the P&P indicated, .Policy: medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.8. Obtain and record vital signs, and when applicable or per physician orders. When applicable, hold medications for those vital signs outside the physicians prescribed parameters.12a.Refer to drug reference material if unfamiliar with the medication, including its mechanism of action and common side effects .During a review of the facility's P&P titled, Pain Recognition and Management, dated 8/2025, the P&P indicated, .Policy: It is the policy of this facility to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, our comprehensive and routine assessments . Procedure: the residents will be interviewed and evaluated for pain . with any change in their status. 2. To the extent possible, and staff will .a. recognize when a resident is experiencing pain and identify circumstances when pain can be anticipated b. evaluate existing pain and the causes. 3. Pain will be identified and documented in the electronic health record (EHR) a using a scale of 1-10 is the most common. 5a. monitor pain status every shift using . the numerical pain rating (1- 10) . 3. During a concurrent observation and interview on 4/21/26 at 6:15 a.m. in Resident 9's room, RN 4 was observed administering 10 units Insulin Lispro to Resident 9's to left lower abdomen. No blood sugar level was checked. RN 4 stated the Resident 9's blood sugar was 170. RN 4 stated the blood sugar reading was taken around 5:30 a.m.During an interview on 4/21/26 at 7:01 a.m. with RN 4, RN 4 stated breakfast was usually served around 7 a.m. and insulin for Resident 9 was administered 45 minutes prior. RN 4 stated Resident 9 could become hypoglycemic if there was a long period between the insulin given and the food served. RN 4 stated breakfast had not been served at 7:08 a.m. RN 4 stated and verified with the kitchen when breakfast would be served and stated breakfast would be served around 7:20 a.m.During a review of Resident 9's AR, dated 4/23/26, the AR indicated Resident 9 was admitted to the facility on [DATE] with a diagnosis which included type 2 diabetes mellitus, hyperlipidemia, chronic kidney disease, and long term (current) use of Insulin.During a review of Resident 9's OSR, dated 3/24/26, the OSR indicated, Resident 9 had an active order for . insulin lispro injection solution 100 UNIT/ML [milliliters- metric unit used to measure the volume of a liquid] .inject. Subcutaneously [under the skin] before meals and at bedtime for Type 2 diabetes mellitus with diabetic chronic kidney . During an observation on 4/21/26 at 11:09 a.m. in Resident 46's room, Licensed Vocational Nurse (LVN) 3 was observed administering 6 units of insulin lispro to Resident 46's upper right quadrant. During an observation on 4/21/26 at 11:21 a.m. in Resident 117's room, LVN 3 was observed administering 4 units of insulin lispro to Resident 117's upper left quadrant.During an interview on 4/21/26 at 12:38 p.m. with LVN 3, LVN 3 stated Resident 46 had not had her meal and Resident 117 ate at noon. LVN 3 stated residents should eat food after insulin was administered. LVN 3 stated it was important to eat within a short time because the blood sugar could go down. During a review of Resident 46's AR, dated 4/23/26, the AR indicated Resident 46 was admitted to the facility on [DATE] with a diagnosis which included Type 2 diabetes mellitus, hyperlipidemia, chronic kidney disease, and long term (current) use of Insulin.During a review of Resident 46's OSR, dated 3/30/26, the OSR indicated, Resident 46 had an active order for . insulin aspart injection solution 100 UNIT/ML .inject. Subcutaneously before meals for DM2 During a review of Resident 117's AR, dated 4/23/26, the AR indicated Resident 117 was admitted to the facility on [DATE] with a diagnosis which included Type 2 diabetes mellitus, hyperlipidemia, end stage kidney disease, and long term use of Insulin.During a review of Resident 117's OSR, dated 4/22/26, the OSR indicated, Resident 117 had an active order for . insulin lispro injection solution 100 UNIT/ML .inject. Subcutaneously four times a day for DM, Give 15 minutes before meal and at [bedtime (HS)] . During an interview on 4/22/26 at 3:19 p.m. with the DON, the DON stated the expectation from nurses was for insulin lispro or aspart to be given when the resident breakfast was available to the resident because the medication was short acting and had a quick onset. The DON stated the insulin should be administered no more than 15 mins before meal started. During a telephone interview on 4/24/26 at 10:14 a.m. with the CRPH, the CRPH stated the insulin lispro or aspart should be administered 15 minutes before the meal or immediately after the meal, so the resident does not become hypoglycemic.During a professional reference review retrieved from National Library of Medicine/National Institute of Health- Daily Med found at https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=2be14cbb-197a-4da8-82c8-2443594e7f6f, titled, INSULIN LISPRO injection, solution, undated, the professional reference review indicated .2.2 Administration Instructions for the Approved Routes of Administration-Subcutaneous Injection-Administer the dose of Insulin Lispro within fifteen minutes before a meal or immediately after a meal by injection into the subcutaneous tissue of the abdominal wall, thigh, upper arm, or buttocks.During a professional reference review retrieved from National Library of Medicine/National Institute of Health- Daily Med found at https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=bee5b358-c863-420b-be73-ced2e920c499, titled, INSULIN ASPART injection, solution, undated, the professional reference review indicated .2.2 Preparation and Administration Instructions for the Approved Routes of Administration- Subcutaneous Injection-Inject Insulin Aspart subcutaneously within 5-10 minutes before a meal into the abdominal area, thigh, buttocks or upper arm.During a review of the facility's P&P titled, Medication Administration, undated, the P&P indicated, .Policy: medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.12a. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action and common side effects.16. Management of a resident's insulin . will be in compliance with practitioner's orders ., blood glucose checks, and as per manufacturers instruction . for the insulin.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled and stored in accordance with the facility policy and procedures (P&P) when:1. In Station 4 medication room, lorazepam (a Schedule IV controlled medication used for short-term treatment of anxiety (the body's natural response to stress, feeling intense worry, fear, or unease), sleep disorders, acute seizures (a sudden, uncontrolled burst of electrical activity in the brain that temporarily disrupts normal brain function) oral solution was not stored at appropriate fridge temperature per manufacturer's guidelines of 2 to 8 C ( C- a scale for measuring temperature) and the medication fridge temperature was 10 C.This failure had the potential to cause degradation (process of something becoming worse, weaker, or less valuable) of the medication, making it ineffective.2. 15 Insulin (injectable medication to help control blood sugar levels) pens for 10 Residents (Residents 46, 117, 170, 67, 148, 42, 76, 107, 30, and 83) were not appropriately labeled. The date open and expiration date labels were on the removable caps of insulin pens and not on the actual pens.This failure had the potential for Residents 46, 117, 170, 67, 148, 42, 76, 107, 30, and 83's pen caps to be swapped between pens which could lead to medication safety error, cross contamination (unintended transfer of bacteria, viruses, or germs from one surface, substance, often leading to illnesses) and infection.3. There were no patient identifiers (name and date of birth ) on Resident 164's Insulin Regular 10 milliliter (ml - unit of measure) Multi-Dose Vial (MDV) and four Residents (Residents 115, 182, 149, and 83)'s Inhalers (a small, portable, handheld device used to deliver medication directly into the lungs by breathing it in through the mouth). This failure had the potential for Resident 164 to become hypoglycemic (condition where sugar levels in the blood drop too low) from inability to identify Resident 164's MDV Insulin and for Residents 115, 182, 149, and 83 to use other residents' inhalers which could lead to respiratory distress (state of difficulty breathing or inadequate breathing), cross contamination and infection.4. Three Residents (Residents 140, 164, and 154) had discontinued medication orders and their medications were not separated or removed and were available for use in the medication cart.This failure had the potential for medication errors which could result in significant harm to Residents 140, 164 and 154, including adverse drug reactions (a harmful, unintended reaction to a medication that occurs at regular doses used for treatment), toxicity (a substance can damage, harm, or poison a living being), or the reversal of positive health changes.5. In Station 1 medication room, Vancomycin (antibiotic medication used to treat infections) 1 gram /200 ml (gm/ml - unit of measure) 0.9% Normal Saline (mixture of salt and water used to replenish fluid and electrolytes) premix and lactated ringers (LR- balanced intravenous (IV) fluid used to rapidly replace fluids and electrolytes (minerals in the blood and other body fluids that carry an electric charge), treat severe dehydration, or manage blood loss) 1Liter (L- unit of measure) bags were not stored in an appropriate room according to manufacturer's guidelines. This failure had the potential for therapeutic failure due to degradation, severe adverse infusion reactions, or physical harm from chemical changes. 6. Two 1 ml testosterone (a hormone that sex organs mainly produce) vials control medication for Resident 181 were found in the top drawer of Station 1 medication cart with over the counter (OTC) medications and were not separated and stored with other controlled medications.This failure had the potential for diversion (the illegal transfer, theft, or misuse of prescription medication), mismanagement, or unaccounted medication, and the potential for medication error due to medication mix up for Resident 181.Findings:1. During a concurrent observation and interview on 4/21/26 at 1:42 p.m. with Charge Nurse (CRN) 1 at station 4 medication room, the medication fridge temperature was 10 C, an opened box of lorazepam oral solution 2 milligram/milliliter (mg/ml-unit of measure) was observed in the fridge, the medication was not labeled with date opened or expiration date. CRN 1 stated the expectation was when medications were opened, they should be labeled with opened date and discard date. CRN 1 stated the lorazepam medication was not labeled. CRN 1 stated the fridge thermometer was at 10 C. CRN 1 stated the temperature was too high at 10 C. CRN 1 stated the lorazepam solution should be stored at 2 to 8 C and the medication should be discarded.During an interview on 4/22/26 at 3:45 p.m. with the Director of Nursing (DON), the DON stated if a medication was not stored at the temperature required, it could affect the potency of the medication, and it would not be effective for the residents. During a telephone interview on 4/24/26 at 10:14 a.m. with the Consultant Pharmacist (CRPH), the CRPH stated the facility staff should be checking the fridge temperature, documenting on the log sheet, and when out of range, notify the appropriate personnel, adjust and follow up to ensure the fridge was in range. The CRPH stated if the manufacturer had guidelines for how the lorazepam should be stored, it could affect stability, effectiveness, and how long the medication would be good for.During a review of the facility's document provided on lorazepam, undated, the document indicated, . lorazepam should generally be stored in the refrigerator at 2 C to 8 C (36 F - 46 F) .During a professional reference review retrieved from National Library of Medicine/National Institute of Health- Daily Med found at https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=711b60a3-028d-41d4-aa17-8f976e6df23e, an article titled, LORAZEPAM liquid, undated, the professional reference review indicated .2 mg per mL Lorazepam Oral Concentrate USP NDC 0121-0770-01:1 fl [fluid] [ounce (oz)] (30 mL) with calibrated dropper (graduations of 0.25 mL [0.5 mg], 0.5 mL [1 mg], 0.75 mL [1.5 mg] and 1 mL [2 mg] on the dropper). PROTECT FROM LIGHT. Keep bottles tightly closed. Store at Cold Temperature. Refrigerate 2 - 8 C (36 - 46 F) .During a review of the facility's P&P titled, Medication Administration, undated, the P&P indicated, .Policy: medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.12a. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action and common side effects .During a review of the facility's P&P titled, Medication Storage, dated 8/1/2025, the P&P indicated, . Policy: it is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/ or medication rooms according to the manufacturers recommendations and sufficient to ensure proper sanitation, temperature, ventilation, moisture control, segregation, and security.1. General guidelines: a. all drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.6a. All medications requiring refrigeration are stored in refrigerators located in the pharmacy and at each medication room. B. Temperatures are maintained within 36 - 46 F. Charts are kept on each refrigerator and temperature levels are recorded daily by the child nurse or other designee. c. In the event that a refrigerator is malfunctioning, the person discovering the malfunction must promptly report such findings to the maintenance department for emergency repair. d. In the event that emergency repairs cannot be made timely, temporary or emergency space is available in the pharmacy refrigerator or the refrigerator located at each medication room.2. During a concurrent observation and interview on 4/22/26 at 11:16 a.m. with Licensed Vocational Nurse (LVN) 3 at station 4A medication cart, 6 insulin pens (Insulin lispro (works quickly to control high blood sugar) for Resident 46, Insulin lispro pen for Resident 117, and Insulin glargine (long acting insulin to control high blood sugar) pen for Resident 170) were observed in the medication cart with date opened and expiration date labels on the removable caps of insulin pens. LVN 3 observed the date opened and expiration date labeling on the caps of insulin pens and made no comments.During a concurrent observation and interview on 4/22/26 at 11:19 a.m. with Registered Nurse (RN) 6, at station 2A medication cart, 6 insulin pens (Insulin lispro and Insulin glargine pens for Resident 67, Insulin Regular (short acting insulin to control high blood sugar) pen for Resident 148, and Insulin lispro, Insulin glargine and Insulin aspart pens for Resident 42) were observed in the medication cart with date opened and expiration date labels on the removable caps of insulin pens. RN 6 stated the caps could get mixed up.During a concurrent observation and interview on 4/22/26 at 11:44 a.m. with RN 2 at station 1A medication cart, 6 insulin pens (Insulin glargine and human insulin flex pen for Resident 76, Insulin lispro and Insulin glargine pens for Resident 107, human Insulin pen for Resident 30, and Insulin lispro pen for Resident 83) were observed in the medication cart with date opened and expiration date labels on removable caps of insulin pens. RN 2 stated labelled caps could accidentally cause wrong expiration dates to be on another pen if switched. RN 2 stated the nursing staff would not know which pen was for which residents. During an interview on 4/22/26 at 3:49 p.m. with the DON, the DON stated if the pen caps were missing, the nursing staff would not know when the insulin was first used, and the insulin pen would have the wrong expiration date if swapped with another pen cap. The DON stated this failure could cause contamination for use more than the expected expiration date and could affect the potency of medication. During a telephone interview on 4/24/26 at 10:14 a.m. with the CRPH, the CRPH stated the opened and expiration date should be put on the actual product in case the pen caps got switched. During a review of the facility's P&P titled, Medication Administration, undated, the P&P indicated, .Policy: medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.16. Management of a resident's insulin . will be in compliance with practitioner's orders ., blood glucose checks, and as per manufacturers instruction . for the insulin. 3. During a concurrent observation and interview on 4/22/26 at 11:27 a.m. with RN 6, at station 2A medication cart, Resident 115 and Resident 182's budesonide and formoterol fumarate dihydrate inhaler (medication to treat lung disease) and Resident 149's fluticasone propionate and salmeterol (medication to treat lung disease) 250-50 inhalers were observed in the medication cart with no patient identifier on the actual products. RN 6 stated the expectation was for nursing staff to label the inhalers with the resident's name, so the nursing staff do not mix the inhalers up. During a concurrent observation and interview on 4/22/26 at 11:27 a.m. with RN 2, at station 1A medication cart, Resident 83's umeclidinium and vilanterol (medication to treat lung disease) 62.5/25 microgram (mcg-unit of measure) inhaler was observed in the medication cart with no patient identifier on the actual product. RN 2 stated it was important to always put the resident's name on the inhaler, so that nursing staff would know whose inhaler it was. During a concurrent observation and interview on 4/22/26 at 1:21 p.m. with CRN 1 at station 4B medication cart, Resident 164's Insulin Regular 10 ml mdv were observed in the medication cart with no patient identifier on the actual product. CRN 1 stated the insulin regular needed to be labeled so the nursing staff knew the right patient for the medication. CRN 1 stated if there was no label, there was the potential to accidentally use the medication for the wrong patient. During an interview on 4/22/26 at 3:51 p.m. with the DON, the DON stated the patient identifier should be on the inhaler and the box to ensure the inhaler was for the right resident and to be sure how many puffs to administer to the resident. The DON stated if there was no identifier on the inhaler or MDV, if given to the wrong resident, it could be an infection control issue. During a telephone interview on 4/24/26 at 10:38 a.m. with the CRPH, the CRPH stated the expectation was for nurses to write the name of the residents on the inhalers. The CRPH stated pharmacy should label the Insulin vial with a patient identifier. The CRPH stated it was important that the medications had identifiers because the nursing staff would not know who the medications belonged to once the medications were out of the box package.During a review of the facility's P&P titled, Medication Administration, undated, the P&P indicated, . Policy: medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.10. Ensure that the six rights of medication administration are followed: a. right resident b. right drug c. right dosage d. right route e. right time f. right documentation .4. During a concurrent observation and interview on 4/22/26 at 11:34 a.m. with RN 6 at station 2A medication cart, Residents 140's discontinued enoxaparin (medication used to prevent blood clots) 40 mg single dose syringes (a medical tool used to inject fluids into or withdraw fluids from the body) containing 6 syringes were observed in the medication cart. The instructions on the box of the medication read Inject 40 mg subcutaneously [beneath the skin] one time a day for [deep vein thrombosis (DVT)-a serious condition where a blood clot forms in a deep vein, usually leg or thigh] prophylaxis [prevent the spread of a disease] for 2 weeks. RN 6 stated the enoxaparin order was discontinued on 4/4/26. RN 6 stated the medication should have been removed and put with the discontinued medications.During a review of Resident 140's Medication Administration Record (MAR) for enoxaparin, dated 3/20/26 , the MAR indicated the order with instructions [Brand name] injection solution prefilled syringe 40mg/0.4ml (enoxaparin sodium). Inject 40 mg subcutaneously one time a day for DVT prophylaxis for 2 weeks. The MAR indicated the medication was administered from 3/20/26 - 4/3/26. During a concurrent observation and interview on 4/22/26 at 1:04 p.m. with CRN 1 at station 4B medication cart, Residents 164 and 154 's discontinued ondansetron (medication used to treat nausea and vomiting) 4 mg medication cards containing 14 tablets and 5 tablets respectively, were observed in the medication cart. Resident 164's ondansetron medication card containing 14 tablets, indicated ondansetron 4 mg, Give 1 tablet by mouth every 8 hours as needed for nausea and vomiting for 14 days, and Resident 154's ondansetron medication card containing 5 tablets, indicated ondansetron 4 mg, Give 1 tablet by mouth every 6 hours as needed for nausea and vomiting for 10 days. CRN 1 stated both Residents 164 and 154's ondansetron orders had been discontinued. CRN 1 stated discontinued medications should be removed from the medication cart, so it was not accidentally given to the residents. During a review of Resident 164's MAR for ondansetron, dated 12/2/26, the MAR indicated the order for ondansetron 4 mg, Give 1 tablet by mouth every 8 hours as needed for nausea and vomiting for 14 days. During a review of Resident 154's MAR for ondansetron, dated 3/26/26, the MAR indicated the order for ondansetron tablet 4 mg Give 1 tablet by mouth every 6 hours as needed for nausea and vomiting for 10 days. During an interview on 4/22/26 at 3:56 p.m. with the DON, the DON stated discontinued medications should be removed from medication cart. The DON stated this was to ensure the medications were not mistakenly given to the residents. During a telephone interview on 4/24/26 at 10:40 a.m. with the CRPH, the CRPH stated the discontinued medications should be removed from active supply and placed in an area for disposal and they should be timely disposed of. During a review of the facility's P&P titled, Medication Storage, dated 8/1/2025, the P&P indicated, . 8 Unused medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacy for discontinued, outdated, defective, or deteriorated medications with worn, eligible, or missing labels. These medications are destroyed in accordance with our destruction of unused drugs policy.5. During a concurrent observation and interview on 4/21/26 at 1:54 p.m. with LVN 4 at station 1 medication room, the room thermometer was observed to be at 80 F and vancomycin 1 gm/200 ml NS premix and two lactated ringers 1L bags were observed to be in the room. LVN 4 acknowledged the room temperature was 80 F. LVN 4 stated room temperature should be 71 F. LVN 4 stated the vancomycin 1 gm/200 ml NS premix bag should be stored below 77 F as indicated on the product package. During an interview on 4/22/26 at 3:45 p.m. with the DON, the DON stated if medication was not stored at the temperature required it could affect the potency of the medication, and it would not be effective for the residents. During a telephone interview on 4/24/26 at 10:36 a.m. with the CRPH, the CRPH stated the vancomycin and lactated ringer solutions were being stored outside of the appropriate temperature range. The CRPH stated if outside of range, stability is gone and they need to get stability.During a professional reference review retrieved from National Library of Medicine/National Institute of Health- Daily Med found at https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=60bee69b-be70-412c-9e83-a24a0a8a5e7b, titled, VANCOMYCIN injection, solution, undated, the professional reference review indicated .Vancomycin Injection, USP is supplied as a ready to use clear, colorless to light brown solution in single-dose flexible bags . 16.2 Storage. Store below 25 C (77 F), in original package.During a professional reference review retrieved from National Library of Medicine/National Institute of Health- Daily Med found at https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=dad7735c-709b-40ea-ab7a-15577e24a966, titled, LACTATED RINGERS- sodium chloride, potassium chloride, sodium lactate and calcium chloride injection, solution, no dated, the professional reference review indicated.Lactated Ringer's Injection, USP is supplied as a clear solution in single-dose. as follows: . Code 2B2324- Size (mL)1000.Storage and Handling- Store at room temperature (recommended 25 C/77 F). Exposure to heat should be minimized. Avoid excessive heat .During a review of the facility's P&P titled, Medication Storage, dated 8/1/2025, the P&P indicated, . Policy: it is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/ or medication rooms according to the manufacturers recommendations and sufficient to ensure proper sanitation, temperature, ventilation, moisture control, segregation, and security.1. General guidelines: a. all drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.6. During a concurrent observation and interview on 4/22/26 at 11:44 a.m. with RN 2, at station 1A medication cart, 1ml testosterone 200mg/ml vials for Resident 181 were observed in the top drawer of the medication cart with other OTC medications.RN 2 stated the testosterone came from the community hospital; therefore, she was unaware it was a controlled medication. RN 2 stated controlled medications should be stored in a locked drawer and it should be logged to monitor the dose and time given. RN 2 stated the resident had an order for the medication and the medication was family supplied. During an interview on 4/22/26 at 3:57 p.m. with the DON, the DON stated when the resident's own medications were brought in by family, and were being used by the facility, the medication should be verified by the pharmacist. The DON stated the controlled medication should not be in medication cart available for use without being verified. The DON stated controlled medications should be stored in compartments and should have log sheets.During a telephone interview on 4/24/26 at 10:42 a.m. with the CRPH, the CRPH stated the testosterone-controlled medication should be locked up and there should be a count sheet and the medication needed to be verified by the pharmacist. The CRPH stated it was important to verify the product matched the physician's order. The CRPH stated the medication was a controlled drug and needed to be accounted for. During a review of the facility's P&P titled, Medications brought to facility by the resident/ family / physician /prescriber, dated 09/01/12, the P&P indicated, . This policy . set forth procedures relating to medications brought to facility by a resident, a resident responsible party, or a residence physician/ prescriber. 1. Facility staff shall not administer medications, including over the counter medications, naturally occurring of substances, and physician/ prescriber medication samples, and brought to the facility by a resident, a residence family, for a residence physician/ prescriber, unless.1.3. Medications are received: 1.3.3 brought from home. These medications must be verified by a pharmacist before they can be used. 1.3. 3.1 send medications requiring verification to pharmacy. 1.3.3.2 pharmacy will verify medications and label container verified 1.3.3.3 pharmacy will return medication to facility after verification.During a review of the facility's P&P titled, Inventory Control of Controlled Substances, dated 01/01/13, the P&P indicated, . 2. Facility should ensure that facility staff count all scheduled III - V controlled substances in accordance with facility policy and applicable law.

Based on observation, interviews and record review, the facility failed to ensure menus were followed for 20 of 66 sampled residents (Residents 8, 65, 84, 92, 71, 60, 98. 33, 57, 109, 102, 119, 172, 145, 78, 106, 116, 51, 21, and 58) when they were not provided mashed sweet potatoes according to the menu during the lunch meal service on 4/21/26.This failure had the potential to result in not meeting the micronutrients (referred to as vitamins and minerals, are vital to healthy development, growth, disease prevention, and well-being) in the physician's prescribed therapeutic diets which could compromise nutritional and medical status of Residents 8, 65, 84, 92, 71, 60, 98. 33, 57, 109, 102, 119, 172, 145, 78, 106, 116, 51, 21, and 58.During a review of the lunch menu for 4/21/26 indicated, baked honey glaze ham, baked sweet potatoes, and French style green beans for the following diets: regular (House), PU4 (Puree level 4), MM5 (Minced and Moist level 5), SB6 (Soft and Bite Level 6), EC7 (Easy to Chew level 7) and CCHO (Consistent Carbohydrate diet for residents with Diabetes Mellitus- a chronic metabolic disorder characterized by high blood sugar (hyperglycemia) due to insufficient insulin production or ineffective insulin) During an observation of the lunch meal service on 4/21/26 starting at 11:57 a.m., in the kitchen on the steam table (commercial kitchen appliance used for hot-holding prepared food at temperatures above 135 degrees Fahrenheit. It consists of a stainless-steel unit with open wells filled with hot water or heated by steam, designed to hold food pans for buffets or cafeteria-style service), there was a large full hotel pan approximately 12 inches by 20 inches long filled with mashed sweet potatoes. The Dietary [NAME] (DC) would portion out 4 ounces of sweet potatoes on the lunch plates for the residents. During an observation of the lunch meal service on 4/21/26 at 1:00 p.m. in the kitchen, the two pans (1 full and 1 half) of mashed sweet potatoes were emptied. Dietary [NAME] (DC) 1 started using mashed potatoes and pasta for lunch meal trays for the last meal cart for 20 Residents (Residents 8, 65, 84, 92, 71, 60, 98. 33, 57, 109, 102, 119, 172, 145, 78, 106, 116, 51, 21, and 58).During a concurrent observation and record review of Resident 8's lunch meal ticket during the lunch meal service on 4/21/26, Resident 8's lunch meal ticket indicated, Diet Order: Regular CCHO. Resident 8's lunch meal plate contained mashed potato.During a concurrent observation and record review of Resident 65's lunch meal ticket during the lunch meal service on 4/21/26, Resident 65's lunch meal ticket indicated, Diet Order: Regular CCHO. Resident 65's lunch meal plate contained mashed potato.During a concurrent observation and record review of Resident 84's lunch meal ticket during the lunch meal service on 4/21/26, Resident 84's lunch meal ticket indicated, Diet Order: Regular. Resident 84's lunch meal plate contained mashed potato.During a concurrent observation and review of Resident 92's lunch meal ticket during the lunch meal service on 4/21/26, Resident 92's lunch meal ticket indicated, Diet Order: Regular. Resident 92's lunch meal plate contained mashed potato.During a concurrent observation and review of Resident 44's lunch meal ticket during the lunch meal service on 4/21/26, Resident 44's lunch meal ticket indicated, Diet Order: Regular. Resident 44's lunch meal plate contained mashed potato.During a concurrent observation and record review of Resident 71's lunch meal ticket during the lunch meal service on 4/21/26, Resident 71's lunch meal ticket indicated, Diet Order: Regular CCHO. Resident 71's lunch meal plate contained mashed potato.During a concurrent observation and review of Resident 60's lunch meal ticket during the lunch meal service on 4/21/26, Resident 60's lunch meal ticket indicated, Diet Order: Regular. Resident 60's lunch meal plate contained mashed potato.During a concurrent observation and record review of Resident 98's lunch meal ticket during the lunch meal service on 4/21/26, Resident 98's lunch meal ticket indicated, Diet Order: Regular, Large Portions, CCHO. Resident 98's lunch meal plate contained mashed potato.During a concurrent observation and record review of Resident 33's lunch meal ticket during the lunch meal service on 4/21/26, Resident 33's lunch meal ticket indicated, Diet Order: Regular, CCHO. Resident 71's lunch meal plate contained mashed potato.During a concurrent observation and record review of Resident 57's lunch meal ticket during the lunch meal service on 4/21/26, Resident 57's lunch meal ticket indicated, Diet Order: Regular, No Added Salt. Resident 57's lunch meal plate contained mashed potato.During a concurrent observation and record review of Resident 109's lunch meal ticket during the lunch meal service on 4/21/26, Resident 109's lunch meal ticket indicated, Diet Order: Regular, No Added Salt. Resident 109's lunch meal plate contained mashed potato.During a concurrent observation and record review of Resident 102's lunch meal ticket during the lunch meal service on 4/21/26, Resident 102's lunch meal ticket indicated, Diet Order: Regular, CCHO. Resident 102's lunch meal plate contained mashed potato.During a concurrent observation and record review of Resident 119's lunch meal ticket during the lunch meal service on 4/21/26, Resident 119's lunch meal ticket indicated, Diet Order: SB6, Regular . Resident 119's lunch meal plate contained mashed potato.During a concurrent observation and record review of Resident 172's lunch meal ticket during the lunch meal service on 4/21/26, Resident 172's lunch meal ticket indicated, Diet Order: PU4 . Resident 172's lunch meal plate contained mashed potato.During a concurrent observation and record review of Resident 102's lunch meal ticket during the lunch meal service on 4/21/26, Resident 102's lunch meal ticket indicated, Diet Order: Regular, CCHO. Resident 102's lunch meal plate contained mashed potato.During a concurrent observation and record review of Resident 145's lunch meal ticket during the lunch meal service on 4/21/26, Resident 145's lunch meal ticket indicated, Diet Order: Regular, Large Portions. Resident 145's lunch meal plate contained mashed potato.During a concurrent observation and record review of Resident 78's lunch meal ticket during the lunch meal service on 4/21/26, Resident 78's lunch meal ticket indicated, Diet Order: Regular, CCHO. Resident 78's lunch meal plate contained mashed potato.During a concurrent observation and record review of Resident 106's lunch meal ticket during the lunch meal service on 4/21/26, Resident 106's lunch meal ticket indicated, Diet Order: Regular, Large Portions, No Added Salt . Resident 106's lunch meal plate contained mashed potato.During a concurrent observation and record review of Resident 116's lunch meal ticket during the lunch meal service on 4/21/26, Resident 116's lunch meal ticket indicated, Diet Order: Regular, Large Portions, No Added Salt . Resident 116's lunch meal plate contained mashed potato.During a concurrent observation and record review of Resident 51's lunch meal ticket during the lunch meal service on 4/21/26, Resident 51's lunch meal ticket indicated, Diet Order: SB6, Regular . Resident 51's lunch meal plate contained mashed potato.During a concurrent observation and record review of Resident 21's lunch meal ticket during the lunch meal service on 4/21/26 in the kitchen, Resident 21's lunch meal ticket indicated, Diet Order: Regular, CCHO, No Added Salt . Resident 21's lunch meal plate contained pasta.During a concurrent observation and record review of Resident 58's lunch meal ticket during the lunch meal service on 4/21/26, Resident 58's lunch meal ticket indicated, Diet Order: Regular, Small Portions, CCHO . Resident 58's lunch meal plate contained pasta.During a concurrent observation and interview on 4/21/26 at 1:16 p.m. with DC 1, in the kitchen, DC 1 completed serving lunch meal. DC 1 stated the mashed sweet potatoes ran out and needed to use regular mashed potatoes and pasta for the remaining lunch meal trays. DC1 stated he used eight of number 10 cans of sweet potatoes in making mashed sweet potatoes for 167 residents. DC 1 stated that number 10 cans can make 25 servings and he used one of number 10 cans for puree. DC 1 stated he would have enough servings for 167 residents but possibly he was serving too big of a size. DC1 stated he used mashed potatoes and pasta as alternative for mashed sweet potatoes.During an interview on 4/22/26 at 9:57 a.m. with the Dietary Manager (DM), the DM stated mashed sweet potatoes ran out towards the end of lunch meal service yesterday (4/21/26) and she made regular mashed potatoes as alternative. The DM stated there was no available supply of sweet potato on hand yesterday (4/21/26) after using six of number 10 cans for 167 residents. The DM stated she placed an order for cans of sweet potatoes yesterday (4/21/26) at a retail's grocery store and that was used to prepare the sweet potatoes for the residents on a puree diet.During a review of invoice from retail's grocery store, dated 4/21/26, indicated, .7 cans, 40-ounce per can of sweet potatoes cut yam in syrup.During a review of invoice from food vendor, dated 4/16/26, indicated, . potato, sweet cut.pack size: 6/#(number)10 CN (Can). One #10 is approximately 108 ounces. During a review of facility's recipe titled, Sweet Potatoes CND, dated 4/21/26, indicated, .Serving pan: 2 full pan . four ounce serving utensil.Yield: 120 portions. It further indicated that four and 3/4 gallon of cut canned yams were needed. The resident census was 162. During a review of facility's recipe titled, Sweet Potatoes CND Cut Up, dated 4/21/26, indicated, .Serving pan: 2 inches full pan.Serving utensil: #8 scoop.Yield: 25 portions.Portions: 25 1/2 cup. It further indicated 25 1/2 cups of canned sweet potatoes were needed. During an interview on 4/22/26 at 3:02 p.m. with the Registered Dietitian (RD), the RD stated it never happened that they ran out of sweet potatoes and they usually have overstock of food. The RD stated she was informed by the DM that mashed potatoes ran out towards the end of the lunch meal service yesterday (4/21/26). The RD validated that they were using six of number 10 cans for sweet potatoes. The RD stated it was her expectation for the dietary cooks to follow menus and recipes for right consistency, amount, and products.During an interview on 4/23/26 at 1:26 p.m. with the RDC and RD, the RDC and RD stated they were reaching out to their food distributor and vendor to seek clarification about recipes and menus for their dietary staff to easily understand and follow. The RDC and RD stated that the facility's recipes and menus were confusing for the dietary staff to follow in ensuring the proper food consistency was being provided for the residents. During a review of the facility's policy and procedures (P&P) titled, Food Preparation, dated 2023, the P&P indicated, The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared.

Based on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 12) was informed in advance, by the physician or other practitioner of the risks and benefits of proposed treatment when Resident 12 did not have a signed physician informed consent (a process in which a healthcare professional educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) prior to the use of bed (side) rails (adjustable metal or rigid plastic bars in various sizes that attach to the bed, and can be placed in a guard (raised) or lowered) position.This failure resulted in the violation of Resident 12's Responsible Party's (RP - individual authorized to act on a resident's behalf regarding care) right to be informed, in advance of alternative treatment options and the risks of using side rails, which had the potential to cause entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail), serious harm, injury, or death to Resident 12.Findings:During an observation on 4/21/2026 at 7:02 a.m. in Resident 12's room, Resident 12 was observed asleep in bed, wearing a gown with side rails up on the left and right side of the bed and a fall mat on the right side of Resident 12's bed.During a review of Resident 12's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 4/23/26, the AR indicated Resident 12 was admitted to the facility from an acute care hospital on [DATE] with diagnoses of cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), schizophrenia (a mental illness that affects a person's ability to think, feel, and behave clearly), depression (persistent feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life), and history of falling.During a review of Resident 12's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 3/18/26, the MDS section C indicated Resident 12 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of three (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 12 was severely cognitively impaired.During a review of Resident 12's MDS, dated 3/16/26, the MDS section GG (Functional Abilities) indicated Resident 12 had, .impairment on one side.upper extremity [shoulder, elbow, wrist, hand].used in the last 7 days.wheelchair.Dependent [helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity].chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair [or wheelchair].During an interview on 4/22/26 at 4:10 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 12 had her side rails up because she tried to get out of bed and had fallen in the past. During a concurrent interview and record review on 4/22/26 at 4:15 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 12's electronic medical record (EMR), undated was reviewed. LVN 1 stated she was unable to find a consent form or physician order for Resident 12's use of side rails.During a concurrent observation and interview on 4/22/26 at 4:28 p.m. with the Assistant Director of Nursing (ADON), in Resident 12's room, Resident 12 was observed sleeping in her bed with the right and left side rails of her bed in the guard position. The ADON stated it was important to have a consent for the use of side rails, as the rails were a form of restraint. The ADON was unable to provide a signed consent form for Resident 12's use of side rails.During an interview on 4/23/2026 at 10:27 a.m. with LVN 1, LVN 1 stated Resident 12 should have a consent form and physician orders for the use of side rails. LVN 1 stated side rails were considered a restraint. LVN 1 stated prior to installing the side rails, staff should have checked on Resident 12 more often, and the physician should have been notified to receive an order for the side rails. LVN 1 stated side rails could have caused an injury to Resident 12, if she tried to climb over the rails to get out of bed or she could have become stuck between the rails. During an interview on 4/24/2026 at 10:32 a.m. with the Director of Nursing (DON), the DON stated Resident 12 should not have had her side rails up on her bed. The DON stated Resident 12 needed a consent and bed assessment before the side rails were applied on her bed. The DON stated the facility was a non-restraint facility and side rails were considered a restrictive device. The DON stated residents could become entrapped or hang themselves on the side rails. The DON stated there needed to be a physician's order for the use of side rails and the resident needed to be assessed prior to the use of side rails to be sure the rails were needed.During a review of the facility's policy and procedure (P&P) titled, Bed Rails, dated 8/2025, the P&P indicated, .it is the policy of this facility to attempt to use appropriate alternatives prior to installing a side or bed rail.if the use of bed rails is recommended by the Interdisciplinary Team [IDT], the facility must obtain informed consent from the resident, or if applicable, the resident representative for the use of bed rails prior to installation or use.During a review of the facility's P&P titled, Restraint Devices, Physical, dated 2006, the P&P indicated, .purpose.to prevent the resident from injuring himself or others.restraints of any type will not be used as punishment or as a substitute for more effective medical and nursing care or for the convenience of the facility staff.physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.assess resident's need for restraint device use.obtain informed consent for restraint device use.During a review of the facility's P&P titled, Resident Rights and Responsibilities, Notice of, dated 8/2025, the P&P indicated, .it is the policy of this facility to inform the resident both orally and in writing of their rights as a resident.should a resident be found incompetent by a court of law, the resident's representative shall act on behalf of the resident.During a review of the facility's document titled, California Standard admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities (AA), undated, the AA section 483.10 indicated, .Resident Rights.a facility must protect and promote the rights of each resident including each of the following rights.be fully informed in advance about care and treatment and of any changes in that care or treatment that may affect the resident's well being.

Based on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 61), was assessed to self-administer and store mediations at bedside when Resident 61 had an expired bottle of [brand name polyethylene glycol 400 0.25% (over the counter eye drop medication used to treat dry eyes)] eye drops stored at bedside for self-administration with no order or Medication Self-Administration Assessment Form (MSA- an assessment form to determine if a resident is clinically appropriate to safely and securely store and self-administer their own medication at bedside).This failure resulted in Resident 61 self-administering and storing expired medication at bedside without oversight which could lead to duplicate therapy, medication interactions, and adverse effects.Findings:During a concurrent observation and interview on 4/21/26 at 7:31 a.m. with Resident 61, in Resident 61's room, Resident 61 was observed lying in bed. Resident 61 was observed with [brand name polyethylene glycol 400 0.25%] eye drops on the center of his bedside table. The expiration date on the eye drops were 10/2018. Resident 61 stated [brand name polyethylene glycol 400 0.25%] eye drops were brought from home when he was admitted , and he had stored them on his bedside table since admission. Resident 61 stated his daughter applied the eye drops to his eyes everyday when she visited.During an observation on 4/21/26 at 7:41 a.m. in Resident 61's room, Certified Nursing Assistant (CNA) 5 was observed delivering Resident 61's breakfast tray. CNA 5 was observed moving Resident 61's eye drops from the center of the bedside table to the corner of the bedside table.During a concurrent interview and record review on 4/22/26 at 10:28 am with Licensed Vocational Nurse (LVN) 5, Resident 61's Medical Record, dated 4/22/26 was reviewed. LVN 5 stated Resident 61 did not have an order for [brand name polyethylene glycol 400 0.25%] eye drops. LVN 5 stated Resident 61 had an as needed order for, polyethylene glycol-propylene glycol eye drops, a different eye drop medication. LVN 5 stated Resident 61 did not have an order to self-administer [brand name polyethylene glycol 400 0.25%] eye drops. LVN 5 stated Resident 61 did not have a Medication Self-Administration Assessment Form (MSA) completed. LVN 5 stated all medications stored and self-administered at bedside were required to have an order and an MSA completed. LVN 5 stated Resident 61 was at risk for unsafe medication storage and self-administration of a medication without an order and MSA completed. LVN 5 stated the eye drops Resident 61 stored at bedside were expired. LVN 5 stated Resident 61 was at risk of side effects, medication interactions, duplicate therapy, unsafe medication storage and access to his expired [brand name polyethylene glycol 400 0.25%] eye drops which were stored at bedside, with no order or MSA. LVN 5 stated all unlicensed and licensed nursing staff were responsible for identifying medications stored and self-administered at bedside to ensure safety.During an interview on 4/22/26 at 10:47 a.m. with Resident 61's Family Member (FM) 1, FM 1 stated she visited Resident 61 on 4/21/26 in the afternoon and administered his eye drops. FM 1 stated Resident 61's eye drops had been stored on his bedside table since admission.During an interview on 4/22/26 at 10:51 a.m. with CNA 5, CNA 5 stated she had observed eye drops on Resident 61's bedside table since his admission. CNA 5 stated licensed nursing staff were responsible for handling medications.During an interview on 4/24/26 at 10:27 a.m. with the Director of Nursing (DON), the DON stated unlicensed and licensed staff were responsible for identifying medications stored and self-administered at bedside. The DON stated residents had the right to store and self-administer medications at bedside, but required an order and an MSA to ensure the resident could safely store and administer their own medications. The DON stated facility policy and procedure was not followed when Resident 61 had expired [brand name polyethylene glycol 400 0.25%] eye drops stored at bedside and was administering them with no physician order or MSA. The DON stated Resident 61 was placed at risk for duplicate therapy, medication interactions, and adverse side effects with no monitoring. During a review of Resident 61's Order Summary Report (OSR), dated 4/22/26, the OSR indicated Resident 61 did not have an order for [brand name polyethylene glycol 400 0.25%] eye drops. The OSR indicated Resident 61 did not have an order to self-administer or store [brand name polyethylene glycol 400 0.25%] eye drops at bedside.During a review of the facility's policy and procedure (P&P) titled, Resident Self-Administration of Medication, undated, the P&P indicated, .a resident may only self-administer medications after the facility's interdisciplinary team has determined which medication may be self-administered safely.when determining is self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following.the medications appropriate and safe for self-administration.the residents physical capacity to.open medication bottles.the residents cognitive status, including their ability to correctly name their medications and know what conditions they are taken for.the residents capability to follow directions and tell time to know when medications need to be taken.the residents comprehension of instructions for the medications they are taking, including the dose, timing, and signs of side effects.the residents ability to ensure that medication is stored safely and securely.the results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record. bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms or to confused roommates of the resident who self-administers medication.all nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage. Unauthorized medications are given to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of policy and procedures regarding resident self-administration when necessary. the nursing staff is responsible for proper rotation of bedside stock and removal of expired medications.

Based on observation, interviews, and record reviews, the facility failed to ensure two of five sampled residents (Resident 3 and Resident 32), were free from unnecessary psychotropic (drugs that affect brain activities with mental processes and behaviors) medications when: a. Resident 3 was prescribed quetiapine fumarate (prescription drugs that alter brain chemistry to affect mood, thoughts, behavior, and perceptions) with inappropriate indication of neurocognitive disorder (decline in mental function-such as memory, attention or language, caused by brain disease, injury or damage). b. There was inadequate monitoring of behaviors for Residents 3's quetiapine fumarate, divalproex sodium (medication used to treat seizures (abnormal electrical activity in the brain) and mood disorders), duloxetine (medication used to treat depression (a serious mood disorder causing persistent sadness, loss of interest, and low energy), anxiety (the body's natural response to stress, feeling intense worry, or unease about the future), and various chronic pain), and trazodone (medication primarily used to treat depression, anxiety, and insomnia (persistent difficulty falling asleep)). c. No gradual dose reductions (GDR-process of slowly lowering the dosage of a medication) were attempted for the use of divalproex sodium, duloxetine, and trazodone. Resident 32 was not adequately monitored for behaviors during the administration of divalproex sodium. These failures resulted in the potential for unnecessary psychotropic medications for Resident 3 and Resident 32 which increased the potential for medication interactions, adverse reactions (unwanted, harmful, or unexpected physical reactions cause by a medication), and unidentified risks associated with the use psychotropic medications including, but not limited to, sedation (use of medication to produce a state of calm, relaxation, or sleepiness), respiratory depression (a serious, potentially fatal condition where breathing becomes shallow, slow or ineffective), memory loss and death. Findings:1a. During a record review of Resident 3's admission Record (AR), dated 4/24/26, the AR indicated Resident 3 was admitted from an acute care hospital on 3/13/25 with diagnosis which included . Alzheimer's Disease [a disease characterized by a progressive decline in mental abilities], Depression, anxiety, and Dementia [a progressive state of decline in mental abilities] . During an observation on 4/22/26 at 9:30 a.m., Resident 3 was observed in his room, sitting in his wheelchair with friend present, and Resident 3 used a whiteboard to communicate.During a record review of Resident 3's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive (mental) and physical functional level) assessment, dated 3/6/26, the MDS section C indicated, Resident 3's Brief Interview for Mental Status (BIMS) assessment score was 15 out of 15 (0-6 severe cognitive (pertaining to reasoning memory and judgement) deficit, 7-12 moderate cognitive deficit, 13-15 cognitively intact). The BIMS scores indicated Resident 3 was cognitively intact. During a review of Resident 3's MDS, dated 3/4/26, the MDS indicated in Section E for behavior, under potential indicators of psychosis, none of the above boxes were checked, indicating no hallucinations and delusions. The MDS indicated under Behavioral symptom - Presence and Frequency, all boxes had 0, which indicated for physical behavioral symptoms directed toward others (for example: hitting, kicking, pushing, scratching, grabbing, abusing others sexually), Verbal behavioral symptoms directed toward others (for example: threatening others, screaming at others, cursing at others), Other behavioral symptoms not directed toward others (for example: physical symptoms, such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing, in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like, screaming, disruptive sounds). The MDS indicated, Coding 0 indicated, Behavior not exhibited.During a review of Resident 3's Physician Orders (PO), dated 11/13/25 and 3/15/25, the PO indicated on 11/13/25, Resident 3 was ordered quetiapine fumarate 25 milligram (mg-a measure of weight), give one tablet by mouth at bedtime every other day for neuro cognitive disorder with behavioral disturbance manifested by verbal aggression as evidenced by yelling and screaming toward other. The PO indicated on 3/15/25, Resident 3 was ordered Depakote 125mg, give one tablet by mouth two times a day manifested by increased agitation resulting in physical aggression toward others; trazodone 100mg, given one tablet by mouth at bedtime for depression manifested by inability to sleep; and duloxetine 30 mg give one capsule by mouth one time a day for expression of sadness.During an interview on 4/23/26 at 1:10 p.m. with the Assistant Director of Nursing (ADON), the ADON stated neurocognitive disorder was not an appropriate indication for use of divalproex sodium and quetiapine. The ADON stated she reached out to the physician about the diagnosis, but the physician kept putting neurocognitive disorder. During an interview on 4/24/26 at 9:26 a.m. with the Medical Director (MD), the MD stated Resident 3 uses divalproex sodium as a mood stabilizer, the order should be worded differently, and the diagnosis should be different. The MD stated the indication needed to be updated or changed to something different.During an interview on 4/24/26 at 9:50 a.m. with the Director of Nursing (DON), the DON stated neurocognitive disorder diagnosis was not appropriate. The DON stated she followed up {named hospital} physician and informed the physician the diagnosis and indication should be appropriate, and it was important to follow regulations. During an interview on 4/24/26 at 10:46 a.m. with the Consultant Pharmacist (CRPH), the CRPH stated the neurocognitive disorder diagnosis would be off label, the CRPH stated it was important to have the appropriate indication. The CRPH stated if using any medication for residents, the medications should be used for an indication that has been studied for effectiveness and safety.1b. During an interview on 4/23/26 at 11:07 a.m. with Registered Nurse (RN) 1, RN 1 stated Resident 3's behaviors were normal, he was cooperative with staff, talked easily, followed all instructions, was alert and oriented, was aware of his blood sugar readings, he knew the medications, took all meals, never argued with staff and residents, and he never showed behaviors. RN 1 stated she had worked with Resident 3 on and off for the last 2 years. RN 1 stated Resident 3 checks his pills, asked about his blood sugar, and if his blood sugar was low, he would be concerned.During an observation on 4/23/26 at 11:25 a.m., Resident 3 was observed sitting in his wheelchair on his way to the dining room. Resident 3 stopped and said hello and smiled.During an interview on 4/23/26 at 12 p.m. with the ADON, the ADON stated monthly behavior tallies were completed. During a review of Resident 3's Care Plan (CP), undated, Resident 3's CP indicated, there were no objective goals for the number of episodes for behaviors being monitored for Resident 3's quetiapine, divalproex, duloxetine, and trazodone. During a concurrent interview and record review on 4/23/26 at 1:19 p.m. with the ADON, Resident 3's CP, undated was reviewed. The ADON stated residents have different individualized goals and it was important to monitor behaviors. The ADON stated residents should have measurable goals. The ADON stated the CP indicated there were no measurable goals for the number of behaviors in Resident 3's care plan. The ADON stated this was important, so the facility staff knew when to increase or decrease medications. During an interview on 4/23/26 at 4:08 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, Sometimes Resident 3 complained about everything that he saw, if another resident with dementia was passing by with a doll, Resident 3 would be irritated. LVN 2 stated, Resident 3 complained about his insulin injection, he wanted his insulin and his blood sugar checked before he ate eat, even though it was not time yet. LVN 2 stated she considered all these as behaviors and would document them as a total of behaviors on each of the monitoring behavior indicators for quetiapine, divalproex, duloxetine, and trazodone on the MAR.During an interview on 4/24/26 at 10:04 a.m. with the DON, the DON stated there should be monitoring of medications for every resident. The DON stated each medication monitored certain behaviors, and the behaviors were monitored to see if the medication was effective or not, so the medications could be adjusted if needed. The DON stated LVN 2 was not appropriately monitoring the behavioral episodes for Resident 3's quetiapine, duloxetine, divalproex and trazodone. The DON stated it was important to document the number of episodes for each behavior for the medication indicated for that particular behavior. The DON stated it was important for LVN 2 to follow documentation specified, because it helped to know if residents would benefit from the medications or not. The DON stated LVN 2 had received further training on how to appropriately monitor and document behavioral episodes for psychotropic medications.1c. During a review of Resident 3's Consultation Report (CR), dated 3/14/25, the CR indicated, the CRPH recommended a gradual dose reduction, . Resident 3 receives multiple antidepressants for depression concomitantly [at the same time] without documentation in the medical record of an inadequate response to monotherapy: Trazodone . escitalopram . duloxetine . and Trazodone . recommendation: please evaluate the continued need of these orders physician's response- checked box to- I decline the recommendations above and do not wish to implement any changes due to the reasons below. Rationale: Patient is receiving care with mental health doctor as outpatient. Continued treatment- signed and dated 3/17/25.During a review of Resident 3's CR, dated 5/28/25, the CR indicated, the CRPH recommended a gradual dose reduction, .Resident 3 Has received an antidepressant, duloxetine . and [brand name] (escitalopram) . for management of depressive symptoms since 3/25/25. recommendation: please attempt a gradual dose reduction (GDR) of duloxetine and [escitalopram ] if indicated at this time Physician's response- checked box to - I decline the recommendations above Because GDR is clinically contraindicated for this individual as indicated below .1 dot checked box to- continued use is in accordance with the current standard of practice and a judiciary attempt at this time is likely to impair this individual's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder as documented below. there was no information provided under Please provide CMS required patient specific rationale describing why GDR attempt is likely to impair function or cause psychiatric instability in this individual: document was signed with no date.During a review of Resident 3's CR, dated 8/16/25, the CR indicated, the CRPH recommended a gradual dose reduction, .Resident 3 receives multiple antidepressants for depression concomitantly without documentation in the medical record of an inadequate response to monotherapy: escitalopram . duloxetine . and Trazodone ., recommendation: please evaluate the continued therapy and consider a reduction to one of the antidepressants with goal of discontinuation . Physicians response- checked box to - I decline the recommendations above and do not wish to implement any changes due to the reasons below. Rationale: managed by psych . During a record review of Resident 3's GDR documents, undated the documents indicated there was no GDR for divalproex sodium, duloxetine, and trazodone. During an interview on 4/23/26 at 1:15 p.m. with the ADON, the ADON stated no GDR attempt was completed for Resident 3's divalproex sodium. The ADON stated Resident 3 was being followed by [named hospital] psychiatrist. The ADON stated Resident 3 had been canceling his appointments. The ADON stated Resident 3 had not been to the [named hospital] psychiatrist since admission to facility in 2025. The ADON stated it was important for residents to receive GDR attempts because of irreversible effects like tardive dyskinesia (a neurological movement disorder characterized by uncontrollable, repetitive, and involuntary movements, commonly in the face, mouth, tongue, arms, or legs).During an interview on 4/24/26 at 9:28 a.m. with the MD, the MD stated on Resident 3 followed up with the psychiatrist, the [named hospital] was a separate entity and [named hospital] was fully aware of the regulations. The MD stated he was unable to speak with them; they had their own physicians. The MD further stated since Resident 3 was in the facility, the interdisciplinary team (IDT) had to follow their policy and procedure (P&P). The MD stated the goal was to have Resident 3 at the lowest effective psychotropic medication dose.During an interview on 4/24/26 at 9:56 a.m. with the DON, the DON stated and acknowledged Resident 3 was not going to his psychiatrist appointments and had not seen a psychiatrist since admission to the facility. The DON stated and acknowledged Resident 3 had not received a GDR for his psychotropic medications despite recommendations from the consultant pharmacist. The DON stated GDR was important because medications could make residents sedated, if the medication was effective, there should be an order to switch to other medications. The DON stated medications have black box warning (potentially serious or life-threatening side effects from medications), especially with the elderly population. During an interview on 4/24/26 at 10:48 a.m. with the CRPH, the CRPH stated if Resident 3 was not going to his psychiatrist appointments, the responsibility would fall back to the attending physician if Resident 3 was not seen by a psychiatrist. The CRPH stated GDR was important to find the lowest effective dose, the situation could change over time and if there was no attempted GDR the IDT would not know.2. During a record review of Resident 32's AR, dated 4/24/26, the AR indicated Resident 32 was initially admitted to the facility on [DATE], and was re-admitted from an acute care hospital on 1/28/26 with diagnosis which included . schizoaffective disorder, bipolar type [a chronic mental health condition combining schizophrenia symptoms (hallucinations/delusions) with intense mood shifts, specifically manic episodes and often major depression], depression, personal history of suicidal behavior.During a record review of Resident 32's PO, dated 9/6/25 to 2/15/26, the PO indicated Divalproex Sodium Oral tab 250mg- Give 2 tablets by mouth one time a day for schizophrenia manifested by having auditory hallucination (the perception of sounds, such as voices, noises, or music, that are not actually occurring) and give 4 tablets by mouth in the evening for schizophrenia with start date 9/6/25- ended 2/11/26, start date 2/12/26-ended 2/17/26 and start 2/18/26- present date. During a record review of Resident 32's MDS, dated 3/2/26, the MDS section C indicated Resident 32's BIMS assessment score was 15 out of 15. The BIMS scores indicated Resident 32 was cognitively intact. During a review of Resident 32's MDS, dated 3/2/26, the MDS indicated in Section E for behavior, none exhibited.During a review of Resident 32's CP, undated, the CP indicated there were no objective goal for the number of episodes for behaviors being monitored. During a review of Resident 32's MAR, dated 3/26, the MAR indicated Monitor behavior for anti-convulsant (anti-seizure medication) used as psychoactive (affecting the mind or behavior) divalproex sodium for diagnosis Mood disorder m/b: Auditory Hallucination- Yes/no .During an interview on 4/23/26 at 11:44 a.m. with LVN 1, LVN 1 stated Resident 32 was alert and oriented and sometimes she was emotional. LVN 1 stated on behavior monitoring and side effects, the number in the MAR was the tally to indicate the number of episodes. LVN 1 stated there was no place to document the side effects or behaviors residents were experiencing. LVN 1 stated the care plan was used to help resolve the issues Resident 32 was experiencing. LVN 1 stated it was important the number of times Resident 32 exhibited symptoms or behaviors was documented because it could be used to ensure the appropriate interventions for Resident 32 were used. During a concurrent interview and record review on 4/23/26 at 2:40 p.m. with the ADON, Resident 32's electronic medical record (EMR), undated was reviewed. The ADON stated when documenting behavior monitoring, the numbers meant the resident had that number of behaviors during the shift. The ADON stated no meant zero (0) behaviors . The ADON stated when there was a behavior exhibited, there should be the number of behaviors the resident manifested in a shift indicated in the MAR. The ADON stated and acknowledged Resident 32's Divalproex- yes or no were documented and stated the IDT would not know how many behavior episodes Resident 32 exhibited during the shift. The ADON stated this was important so the IDT could determine through the tallying of behaviors if they needed to make any changes. The ADON stated the monitoring of side effects, the documentation did not reflect what type of side effects Resident 32 had. The ADON stated residents should have individualized care plans according to their needs and goals. The ADON stated Resident 32's care plan was generic and was not individualized. The ADON stated ensuring the care plan was individualized would be a guide on what to do and ensured nursing staff called the physician or could help in adjusting the resident's medication appropriately. During an interview on 4/24/26 at 9:35 a.m. with the MD, the MD stated it was important to document behavior tallies, because it helped to determine whether the medication was effective, and if effective, there could be a reduction in dose or frequency. When informed of LVN 2's understanding of documenting the behavior tallies, the MD stated it was not right to tally behavior medications for different symptoms and indications, it was important that they were differentiated so the IDT knew how severe the behaviors were and the medications could be adjusted appropriately. During an interview on 4/24/26 at 10 a.m. with the DON, the DON stated it was important to monitor behaviors to make sure medication was effective. The DON stated if behaviors were decreasing, a GDR could be attempted, and the medication decreased, if escalated behavior, there would be a need to adjust the medication. The DON stated this was important to have measurable goals when monitoring behaviors, this made it easy to assess if the goals were met and if the goals were not met, then they would be able to determine the next plan.During an interview on 4/24/26 at 10:51 a.m. with the CRPH, the CRPH stated goals helped to analyze if medications were effective or not. The CRPH stated the nursing staff needed to evaluate each behavior separately and when it was time to attempt a GDR, there should be documentation of the correct behaviors to effectively know what medication was working. The CRPH stated there should be a number of episodes to truly measure the number of behaviors residents were exhibiting.During a review of the facility's P&P titled, Medication (Drug) Regimen Review (MRR), dated 8/25, the P&P indicated, . Policy: It is the policy of this facility that the drug regimen of each resident will be refilled at least once a month by a licensed pharmacist. In medication regimen review (MRR) includes a review of the resident's medical chart, identified irregularities will be documented on a separate written report that includes the residents' name, the relevant drug, and the irregularity identified. The report will be sent to the attending physician, the facility's medical director and the director of nursing services (DNS) to be acted upon.During a review of the facility's P&P titled, Comprehensive person centered care planning, dated 8/25, the P&P indicated, . Policy: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person centered care plan for each resident that includes measurable objectives and time frames to meet a residence medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Definition . measurable- is the ability to be evaluated or quantified . objective- is a statement describing the results to be achieved to meet the residents' goals.During a review of the facility's P&P titled, Chemical restraints on psychotropic medication management, dated 8/25, the P&P indicated, . Policy: It is the policy of this facility to ensure that residents are free from chemical restraints imposed for purposes of discipline or convenience or that are not required to treat a specific condition as diagnosed and documented in the clinical record. based on a comprehensive assessment, the facility will ensure that: residents who use psychotropic drugs receive gradual drug reduction (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;. Definitions- gradual dose reduction (GDR) is the stepwise tapering of dose to determine if symptoms, conditions, or risk can be managed by a lower dose or if the dose of medication can be discontinued. a. The medical record must show documentation of the diagnosed condition for which a psychotropic medication is prescribed. 7. The Social Services (SSD) and/or nursing designee will be responsible for initiating the resident's individualized, person-centered psychosocial plan of care, based on their comprehensive initial admission assessment. a. Psychotropic medication was prescribed to treat a specific diagnosed condition, as documented in the clinical record.d. Monitoring for adverse consequences and effectiveness of medications are in place. Informed consent was obtained prior to medication use; g. Review of plan of care shows individualized, person-centered care approaches to manage behavior with non-pharmacological interventions; h. Attempt/consider a GDR (Gradual Dose Reduction), if appropriate.

Based on observation, interview, and record review, the facility failed to ensure a comprehensive person-centered care plan (CP - a detailed approach to care customized to an individual resident's needs) was developed and implemented for four of 14 sampled residents (Resident 12, Resident 15, Resident 120 and Resident 139) when:1. Resident 12 had two bed (side) rails (adjustable metal or rigid plastic bars in various sizes that attach to the bed and can be placed in a guard [raised position that is intended to prevent an individual from inadvertently rolling out of bed] or lowered position) on each side of the bed in the guard position. Resident 12 did not have a plan of care developed and initiated for getting out of bed unassisted and prior to the use of the bed rails. This failure had the potential to result in Resident 12 receiving inadequate person-centered care and placed Resident 12 at risk of not having her needs met and sustaining injury from entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail), which could cause serious harm, injury, or death.2. Resident 15's care plan was not developed and initiated for refusal of having her nails trimmed.This failure had the potential to result in Resident 15 receiving inadequate person-centered care and placed Resident 15 at risk of not having her needs met and sustaining injury from having long nails. 3. Resident 120 did not have a care plan for the use of antibiotics (medication used to treat bacteria) for peritoneal abscess (pocket of infected fluid or pus that collects inside the belly [abdominal cavity]).This failure had the potential for Resident 120's use of antibiotics to not be monitored for side effects like diarrhea, nausea, and stomach pain.4. Resident 139 did not have a care plan when a right nephrostomy tube (small, flexible tube placed through the skin in the back into the kidney to drain urine directly into an external bag) was inserted and was readmitted to the facility. This failure had the potential for Resident 139 to not receive the care needed for his right nephrostomy tube.Findings: 1. During an observation on 4/21/2026 at 7:02 a.m. in Resident 12's room, Resident 12 was observed asleep in bed, wearing a gown with side rails up on the left and right side of the bed and a fall mat on the right side of Resident 12's bed. During a review of Resident 12's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 4/23/26, the AR indicated Resident 12 was admitted to the facility from an acute care hospital on [DATE] with diagnoses of cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), schizophrenia (a mental illness that affects a person's ability to think, feel, and behave clearly), depression (persistent feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life), and history of falling. During a review of Resident 12's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 3/18/26, the MDS section C indicated Resident 12 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of three (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 12 was severely cognitively impaired. During a review of Resident 12's MDS, dated 3/16/26, the MDS section GG (Functional Abilities) indicated Resident 12 had, .impairment on one side.upper extremity [shoulder, elbow, wrist, hand].used in the last 7 days.wheelchair.Dependent [helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity].chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair [or wheelchair]. During an interview on 4/22/26 at 4:10 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 12 had her side rails up because she tried to get out of bed and had fallen in the past. During a concurrent interview and record review on 4/23/2026 at 3:51 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 12's Care Plan (CP), undated was reviewed. LVN 1 stated there was no CP for Resident 12 getting out of bed unassisted, or a CP for Resident 12's use of side rails. LVN 1 stated a CP was important for Resident 12's use of side rails and assisting Resident 12 out of bed to prevent Resident 12 from getting injured and to provide resident safety. LVN 1 stated a CP informed staff what level of care Resident 12 required. LVN 1 stated the CP should have been specific for Resident 12's needs. During an interview on 4/24/2026 at 10:32 a.m. with the Director of Nursing (DON), the DON stated Resident 12 should not have her side rails up. The DON stated the facility was a non-restraint facility and side rails were considered a restrictive device. The DON stated side rails could have caused entrapment, or the residents could have hung themselves on the bars. The DON stated Resident 12 should have had a care plan to monitor her, and to make sure the device used to assist her was safe and not loose. The DON stated a care plan gave staff information of the resident's plan of care based on the resident's needs. The DON stated the care plan should have been patient-centered and each resident should have had their own plan of care. The DON stated if the resident had a change of condition, any nurse could have entered a care plan for the change in the resident's condition. During a review of the facility's policy and procedure (P&P) titled, Bed Rails, dated 8/2025, the P&P indicated, .it is the policy of this facility to attempt to use appropriate alternatives prior to installing a side or bed rail.bed rails should be selected and placed to discourage climbing over the rails to get in and out of bed, which may result in falling over bed rails.no gaps wide enough to entrap a resident's head, body, or limbs should be present post-installation or during the course of use.update the resident care plan as needed related to the identified and/or ongoing need or resident choice for the use of bed rails. 2. During an observation on 4/21/2026 at 7:09 a.m. in Resident 15's room, Resident 15 was observed asleep in bed, dressed, wearing an oxygen nasal cannula (a tube that delivers oxygen through the nose to people who have low oxygen levels), and a gauze dressing on her left upper arm. During a review of Resident 15's AR, dated 4/23/26, the AR indicated Resident 15 was initially admitted to the facility from an acute care hospital on [DATE] with a re-admission on [DATE] with diagnoses of arthritis (joint inflammation) due to other bacteria to the right knee, dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), dysphagia (difficulty swallowing), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), acquired absence (surgical removal of finger, toe, hand, foot, arm or leg) of right great toe, and depression. During a review of Resident 15's MDS, dated 2/27/26, the MDS section C indicated Resident 15 had a BIMS score of seven, which indicated Resident 15 was severely cognitively impaired. During a review of Resident 15's MDS, dated 2/27/26, the MDS section GG indicated, Resident 15 had, .impairment on both sides.upper extremity.used in the last 7 days.wheelchair.Dependent .personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands. During a concurrent observation and interview on 4/21/2026 at 1:04 p.m. in Resident 15's room, Resident 15 was observed dressed in bed, and wearing an oxygen nasal cannula. Observed skin tear to the pinky of the right hand, dry/discoloration on left shin, missing toes to right and left foot, right and left hands contracted (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) with long, dark colored right thumb nail. Resident 15 stated she was not sure how she got the skin tear. Observed Resident 15's meal tray delivered, with CNA 3 setting up tray to feed Resident 15. CNA 3 stated Resident 15 needed assistance with meals. Resident 15 did not want to answer any more questions. During a review of Resident 15's electronic medical record (EMR), the EMR indicated there was no CP for refusal of nail care for Resident 15 and no CNA documentation in Resident 15's Tasks of refusal of nail care. During an interview on 4/22/2026 at 3:49 p.m. with Registered Nurse (RN) 1, RN 1 stated there were no paper shower slips the CNAs documented on for Resident's showers, skin or nail assessments. RN 1 stated if a resident refused a shower or bath, or had skin issues, including nail care, the CNA informed the nurse and the nurse documented in the progress notes. RN 1 stated if a resident refused care, the nurse informed the next shift. During a concurrent interview and record review on 4/22/2026 at 3:50 p.m. with LVN 1, Resident 15's CP, undated was reviewed. LVN 1 stated Resident 15 had a care plan initiated yesterday, 4/21/26 for refusing nail care. LVN 1 stated Resident 15 had been refusing nail care. LVN 1 stated if a resident kept refusing care, the nurse should have made a non-compliant care plan, explained the risks and benefits to the resident and/or responsible party (RP), and notified the resident's physician. During a concurrent interview and record review on 4/22/26 at 4:03 p.m. with CNA 1, Resident 15's EMR, undated was reviewed. CNA 1 stated residents received nail care on their shower days. CNA 1 stated Resident 15 had been refusing nail care. CNA 1 stated if a resident refused care, the CNA informed the nurse and during shift report also notified the next shift so they could try to give nail care to the resident. CNA 1 stated the nurse notified the resident's family if a resident refused care. CNA 1 stated the CNAs documented in their point of care (POC) documentation system and it gave an alert to staff regarding the resident's refusals. CNA 1 stated the EMR indicated the POC system and was unable to check past documentation history of Resident 15's care. During an interview on 4/24/2026 at 10:35 a.m. with the DON, the DON stated the refusal of nail care should have been care planned. The DON stated a CP gave staff information of the resident's plan of care based on the resident's needs. The DON stated the CP should have been patient centered and each resident should have their own plan of care. The DON stated if there was a change in the resident's condition any nurse could have entered a CP for the resident's change of condition. The DON stated if a resident refused nail care, they needed to have a CP, and the family needed to be informed. During a review of the facility's P&P titled, Nail Care, dated 2024, the P&P indicated, .the purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health.assessments of resident nails will be conducted on admission and readmission to determine the resident's nail condition, needs, and preferences for nail care.report unusual or abnormal conditions of the nails to the physician and the responsible party [e.g., curling, color changes, separation from the nailbed, redness, bleeding, pain, odor, infection, etc.].identify conditions that increase risk for foot or nail problems, such as diabetes, peripheral vascular disease, heart failure, renal disease, or stroke.routine cleaning and inspection of nails will be provided during Activities of Daily Living [ADL] care on ongoing basis.routine nail care, to include trimming and filing, will be provided on a regular schedule.nail care will be provided between scheduled occasions as the need arises.the resident's plan of care will identify.the frequency of nail care to be provided.the type of nail care to be provided.the person[s] responsible for providing nail care.nails should be kept smooth to avoid skin injury.document completion of task, any complications, or if resident refuses. During a review of the facility's P&P titled, Comprehensive Person-Centered Care Planning, dated 8/2025, the P&P indicated, .it is the policy of this facility that the interdisciplinary team [IDT] shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.the resident has the right to refuse or discontinue treatment. In the event that a resident refuses certain services posing a risk to resident's health and safety, the comprehensive care plan will identify care or service declined, the associated risks, IDT's effort to educate the resident and resident representative and any alternate means to address risk. 3. During an observation on 4/21/26 at 6:50 a.m. during initial tour in Resident 120's room. Resident 120 was observed lying in bed, eyes closed and did not answer questions asked. During a review of Resident 120's AR, dated 4/23/26, the AR indicated Resident 120 was admitted to the facility on [DATE] with diagnoses which included fibromyalgia (a chronic [long-lasting] disorder characterized by widespread pain, stiffness, and tenderness throughout the body, accompanied by intense fatigue and sleep issue), pressure ulcer of sacral region (at the bottom of the spine), urinary tract infection (bacterial infection in the bladder), and peripheral vascular disease (a slow circulation problem where blood vessels outside the heart and brain-usually in the legs-become narrowed, blocked, or damaged). During a concurrent interview and record review on 4/23/26 at 10:37 a.m. with LVN 3, Resident 120's EMR, undated was reviewed. LVN 3 stated she was familiar with Resident 120. LVN 3 stated the EMR indicated Resident 120 was sent out to the acute hospital and returned to the facility with an order for an antibiotic. LVN 3 stated she did not find a care plan for the antibiotic order. LVN 3 stated there should have been a care plan initiated and it was the responsibility of all licensed nurses to initiate a care plan. During a concurrent interview and record review on 4/24/26 at 10:50 a.m. with the Assistant Director of Nursing (ADON), Resident 120's EMR, dated 4/10/26 was reviewed. The ADON stated the EMR indicated Resident 120 was sent out to the acute hospital on 4/10/26 and returned to the facility on 4/13/26 with an antibiotic order for peritoneal abscess (infected pus pocket in the belly) to be given for three days. The ADON stated the EMR indicated there was no care plan for the antibiotic. The ADON stated there should have been a care plan initiated but there was none. The ADON stated care plans were important, and it should be patient centered to direct staff to properly care for residents. 4. During an observation on 4/21/26 at 6:38 a.m. during initial tour in Resident 139's room, Resident 139 was observed lying in bed, eyes closed and did not answer questions asked. During a review of Resident 139's AR, dated 4/23/26, the AR indicated Resident 139 was admitted to the facility on [DATE] with diagnoses which included unspecified hydronephrosis (kidney swelling or a fluid-filled kidney), obstructive (blockage in the urinary system that prevents urine from flowing freely) and reflux uropathy (backward flow of urine from the bladder toward the kidneys). During a concurrent interview and record review on 4/23/26 at 11:05 a.m. with LVN 3, Resident 39's EMR, undated was reviewed. LVN 3 stated she was Resident 139's nurse. LVN 3 stated the EMR indicated Resident 139 was re-admitted to the facility on [DATE]. LVN 3 stated Resident 139 had a cystoscopy (a medical procedure using a thin, lighted tube with camera to look inside the bladder and the tube that drains urine) appointment at the general acute care hospital (GACH) and was kept overnight. LVN 3 stated the EMR indicated Resident 139 was readmitted to the facility with nephrostomy tubes on both the right and left side. LVN 3 stated she was not sure if Resident 139 had nephrostomy tubes on both right and left side prior to admission to the hospital. LVN 3 stated she did not find a care plan for the right nephrostomy tube. During a concurrent interview and record review on 4/24/26 at 9:55 a.m. with the ADON, Resident 139's EMR, dated 12/20/25 was reviewed. The ADON stated the EMR indicated Resident 139 was admitted to the facility with one nephrostomy tube, but she was not sure which side. The ADON stated the EMR indicated the hospital record titled, Discharge Summary, indicated Resident 139 had a nephrostomy tube placed on the right side. The ADON stated she did not find a care plan for the placement of the right nephrostomy tube and there should have been a care plan. The ADON stated care plans were very important to guide staff on how to care for residents. During an interview on 4/24/26 at 11:31 a.m. with the DON, the DON stated care plan was the responsibility of every nurse. The DON stated her expectation was to ensure a care plan was initiated when there was a change in condition, a new order or medication, or a change in medications. The DON stated basic care plans were initiated and completed within 48 hours, and comprehensive care plans were initiated and completed within 21 days of admission. During a review of facility's policy and procedures (P&P) titled, Comprehensive Resident Centered Care Plan, revised date 8/25, the P&P indicated, It is the policy of this facility that the interdisciplinary team (IDT-group of experts from different fields working together closely to solve a complex problem or care for a person, rather than working in isolation) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet resident's medical, nursing, mental and psychosocial needs. The IDT team will also develop and implement a baseline care plan for each resident. to properly care for each resident .

Based on observation, interview, and record review, the facility failed to ensure activities of daily living (ADL's- routine activities such as grooming, bathing, dressing and toileting a person performs daily to care for themselves) was not provided for one of three sampled residents (Resident 178), when Resident 178's fingernails on both hands were long, jagged (sharp, uneven edges), and dirty with brownish to blackish dirt built up underneath her nails.This failure had the potential for Resident 178 to obtain skin-related injuries including cuts, scratches, and infections.During a concurrent observation and interview on 4/22/26 at 1:03 p.m. with Resident 178 in Resident 178's room, Resident 178 was observed having a Peripherally Inserted Central Catheter (PICC -a long, thin tube that's inserted through a vein in the arm) line placed to her right upper arm. Resident 178 stated her antibiotic was given through the PICC line. Resident 178 stated she was admitted to the facility since April 19, 2026. Resident 178 stated her nails were long, dirty, and felt like a mess. Resident 178 stated she wanted to have her fingernails cleaned and trimmed.During a review of Resident 178's admission Record (AR), dated 4/19/26, the AR indicated, Resident 178 was admitted to the facility with the diagnosis which included Sepsis (the body's extreme, dangerous response to an infection), Diverticulitis (infected or inflamed pockets in the colon) and Restless leg syndrome (fidgety legs, tingling, pulling, or aching sensation deep in the legs, which is temporarily relieved by movement).During a concurrent observation and interview on 4/22/26 at 1:31 p.m. with Certified Nursing Assistant (CNA) 6, in Resident 178's room, Resident 178 was lying in bed, needed assistance with repositioning and noted that the fingernails on both hands appeared long, jagged, and dirty. CNA 6 stated Resident 178 was unable to reposition independently in bed and needed assistance. CNA 6 stated Resident 178's fingernails were long and dirty. CNA 6 stated nail care was provided during ADL care, on scheduled shower days twice a week, and as needed.During a concurrent observation and interview on 4/22/26 at 1:54 p.m. with Registered Nurse (RN) 6, in Resident 178's room, Resident 178 was lying in bed and noted that fingernails on both hands appeared long, jagged, and dirty. RN 6 stated Resident 178's fingernails were long, uneven with sharp edges and dirty with brownish to blackish buildup underneath the nail bed. RN 6 stated the CNA could have provided nail care, such as trimming and filling fingernails for Resident 178 because the resident was non-diabetic (a person who does not have a problem with high blood sugar). RN 6 stated if a resident was diabetic (a person who has a problem with high blood sugar), only the nurses may provide nail care. RN 6 stated keeping nails short and clean helped prevent Resident 178 from scratching her skin, which could lead to skin breakdown and infection.During an interview on 4/24/26 at 9 a.m. with the Director of Staff Development (DSD), the DSD stated CNA's or nurses were expected to perform and assist with hand hygiene for residents during ADLs, before and after meals, including nail care, and as needed.During an interview on 4/24/26 at 10:05 a.m. with the Director of Nursing (DON), the DON stated nail care was part of ADL's and hand hygiene. The DON stated proper nail care and hand hygiene helped prevent the transmission of infection, bacteria and other microorganisms, such as multi drug-resistant organisms (any living thing), especially if a resident had an intravenous (something that goes directly into a vein) line or PICC line.During a review of the facility's policy and procedures (P&P) titled, Nail Care, dated 2024, the P&P indicated, .Assessments of resident nails will be conducted on admission.Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis.Nails should be kept smooth to avoid skin injury.

Based on observation, interview, and record review, the facility failed to ensure acceptable parameters of nutritional status were maintained for one resident (Resident 12) when when weekly weights were not implemented to track and monitor the effectiveness of interventions that were put into place such as snacks, nutritional shakes and daily intake.This failure resulted in a weight loss of 4.49 % (percent) in a month from 11/19/25 to 12/17/25, 13.48 % in three months from 11/19/25 to 2/18/26, and 9.14% in three months from 12/17/25 to 3/18/26 for Resident 12. Findings: During an observation on 4/21/26 at 8:19 a.m. with Resident 12, in Resident 12's room, Resident 12 was sitting up in bed with breakfast tray on bedside table, cover off plate with a hard-boiled egg.During an observation on 4/23/26 at 10:08 a.m. with Resident 12, in Resident 12's room, Resident 12 was lying asleep in bed, with bilateral mats (a cushioned floor pad designed to help prevent injury should a person fall) on the floor.During an observation on 4/23/26 at 10:10 a.m., at the nursing station, Resident 12's nutrition shake (health shake - nutrient-dense, blended beverages designed to improve health, manage weight, or supplement diets with protein, vitamins, and minerals) and chocolate pudding were stored in a bucket labeled with Resident 12's name.During an observation on 4/23/26 10:16 a.m. with Resident 12, in Resident 12's room, an unopened health shake and chocolate pudding were on top of her bedside table. Resident 12 was asleep in bed. During an interview on 4/23/26 at 10:19 a.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated she was distributing residents' supplements and snacks. CNA 4 stated Resident 12 was one of her residents. CNA 4 stated Resident 12's had been sleeping since the beginning of her shift. CNA 4 stated she assisted Resident 12 for breakfast today (4/23/26) in her room. CNA 4 stated Resident 12 did not eat her breakfast. CNA 4 stated Resident 12 drank only one third of the juice and few sips of milk. During a review of Resident 12's Face Sheet (FS - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 4/23/23, the FS indicated Resident 12 was admitted to the facility on [DATE] with diagnoses of cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), type 2 diabetes mellitus (when the blood sugar levels in the body are too high), and protein calorie malnutrition (a condition resulting from inadequate intake of protein and calories, often due to decreased oral intake). During a review of Resident 12's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 3/18/26, the MDS section C indicated Resident 12 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 3 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 12 had a severe cognitive impairment.During a review of Resident 12's Electronic Medical Records (EMR) titled Weights, indicated, 11/19/25 155.8 lbs. (pounds - a unit of weight), 12/17/25 148.8 lbs., 2/18/26 134 lbs., 3/18/26 135.2 lbs. Resident 12 had a weight losses of 4.49 % (percent) in a month from 11/19/25 to 12/17/25, 13.48 % in three months from 11/19/25 to 2/18/26, and 9.14% in three months from 12/17/25 to 3/18/26.During a review of physician orders dated 4/23/26 indicated CCHO (Consistent Carbohydrate) NAS (No Added Salt) Regular, Thin Liquids diet. Dated 2/20/26 indicated Health shake twice a day between meals. Dated 10/11/22 indicated snacks two times a day. Dated 10/9/22 indicated CCHO, regular NAS diet. During a review of Resident 12's Order Summary Report, dated 3/31/26, indicated, CCHO, NAS, Regular texture, Thin Liquids, Health shake two times a day 4 oz BID (twice a day) between meals, Snacks two times a day.During a review of Resident 12's medical record titled, Mini Nutritional assessment dated [DATE] and 3/18/26, indicated, . 12/19/25 Weight loss during the last 3 months: weight loss greater than 3 kg (6.6 lbs.) . care planning 1. Potential for Malnutrition.Goal Resident Intake of Nutrients Will Metabolic Needs.Intervention: Monitor weight closely for gain/loss.3/18/26 Weight loss during the last 3 months: weight loss between 1 and 3 kg (2.2 and 6.6 lbs.) .During a review of the Clinical Interdisciplinary Team (IDT) assessment dated [DATE], indicated Resident 12's po (oral) intake had decreased meal intake and was at 54%; Recommendations: change to weekly weights.Review Date: 2/18/26 indicated Resident 12 with poor po intake meal intake at 27% .Weight change: -7.4 lbs. x 1 month. Recommendations indicated to change to weekly weights, implement four-ounce health shake twice a day and MD (Doctor of Medicine) to follow up with RP (responsible party) regarding weight loss. Review Date: 2/25/26 indicated Resident 12 with poor po intake meal intake at 25%. Started on Mirtazapine (medication to treat major depressive disorder with a common side effect of weight gain). Weight: -12.2 lbs. x 9 weeks. Recommendations: continue weekly weights, snacks and health shake twice a day. Review Date: 3/4/26 indicated poor po intake decline in condition, meal intake 33% Weight change: -13.6 lbs. x 9 weeks, started Mirtazapine on 2/21/26 and monitoring weekly weights. During an interview with the Registered Dietitian (RD), in the kitchen, on 4/22/26 at 3:02 p.m., the RD stated she works full time at the facility. The RD stated she will see residents for weight variance that trigger five pounds in one week and one month, 5% in one month, 7.5% in three months and 10% in six months. During a concurrent interview and clinical record review on 4/23/26 at 10:33 a.m. with the RD, Resident 12's weights (11/19/25 to 3/18/26), and Clinical Interdisciplinary (IDT) Assessments (1/21/26 to 3/18/26), Nutrition notes and physician orders were reviewed. The weights indicated, 3/18/26 135.2 lbs,3/11/26 137.4 lbs., 3/4/26 135.2 bs, 2/25/26 136.6 lbs., 2/18/26 134.8 lbs.,1/21/2026 142.2 lbs.,12/17/25 148.8 lbs.,12/17/25 148.8 lbs., and 11/19/25 155.8 lbs. The RD indicated Resident 12's had been losing weight and had a significant weight loss which triggered in 12/2025. The RD acknowledged that it should have triggered her to see the resident in December and that did not happen. The RD stated there was only a mini assessment in December and no interventions. The RD stated Resident 12's son and friends visit and brings variety of foods regularly but stopped in 11/2025. The RD stated Resident 12's oral intake continuously declined which resulted in significant weight losses on weekly and monthly weights. The RD stated physicians were always in agreement with RD recommendations and should be followed to address further weight changes. The RD stated Resident 12's monthly weight was changed to weekly weights as the only intervention when declined in oral intake and significant weight loss were identified on 1/22/26. The RD acknowledged Resident 12's weekly weights were not done at that time. The RD stated Resident 12's weekly weights should be completed to closely monitor her weight and implement necessary nutrition interventions and services to prevent further weight loss. The RD stated they do not have physician orders for weights at the facility. The RD stated nutritional interventions such as supplements (nutrition shake) and snacks consumption should be documented to accurately reflect the actual percentage of consumption to assess the effectiveness of the interventions. The RD stated the goal is to achieve Resident 12's usual desirable weight. During a concurrent interview and record review on 4/23/26 at 11:14 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 12's electronic medication administration record (EMAR- a daily digital documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 4/2026 was reviewed. The EMAR indicated, Health shake two times a day 4 oz BID (twice a day) between meals and snacks two times a day 10:00 a.m. and 1400 (2:00 p.m.) showing check marks with Licensed Nurses' initials. LVN 1 stated green check marks in Resident 12's EMAR for snacks and health shake indicated it was given and does not mean consumption. LVN 1 stated Resident 12's health shake and snack were given by the CNAs. During an interview on 4/23/26 at 11:29 a.m. with CNA 4, CNA 4 stated Resident 12 refused her health shake and snacks. CNA 4 stated she put some chocolate pudding to Resident 12's lips and used a straw for the health shake but Resident 12 was not participating and started to close her mouth. CNA 4 stated Resident 12 remained sleepy. During a concurrent interview and record review on 4/23/26 at 12:07 p.m. with Restorative Nurse Assistant (RNA) 1, Resident 12's weekly weights dated 1/28/26, 2/11/26, and 2/18/26 were reviewed. The weekly weights indicated, 1/28/26 Resident 12 refused two times. On 2/11/26, and 2/18/26 Resident 12's name was not written. RNA 1 stated Resident 12 refused weight on 1/28/26 and was not listed for weekly weights in the succeeding weeks of 2/11/26 and 2/18/26. RNA 1 stated Resident 12's one time refusal of weight does not mean taking her off the weekly weights. RNA 1 stated Resident 12's weekly weights were not done and should be completed. RNA 1 should continue weighing Resident 12 weekly until a notification from the RD to discontinue her weekly weights. RNA stated they were responsible in weighing residents on admission for 3 days (to establish the baseline), weekly weights and monthly weights. RNA 1 stated the RD gave them a list of residents of needing weights and RNAs handwritten residents' names in their weekly weights paper form. During an observation on 4/24/26 at 8:34 a.m. with Resident 12, in Resident 12's room, Resident 12 was awake shouting with LVN 1 and CNA 4. During an interview on 4/24/2026 at 8:36 a.m. with CNA 4, CNA 4 stated Resident12 refused her breakfast and pushed away her breakfast tray. During a concurrent interview and record review on 4/24/26 at 8:50 a.m. with the Assistant Director of Nursing (ADON), Resident 12's EMAR dated 4/23/26 was reviewed. The EMAR indicated, Health shake two times a day 4 oz BID (twice a day) between meals two times a day -10:00 a.m. and 1400 (2:00 p.m.) showing check mark with LVN 1's initial. The ADON stated Resident 12's EMAR with a check mark for health shake indicating heath shake was given and consumed by Resident 12. The ADON stated if Resident 12 refused the health shake on 4/23/26, LVN 1 should document refused. The ADON acknowledged Resident 12's EMAR for health shake and snacks does not indicate percentage of consumption. The ADON stated Licensed Nurses and CNAs should document percentage of consumption to determine if the nutritional interventions were effective. The ADON stated RD recommendations such as weekly weights should be followed and completed to determine a weight change (gain or loss) to implement appropriate additional interventions.During a concurrent interview and record review on 4/24/26 at 9:15 a.m. with the ADON, Resident 12's amount eaten from the last 30 days (3/26/26 -4/23/26), indicated, there were 21 meals of 0-25% and 24 meals of refusals. Resident 12 refused or ate 25% or less 45 out of 87 meals (50% of the month). The ADON stated Resident 12 had a poor oral intake and should be closely monitored for further weight loss and decline in health.During an interview on 4/24/26 at 10:50 a.m. with the Director of Nursing (DON), the DON stated significant weight changes including loss and gain applies to 5% in 1 month, 7.5% in three months, and 10% in six months. The DON stated the facility also addresses a five pounds weight loss in a week and in a month. The DON stated RD recommendations include weekly weights and nutritional supplements should be followed and implemented. The DON stated RNAs were responsible in doing weekly weights for the residents. The DON stated Resident 12's weekly weights should be implemented and completed to monitor Resident 12's weights to identify and evaluate the root cause of weight losses and prevent a delay in the implementation of new interventions. The DON acknowledged nutritional supplements and snacks consumption should be documented to validate effectiveness of nutritional interventions. During a review of facility's policy and procedures (P&P) titled, Nutrition Status Management, dated 8/2025, the P&P indicated, It is the policy of this facility to assess each resident's nutritional status and needs, including medications and medical conditions to ensure that all residents maintain acceptable parameters of nutritional status, such as body weight ad other available data, unless the resident's clinical condition demonstrates that this is not possible. 3. Clinical Evaluation: a. Nutritional assessment may include: Weighing and weight changes: Oral intake of foods and fluid. b. Any resident weight that varies from the previous reporting period by more than 5% in 30 days, 7.5% in 90 days and 10% in 180 days will be evaluated by the Interdisciplinary Team (IDT) to determine the cause of weight loss/gain and intervention required. d. Any resident meeting the criteria for weight loss and any resident at risk will be weighed weekly with the weight entered into POC/PCC. Weekly weights will be reviewed by the Registered Dietician (RD)/designee.During a review of facility's policy and procedures (P&P) titled, Weight Management, dated 8/2025, the P&P indicated, Residents identified to be at risk for weight variance, will have routine assessment and care plan interventions implemented in accordance with Advance Directives. The objective of this process is to assess, and manage weight variances, to determine appropriate referrals and/or interventions to achieve the best possible clinical outcomes. 6. Weekly weight monitoring may be appropriate for: Significant unplanned weight loss/gain: Clinical conditions which may require more frequent monitoring.

Based on observation, interview, and record review, the facility failed to ensure one of seven sampled Residents (Resident 12) was assessed for the risk of entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail) from bed (side) rails (adjustable metal or rigid plastic bars in various sizes that attach to the bed, and can be placed in a guard (raised) or lowered) prior to installation and had a consent form (form signed by resident or family explaining the risks of side rail use), physician order, indication for use, and care plans prior to the use of side rails when, Resident 12 had bed rails on the right and left side of her bed in the guard position (a position that is intended to prevent an individual from inadvertently rolling out of bed).These failures had the potential to cause entrapment, serious harm, injury, or death to Resident 12.Findings:During an observation on 4/21/2026 at 7:02 a.m. in Resident 12's room, Resident 12 was observed asleep in bed, wearing a gown with side rails up on the left and right side of the bed and a fall mat on the right side of Resident 12's bed.During a review of Resident 12's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 4/23/26, the AR indicated Resident 12 was admitted to the facility from an acute care hospital on [DATE] with diagnoses of cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), schizophrenia (a mental illness that affects a person's ability to think, feel, and behave clearly), depression (persistent feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life), and history of falling.During a review of Resident 12's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 3/18/26, the MDS section C indicated Resident 12 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of three (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 12 was severely cognitively impaired.During a review of Resident 12's MDS, dated 3/16/26, the MDS section GG (Functional Abilities) indicated Resident 12 had, .impairment on one side.upper extremity [shoulder, elbow, wrist, hand].used in the last 7 days.wheelchair.Dependent [helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity].chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair [or wheelchair].During an interview on 4/22/26 at 4:10 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 12 had her side rails up because she tried to get out of bed and had fallen in the past. During a concurrent interview and record review on 4/22/26 at 4:15 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 12's electronic medical record (EMR), undated was reviewed. LVN 1 stated she was unable to find a consent or physician order for Resident 12's use of side rails.During a concurrent observation and interview on 4/22/26 at 4:28 p.m. with the Assistant Director of Nursing (ADON), in Resident 12's room, Resident 12 was observed sleeping in her bed with the right and left side rails of her bed in the guard position. The ADON stated it was important to have a consent for the use of side rails, as the rails were a form of restraint. The ADON was unable to provide a consent for Resident 12's use of side rails.During an interview on 4/23/2026 at 10:27 a.m. with LVN 1, LVN 1 stated Resident 12 should have a consent form and physician orders for the use of side rails. LVN 1 stated side rails were considered a restraint. LVN 1 stated prior to installing the side rails, staff should have checked on Resident 12 more often, and the physician should have been notified to receive an order for the side rails. LVN 1 stated side rails could have caused an injury to Resident 12, if she tried to climb over the rails to get out of bed or she could have become stuck between the rails.During a concurrent observation and interview on 4/23/2026 at 1:04 p.m. with the Maintenance Supervisor (MNT) in Resident 12's room, the MNT stated before installing any bed rails, he needed a physician's order and then completed a bed assessment. The MNT stated a bed assessment consisted of measuring from the bed headboard to the end of the mattress, and from the headboard to the end of the rail. The MNT observed Resident 12's side rails in guard position. The MNT stated Resident 12 should have had grab bars that were secured to the bed. The MNT stated he was not sure why Resident 12's grab bars were not secured to the bed and were on the floor, and why she had side rails up. The MNT stated he needed to check if Resident 12 had a bed assessment for the use of side rails. During an interview on 4/23/2026 at 1:34 p.m. with the MNT, the MNT stated Resident 12 did not have a physician's order or bed assessment for the use of side rails. The MNT stated he did not know why Resident 12 had her side rails up. During an interview on 4/24/2026 at 10:32 a.m. with the Director of Nursing (DON), the DON stated Resident 12 should not have her side rails up on her bed. The DON stated Resident 12 needed a consent and bed assessment before the side rails were applied on her bed. The DON stated the facility was a non-restraint facility and side rails were considered a restrictive device. The DON stated residents could become entrapped or hang themselves on the side rails. The DON stated there needed to be a physician's order for the use of side rails and the resident needed to be assessed prior to the use of side rails to be sure the rails were needed. The DON stated interventions that needed to be completed prior to the use of side rails were to put Resident 12's bed in the lowest position, place a fall mat on the floor next to Resident 12's bed, place Resident 12 close to the nurses' station, and have Resident 12 attend activities in the morning and afternoon so staff could watch her. The DON stated if Resident 12 continued trying to get out of bed unassisted, staff needed to meet as a team to see what other interventions could have been put in place. The DON stated if a resident had bed rails, the resident needed a care plan to monitor the resident and make sure the device was safe and not loose.During a review of the facility's policy and procedure (P&P) titled, Bed Rails, dated 8/2025, the P&P indicated, .it is the policy of this facility to attempt to use appropriate alternatives prior to installing a side or bed rail .after the facility has attempted alternatives to bed rails and determined that these alternatives failed to meet the resident's assessed needs, the facility interdisciplinary team [IDT] will assess the resident for risks of entrapment.if the use of bed rails is recommended by the IDT, the facility must obtain informed consent from the resident, or if applicable, the resident representative for the use of bed rails prior to installation or use.During a review of the facility's P&P titled, Restraint Devices, Physical, dated 2006, the P&P indicated, .purpose.to prevent the resident from injuring himself or others.restraints of any type will not be used as punishment or as a substitute for more effective medical and nursing care or for the convenience of the facility staff.physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.assess resident's need for restraint device use.obtain informed consent for restraint device use.obtain physician's order for restraint device.list necessary monitoring and observation of the condition that necessitates restraint use.list alternate methods used.list plan to reduce and eliminate restraint use.list observation for risks and complications.

Based on observation, interview and record review, the facility failed to ensure residents were free of significant medication errors, when one resident (Resident 34) was administered expired latanoprost ophthalmic solution (a medication for glaucoma-eye diseases that damage the optic nerve, often due to high fluid pressure inside the eye, leading to irreversible vision loss or blindness) for over one month.This failure put Resident 34 at risk for infection due to bacteria or fungi growth from the expired medication and at risk of uncontrolled glaucoma, leading to permanent vision loss over time.Findings:During a concurrent observation, interview and record review on [DATE] at 1:14 p.m. in nursing station 4b with Charge Nurse (CRN) 1, latanoprost 2.5 ml (milliliters- metric unit used to measure the volume of a liquid) ophthalmic solution partially used and almost empty bottle with open date [DATE] and beyond use date [DATE] was in the medication cart available for use for Resident 34. CRN 1 stated discontinued medications should be removed from cart, so they are not accidentally administered. CRN 1 stated Resident 34 was using the medication at bedtime. CRN 1 stated there was no other latanoprost ophthalmic solution available in the medication cart to administer to Resident 34. The Medication Administration Record (MAR) for Resident 34 was reviewed. CRN 1 stated the medication was administered to Resident 34 from [DATE]- [DATE] and from [DATE]- [DATE]. CRN 1 stated expired medication was administered to Resident 34. CRN 1 stated it could cause adverse reactions, and the medication would not work like it should.During a review of Resident 34's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated [DATE], the AR indicated Resident 34 was admitted to the facility on [DATE] which included type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), low tension glaucoma.During a review of Resident 34's Order Summary Report (OSR), dated [DATE], the OSR indicated, Resident 34 had an active order for .Latanoprost ophthalmic solution .Instill 1 drop in both eyes at bedtime for Glaucoma During an interview on [DATE] at 3:40 p.m. with the Director of Nursing (DON), the DON stated latanoprost is for glaucoma, a disease that could cause blindness. The DON stated if the medication was given beyond use date (shorten expiration date specified by manufacturer after opening of the product), then the medication was not potent. The DON stated that administering expired eye drops was also an infection control issue.During an interview on [DATE] at 10:32 a.m. with the Consultant Pharmacist (CRPH), the CRPH stated the expectation was nursing staff should dispose of the latanoprost ophthalmic solution 6 week after opening. The CPRH stated it could be stability or infection control issue.During a professional reference review retrieved from National Library of Medicine/National Institute of Health- Daily Med found at https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=2c87e99e-33d4-4060-8876-ff05557c05eb, titled, LATANOPROST OPHTHALMIC SOLUTION solution/ drops, no dated, the professional reference review indicated .Storage: . Once a bottle is opened for use, it may be stored at room temperature up to 25 C (77 F) for 6 weeks.During a review of the facility's policy and procedure (P&P) titled, Medication Storage, dated [DATE], the P&P indicated, . 8 Unused medications: The pharmacy on all medication rooms are routinely inspected by the consultant pharmacy for discontinued, outdated, defective, or deteriorated medications with worn, eligible, or missing labels. These medications are destroyed in accordance with our destruction of unused drugs policy.During a review of the facility's P&P titled, Medication Administration, no date, the P&P indicated, . Policy: medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.13. Identify expiration date. If expired, notify nurse manager. 14. Remove medication from source, taking care not to touch medication with bare hand.

Based on observation, interviews, and record review, the facility failed to ensure residents' food was prepared and processed appropriately to meet residents' needs for two of three sampled residents (Resident 86 and Resident 73) when large pieces of broccoli were not in proper form of minced and moist on their lunch meal tray on 4/23/26.This failure to properly process the minced and moist food can result in choking (when the airway is obstructed by food, drink, or foreign objects) for Residents 86 and 73 on a minced and moist diet at the facility. During a review of the lunch menu for 4/23/26 indicated, for the MM5 (minced and moist level 5 diet) the following: Japanese Vegetable Blend. soft mashed broccoli, sweet and sour pork SBMM (soft and bite and minced and moist), rice, puree bread.During an observation of the lunch meal service on 4/23/26 at 12:39 p.m. in the kitchen, Resident 86's lunch plate contained minced sweet and sour pork, rice, puree bread and large pieces of broccoli. The Registered Dietitian Consultant (RDC) was watching the lunch meal preparation. During a review of Resident 86's lunch meal ticket during the lunch meal service on 4/23/26, Resident 86's lunch meal ticket showed a handwritten diet order of minced and moist.During a concurrent observation and interview on 4/23/26 at 12:39 p.m. with Dietary [NAME] (DC) 2, DC 2 was looking at Resident 86's lunch meal plate containing minced sweet and sour pork, rice, puree bread and large pieces of broccoli. DC 2 stated the broccoli needed to be soft and the size was okay. The lunch meal tray continued down the tray line and placed into the meal cart.During a concurrent observation and interview on 4/23/26 at 12:40 p.m. with the RDC and the Dietary Manager (DM), in the kitchen, the RDC informed the DM, and the DM took out Resident 86's lunch meal tray from the meal cart. The DM started mashing the broccoli with the use of fork. The DM stated the broccoli needed to be soft and able to be mashed with a fork. The RDC stated the pieces of broccoli needed to be smaller. During an interview on 4/23/26 at 12:42 p.m. with the RDC, the RDC stated the dietary cooks were looking at incorrect recipe and they should have it to be at 4mm (Millimeters -used to measure food ingredient thickness, precise cuts, or small items) by 15 mm for minced and moist diet.During an interview on 4/23/26 at 12:43 p.m. with the DM, the DM stated Resident 73's lunch meal tray for small dining room was prepared at the beginning of meal service. The DM stated Resident 73 was on moist and minced diet and received the improper form of vegetable (broccoli). During a review of Resident 73's lunch meal ticket on 4/23/26, Resident 73's lunch meal ticket indicated, Diet Order: Minced and Moist Level 5.During a review of Resident 73's Face Sheet (FS - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 4/23/26, the FS indicated Resident 73 was admitted to the facility on [DATE] with diagnosis of dysphagia (difficulty swallowing).During a review of Resident 86's FS, dated 4/23/26, the FS indicated Resident 86 was admitted to the facility on [DATE] with diagnosis of hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), and acute respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a waste gas] from the blood).During an interview on 4/22/26 at 3:55 p.m. with the Registered Dietitian (RD), the RD stated it was her expectation for the dietary cooks to follow menus and recipes for right consistency and products. The RD stated dietary staff received training for International Dysphagia Diet Standardization Initiative (IDDSI) which was implemented in 1/2026. The RD stated she would expect dietary staff to test for consistency for the IDDSI diets. During an interview on 4/23/26 at 1:26 p.m. with the RDC and RD, the RDC and RD stated they were reaching out to their food distributor and vendor to seek clarification about recipes and menus for their dietary staff to easily understand and follow. The RDC and RD stated that the facility's recipes and menus were confusing for the dietary staff to follow in ensuring the proper food consistency was being provided for the residents. During a review of the facility's recipe titled, Soft Mashable Broccoli FL OR FZN, dated 4/23/26, the recipe indicated, .For the IDDSI Minced and Moist/Level 5 diet, all food pieces must be less than 4mm x 15mm in size.During a review of facility's dietary manual titled, IDDSI Food Level 5 Minced and Moist (Orange), undated, indicated, IDDSI Food Level 5/ Minced and Moist/Orange (MM5) diet is based on the Nutrition Care Manual's (NCM) Minced and Moist Food, Level 5 (Orange) diet and International Dysphagia Diet Standardization Initiative. Requires minimal chewing ability and consists of foods that are easy to swallow because they are minced, very soft, and moist and can be scooped and shaped. Foods pieces should be no larger than 4mm width by 15mm length for adults with no separate thin liquids present. Minced pieces of food should fit in between the tines of a fork.testing must be conducted at the community level to ensure all foods meet texture and size requirements as per the IDDSI testing methods.Vegetables - must be under 4 mm in size, non-stringy and non-fibrous, cooked until soft and easily mashable with a fork, spoon, or fingers, and drained of excess liquid.During a review of the facility's policy and procedures (P&P) titled, Food Preparation, dated 2023, the P&P indicated, .The facility will use approved recipes.

Based on observation, interview and record review, the facility failed to ensure resident's food preference was provided for one of 20 sampled residents (Resident 26) when Resident 26's lunch tray did not include double protein (one of the many substances found in food such as meat, cheese, fish, or eggs, that is necessary for the body to grow and be strong) on 4/21/26.This failure had the potential for Resident 26 not to receive her food preference which can result in undernutrition that could compromise her medical and nutritional status.During a review of the lunch menu for 4/21/26 indicated, for the house (regular diet) the following: .Baked Honey Glazed Ham 4.4 oz (ounces- a standard unit of weight), Baked Sweet Potato1 each, French Style [NAME] Beans 1/2 (half) cup.During a review of Resident 26's lunch meal ticket during the lunch meal service, Resident 26's lunch meal ticket showed two servings of protein under the standing order. During a concurrent observation of the lunch meal service and interview on 4/21/26 at 12:13 p.m. with Dietary Aide (DA) 1, DA 1 checked Resident 26's meal ticket according to the food provided in Resident 26's lunch tray. DA 1 put Resident 26's lunch tray into a food cart and validated that there was only one slice of ham in Resident 26's lunch tray. DA 1 confirmed that Resident 26's needed two slices of ham. DA 1 asked Dietary [NAME] (DC) 1 to provide another slice of ham. During a concurrent interview and record review on 4/21/26 at 12:14 p.m. with DA 1, Resident 26's lunch meal ticket was reviewed. The lunch meal ticket indicated, .Standing orders: Entree/Protein (2X) . DA 1 stated Resident 26 should be provided with double protein, and her lunch plate should include two slices of ham.During a concurrent interview and record review on 4/22/26 at 3:55 p.m. with the Registered Dietitian (RD), Resident 26's lunch meal ticket dated 4/21/26 was reviewed. The lunch meal ticket indicated, Diet Order: Regular.Standing orders: Entree/Protein (2X) . The RD stated the standing order was Resident 26's food preferences and not a physician's order. The RD stated Resident 26's food preference of double protein should be provided, and she should have two slices of ham in her lunch tray yesterday (4/21/26). During a review of Resident 26's Face Sheet (FS - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 4/22/26, the FS indicated Resident 26 was admitted to the facility on [DATE] with primary diagnosis of pneumonia (an infection that affects one or both lungs, causing the air sacs of the lungs to fill with fluid), type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), and protein calorie malnutrition (PCM- when a person doesn't eat enough proteins and calories to meet nutritional needs).

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared and served in accordance with professional standards for food safety when:1. Gloves were not changed by Dietary [NAME] (DC) 2 after handling non-food items (a box made of cardboard) while making sandwiches for the residents' lunch meal on 4/22/26.This failure had placed residents at an increased risk of acquiring food-borne illnesses (an illness that comes from eating contaminated food [refers to food or beverages containing harmful microorganisms (bacteria, viruses, parasites), toxins, or foreign physical/chemical substances that make them unsafe for human consumption]).2. Incorrect thermometer usage in residents' freezer. Residents' freezer contained an oven thermometer (used to measure high heat to ensure accurate baking and identify hot spots).This failure had the potential for not obtaining and maintaining accurate temperatures for cold foods which could lead to the growth of microorganisms (bacteria) and placed residents at an increased risk of acquiring food-borne illnesses.3. Unlabeled frozen food was stored in residents' freezer.This failure had the potential to be served and consumed by other residents which could have a negative effect such as allergic reactions, aspiration (when food or liquid enters the lungs) and choking (when the airway is obstructed by food, drink, or foreign objects).1.During an observation on 4/22/26 at 10:25 a.m. with Dietary [NAME] (DC) 2, in the kitchen, DC 2 was preparing a turkey sandwich on top of the preparation table using gloves. DC 2 was placing five slices of turkey breast meat in each bread. DC 2 opened a cardboard box containing bags of bread, opened two plastic bags of bread and placed each bread on the preparation table. DC 2 touched all the bread on the preparation table with the same gloves. DC 2 did not change her gloves after opening the cardboard box of bread and continued to make a turkey sandwich using the same gloves.During an interview on 4/22/26 at 3:02 p.m. with the Registered Dietitian (RD), the RD stated it was her expectation to change gloves when touching anything else or visibly dirty. The RD stated gloves should be changed after opening a cardboard box and perform handwashing before continuing making a sandwich to prevent cross-contamination (when germs or allergens transfer from one substance to another).During an interview on 4/24/26 at 9:45 a.m. with the Infection Preventionist (IP), the IP stated he provided infection control training for all dietary staff for infection control. The IP stated dietary staff received training for handwashing and proper use of gloves. The IP it was his expectation to follow facility's policy and procedures (P&P) for handwashing and glove use to prevent cross-contamination and infection (the invasion and growth of germs in the body). The IP stated gloves should be changed after handling or touching non-food items and perform handwashing to prevent cross-contamination and potential risk of foodborne illnesses.During a review of facility's P&P titled, Glove Use Policy, dated 2023, the P&P indicated, The appropriate use of gloves is essential in preventing food borne illness. Gloved hands are considered a food contact surface that can get contaminated or soiled. Disposable gloves are a single use item and should be discarded after each use, and especially before handling clean food items. WHEN GLOVES NEED TO BE CHANGED. 2. Before beginning a different task. 2. During a concurrent observation and interview on 4/22/26 at 2:14 p.m. with the Activity Director (AD), in the activity room, the AD opened the residents' refrigerator with top mounted freezer. The top freezer of resident's refrigerator contained an oven thermometer. The AD stated she was responsible for monitoring the temperature of the residents' refrigerator. The AD stated she was unaware that an oven thermometer was used to check the temperature of the freezer. During a concurrent observation and interview on 4/22/26 at 2:15 p.m. with the Registered Dietitian Consultant (RDC), in the activity room, the RDC was checking the thermometer found at residents' freezer and validated it was an oven thermometer. The RDC stated the Registered Dietitian (RD) will provide a correct thermometer for the residents' freezer. The RDC stated it was important that correct thermometer for the freezer should be used to ensure frozen food remained frozen and maintained an accurate cold temperature. During an interview on 4/22/26 at 3:55 p.m. with the RD, the RD stated that oven thermometer was not the correct thermometer for the freezer and should not be used to monitor the temperature of the freezer. The RD stated a freezer thermometer should be used in monitoring the temperature of the freezer to ensure temperature accuracy. During a review of facility's P&P titled, PROCEDURE FOR FREEZER STORAGE, dated 2023, the P&P indicated, 1. The freezer should be maintained at a temperature of 0 or lower. 2. Each freezer must have at least one thermometer that is easily visible.During a professional reference review, retrieved from http://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basics/appliance-thermometers titled, Appliance Thermometers, the professional reference indicated, One of the critical factors in controlling bacteria in food is controlling temperature. Pathogenic microorganisms grow very slowly at temperatures below 40 F, multiply rapidly between 40 and 140 F, and are destroyed at temperatures above 140 F. For safety, food must be held at proper cold temperatures in refrigerators or freezers and they must be cooked thoroughly Using Appliance Thermometers -Refrigerator/freezer thermometers are specially designed to provide accuracy at cold temperatures. Oven Thermometers -An oven thermometer can be left in the oven to verify that the oven is heating to the desired temperatures.3. During a concurrent observation and interview on 4/22/26 at 2:14 p.m. with the Activity Director (AD), in the activity room, the AD opened the residents' refrigerator with top mounted freezer. The top freezer of resident's refrigerator contained frozen food without a label. The AD stated she was responsible in labeling food items stored in residents' refrigerator and freezer. The AD stated all food items stored in residents' refrigerator should be labeled.During an interview on 4/22/26 at 3:55 p.m. with the RD, the RD stated all food stored in residents' refrigerator should be labeled. During a review of facility's P&P titled, Foods Brought by a Family or Visitor, dated 7/21/21, the P&P indicated, .Resident food shall be stored in the facility in the following locations: Resident refrigerator.All foods shall be labeled accordingly.During a review of facility's P&P titled, PROCEDURE FOR FREEZER STORAGE, dated 2023, the P&P indicated, .6. All frozen food should be labeled and dated.

Based on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program to help prevent the development and transmission of infections for two of seven sampled residents (Resident 18, and Resident 43) when:1. Resident 18 was placed on Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of resistant organisms [bacteria that have become resistant to certain antibiotics] that requires gown and glove use during high contact resident care activities) and Certified Nursing Assistant (CNA) 2 and CNA 3 did not put on the appropriate personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) prior to providing high contact care to Resident 18.2. Resident 43's nasal cannula (NC-a flexible tube with two prongs that fit inside the nostrils), and oxygen tubing (flexible tube connected to an oxygen source) were found wrapped around Resident 18's oxygen concentrator (a device that produces 90 percent to 95 percent oxygen from room air).3. Resident 43's foley catheter drainage tubing (a tube that is inserted into the urinary bladder to collect urine into a bag) was touching the floor and contained a white sediment (solid particles found in urine) inside the tubing and urine.These failures placed Resident 18 and Resident 43 at risk for cross-contamination (the process when germs are unintentionally transferred from one substance or object to another, which causes a harmful effect), infection (an invasion of the body by germs that cause disease) and illness.Findings:During a concurrent observation and interview on 4/21/2026 at 7:28 a.m. with CNA 2 and CNA 3 in Resident 18's room, a sign was observed outside Resident 18's door, which indicated EBP were in place for residents in the room, and a brown sticker was next to Resident 18's name, which indicated Resident 18 was on EBP. Resident 18 was observed in bed, with her curtain drawn and CNA 2 and CNA 3 observed dressing Resident 18 and transferring her to a wheelchair. CNA 2 and CNA 3 were not wearing gowns and CNA 2 did not wear gloves. CNA 3 donned gloves and removed Resident 18's bed linens. CNA 3 stated today was his second day orienting with CNA 2 and he needed to wear a gown and gloves when providing care for residents on EBP. CNA 2 stated the brown sticker by a resident's name meant the resident was on EBP. CNA 2 stated she and CNA 3 should have worn appropriate PPE, a gown and gloves, before dressing Resident 18, transferring her to a wheelchair, and changing her bed linens. CNA 2 stated if staff did not wear the appropriate PPE, there was a risk of getting germs on the resident, on herself and transferring germs to other residents. CNA 2 and CNA 3 continued providing care to Resident 18, including putting Resident 18's shoes on without donning appropriate PPE.During a review of Resident 18's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 4/23/26, the AR indicated Resident 18 was admitted to the facility from an acute care hospital on 1/12/26 with diagnoses of subdural hemorrhage (bleeding in the area between the brain and the skull), multiple fractures of the pelvis (a break of the ring of bones that connect your spine to the hips), type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).During a review of Resident 18's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 4/13/26, the MDS section C indicated Resident 18 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of three (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 18 was severely cognitively impaired.During a concurrent interview and record review on 4/23/2026 at 10:07 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 18's Electronic Medical Record (EMR), undated was reviewed. LVN 1 stated a brown sticker indicated which resident in the room was on EBP. LVN 1 was unable to state why Resident 18 was on EBP. LVN 1 stated the Infection Preventionist (IP) placed residents on EBP precautions and informed and educated the staff why residents were on EBP and what PPE were needed to care for the residents. LVN 1 stated it was important for staff to know why a resident was on EBP and to wear appropriate PPE for patient safety and to prevent spreading of infections.During a concurrent interview and record review on 4/23/2026 at 10:47 a.m. with the IP, Resident 18's Care Plan (CP), undated was reviewed. The CP indicated, .the resident is on enhanced barrier precautions [EBP] related to [r/t] surgical incisions to left hip.date initiated: 1/30/26.the resident will remain free from infection related to open wounds through the review date.direct care staff to utilize gowns and gloves for all personal care.date initiated: 1/30/26. The IP stated Resident 18 was on EBP for surgery incisions to the left hip initiated on admission and discontinued today, 4/23/26. The IP stated he made the determination if a resident was to be put on EBP, and when a resident came off EBP. The IP stated he put an EBP sign on the resident's door and a brown sticker next to the resident's name if they were on EBP, and staff were educated and informed of what type of precautions and PPE were needed when caring for the resident. The IP stated staff should have used PPE during high contact care activities such as dressing and transferring Resident 18. The IP stated staff should have adhered to EBP practices and worn appropriate PPE if a resident had a dot by their name to prevent the transfer of germs and prevent Resident 18 from getting infections.During a review on 4/24/2026 at 10:27 a.m. with the Director of Nursing (DON), the DON stated EBP practices were put in place to protect the residents from getting infections. The DON stated every staff member needed to wear a gown and gloves during high contact with a resident on EBP.During a review of the facility's policy and procedure (P&P) titled, IPCP Standard and Transmission-Based Precautions, dated 1/2024, the P&P indicated, .it is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions.Enhanced Barrier Protection [EBP]: expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of Multidrug Resistant Organisms [MDRO - bacteria that have become resistant to multiple types of antibiotics making them more difficult to treat, can spread rapidly, and threaten patient safety] to staff hands and clothing then indirectly transferred to residents or from resident-to-resident.examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include.dressing.transferring.providing hygiene.changing linens.the facility will implement a system to alert staff, residents and visitors that a resident is on transmission Based Precautions [TBP-used when standard precautions alone are not sufficient to prevent the spread of an infectious agent].post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE.for Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. 2. During an observation on 4/21/2026 at 7:22 a.m. in Resident 43's room, Resident 43 was observed wearing a gown and an oxygen nasal cannula, asleep in her bed. Oxygen flow rate was set at 3 liters per minute (L/min-a unit of measurement).During a review of Resident 43's AR, dated 4/24/26, the AR indicated Resident 43 was admitted to the facility from an acute care hospital on [DATE] with diagnoses of Encephalopathy (damage or disease that affects the brain), spinal stenosis (a narrowing of the spine that causes pressure on the spinal cord and nerves and can cause pain) of the neck and lower back regions, atrial fibrillation (an irregular heartbeat), stiffness of the right hand, and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities).During a review of Resident 43's MDS, dated 3/12/26, the MDS section C indicated Resident 43 had a BIMS score of 14, which indicated Resident 43 was cognitively intact.During a review of Resident 43's Order Review List (ORL), undated, the ORL indicated, .oxygen at 3 Liters per minute [LPM] via NC as needed [PRN].change oxygen tubing and oxygen storage bag monthly.During a concurrent observation and interview on 4/21/2026 at 1:11 p.m. in Resident 43's room, Resident 43 was observed in bed, feeding herself her meal. Resident 43 was not wearing her oxygen NC. Resident 43's oxygen tubing and NC were observed sitting on top of her oxygen concentrator machine, with the machine turned on. Resident 43 stated she was feeling okay.During an interview on 4/22/26 at 4:06 p.m. with CNA 1, CNA 1 stated the CNAs will tell the nurse if a resident was not wearing their oxygen nasal cannula and the nurse put it in a bag. CNA 1 stated the CNAs moved the tubing, if needed, but the nurse put it away in a bag. During an interview on 4/23/2026 at 10:19 a.m. with LVN 1, LVN 1 stated when a resident was not using their oxygen tubing, the nurse put the oxygen tubing in the bag, not the CNA. LVN 1 stated Resident 43's oxygen tubing should have been put in a bag when not in use for Resident 43's safety and to prevent infection of Resident 43.During an interview on 4/23/2026 at 11 a.m. with the IP, the IP stated Resident 43's oxygen tubing should have been stored in a bag when not in use for infection control. The IP stated storing the tubing in a bag prevented Resident 43 from getting an infection. The IP stated it was not his expectation for staff to place Resident 43's nasal cannula and tubing on the oxygen concentrator machine and in a bag when not in use.During an interview on 4/24/2026 at 10:27 a.m. with the DON, the DON stated her expectation was for the oxygen tubing and nasal cannula to be stored in a clean, dated bag when not in use. The DON stated storing the tubing and nasal cannula in a clean bag was to prevent the tubing and nasal cannula from collecting dust and germs and to prevent infection to the resident.During a review of the facility's P&P titled, Oxygen Administration, dated 2025, the P&P indicated, .oxygen is administered to residents who need it, consistent with professional standards of practice.change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.keep delivery devices covered in plastic bag when not in use.3. During a concurrent observation and interview on 4/21/2026 at 1:11 p.m. with Resident 43, in Resident 43's room, Resident 43 was observed dressed, and sitting up in bed. Resident 43 stated she was doing okay, with no complaints. Observed Resident 43's urinary catheter touching the floor with white sediment observed in the urine inside the catheter tubing.During an interview on 4/22/26 at 4:06 p.m. with CNA 1, CNA 1 stated the CNAs drained resident urinary bags at the end of the shift or if the urine in the bag was overflowing. CNA 1 stated if the resident's urine was dark or with sediment, the CNA notified the nurse. CNA 1 stated resident's catheter tubing should not touch the floor but should have been put in the dignity bag (a cover that conceals urinary drainage bags from public view to protect a resident's dignity) with the drainage bag. CNA 1 stated it was important for the drainage tubing to not touch the floor because residents could get infection if germs went into the tubing. CNA 1 stated resident's urine tubing and urine bag should be checked throughout the day and during resident care to make sure no interventions were needed.During an interview on 4/23/2026 at 10:23 a.m. with LVN 1, LVN 1 stated residents with catheters had orders to flush the tubing if there was sediment present, then verify if the new urine came out clear. LVN 1 stated if the urine was not clear and continued to have sediment, the nurse notified the physician for a urinalysis (u/a - a test of the urine, often to check for a urinary tract infection, kidney problems, or diabetes) order. LVN 1 stated the CNA should have reported Resident 43's sediment in her urine tubing to the nurse. LVN 1 stated resident's catheter tubing should not touch the floor to prevent germs from getting into the catheter and prevent infection to the resident. LVN 1 stated both CNAs and nurses checked the resident's catheter tubing. LVN 1 stated she was not notified Resident 43 had sediment in her urine catheter tubing. LVN 1 stated Resident 43 has had urinary tract infections.During an interview on 4/23/2026 at 11:00 a.m. with the IP, the IP stated Resident 43's catheter tubing should not have been on the ground. The IP stated it was an infection control issue, and the tubing should have been put in Resident 43's dignity bag to prevent the resident from getting an infection. The IP stated there should not be sediment in the catheter tubing. The IP stated the catheter tubing should have been changed to prevent a risk of infection to Resident 43.During an interview on 4/24/2026 at 10:35 a.m. with the DON, the DON stated catheter tubing should be stored in the resident's dignity bag and should not have been on the floor. The DON stated keeping the catheter tubing in the resident's dignity bag was for infection control and to prevent a dignity issue by being visible to others. The DON stated the CNA should have notified the nurse if the catheter tubing was seen on the floor, or if there was sediment in the resident's catheter tubing so the nurse could act on the issues and prevent the resident from getting an infection.During a review of the facility's P&P titled, Indwelling Urinary Catheter Care, dated 4/2025, the P&P indicated, .it is the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and as needed [PRN] to promote hygiene, comfort, and decrease the risk of infection.During a review of the facility's P&P titled, Infection Prevention and Control Program, dated 8/2025, the P&P indicated, .the infection prevention and control program is a facility-wide effort involving all disciplines and individuals.goals.decrease the risk of infection to residents and personnel.identify and correct problems relating to infection control.appropriate use of personal protective equipment.infection control practices during the provision of resident care and treatments.appropriate use of transmission-based precautions.the facility personnel will conduct themselves and provide care in a way that minimizes the spread of infection.

Based on interview and record review, the facility failed to meet professional standards of quality and the standard of practice according to the facility's policy and procedure (P&P) titled, Charting and Documentation for five of five sampled residents (Resident 1, 2, 3, 4, and 5), when:Licensed Vocational Nurse (LVN) 1 did not document the wound (any physical injury that disrupts the anatomical structure and functional integrity of skin, mucous membranes, or other body tissues) care for Resident 1 on 12/27/25 during the day shift.LVN 2 did not document the wound care for Resident 2 on 12/4/25 during the night shift.LVN 2 did not document the wound care for Resident 3, 4, and 5 on 1/21/26 during the night shift.This failure had the potential to result in infection and delayed wound healing for Resident 1, 2, 3, 4, and 5.Findings:During a record review of Resident 1's admission Record (AR), dated 4/1/26, the AR indicated Resident 1 had a history of Metabolic Encephalopathy (a brain dysfunction caused by systemic illness, organ failure, or toxicities, rather than structural damage), Chronic Obstructive Pulmonary Disease (COPD-a chronic, progressive and typically irreversible inflammatory lung disease that causes obstructed airflow making it difficult to breathe), Chronic Venous Hypertension (a condition of sustained high blood pressure within the leg veins that allow blood to pool rather than flow back to the heart) with Ulcer (wound) and Inflammation (the body's natural immune response to injury, infection, or irritation designed to protect tissues and initiate healing characterized by redness, heat, swelling, pain, and loss of function) of the Left Lower Extremity (left leg), Prediabetes (blood sugar levels higher than normal but not high enough for a diagnosis representing a critical and reversible stage), Dependence on Respirator (a medical condition where a patient cannot sustain independent breathing and relies on a machine for life support), and Dependence on Supplemental Oxygen (a medical condition where a patient requires a device to deliver higher than atmospheric concentrations of oxygen to maintain adequate blood oxygen levels). During a record review of Resident 1's Order, dated 12/6/25, the Order indicated, Cleanse venous stasis [a medical condition characterized by the slow or sluggish flow of blood in the veins, usually in the lower extremities, causing blood to pool] to right lower leg with normal saline [a sterile mixture of 0.9 percent [%] sodium chloride in water], pat and dry, cover with abdominal pads [a type of gauze], wrap with kerlix [a type of dressing] and ace wrap [a type of dressing] every day shift. Start date: 12/6/25.During a record review Resident 1's Order, dated 12/22/25, the Order indicated, Cleanse the skin tear to right arm with normal saline, pat [and (&)] dry, apply [brand name antibiotic (abx)-a class of medications specifically designed to treat or prevent infections caused by bacteria] apply abdominal pad and cover it with kerlix and ace wrap every day shift. Start date: 12/22/25.During a record review Resident 1's Order, dated 12/22/25, the Order indicated, Cleanse the skin tear to left arm with normal saline, pat & dry, apply [brand name] abx apply abdominal pad and cover it with kerlix and ace wrap every day shift. Start date: 12/22/25.During a concurrent interview and record review on 4/1/26 at 10:41 a.m. with the Assistant Director of Nursing (ADON), Resident 1's Treatment Administration Record (TAR), dated 12/1/25 to 12/31/25 was reviewed. The TAR indicated on 12/27/25, for the day shift administration time, there were no licensed staff initials in the box for Resident 1's venous stasis to right lower leg wound, skin tear to the right arm wound and skin tear to the left arm wound to demonstrate the wound care was provided as ordered. The ADON stated LVN 1 was assigned to Resident 1 during the day shift and should have checked and initialed the box on 12/27/25 to indicate that the wound care was provided for the day shift as ordered and it was not. The ADON stated, If it wasn't documented, it wasn't done.During a review of Resident 2's AR, dated 4/1/26, the AR indicated Resident 2 had a history of Diabetes Mellitus Type 2 (a chronic metabolic disorder characterized by high blood sugar due to insulin resistance), and Cervical Disc Disorder at C5-C6 with Radiculopathy (a condition where a damaged, herniated, or degenerated intervertebral disc at the C5-C6 level causes compression or inflammation of the nerve root, leading to pain, numbness, or weakness radiating from the neck into the shoulder, arm, or hand) and Malignant Neoplasm of Skin (an abnormal growth of cells on the skin).During a concurrent interview and record review on 4/1/26 at 12:49 p.m. with the Director of Nursing (DON), Resident 2's TAR, dated 12/1/25 to 12/31/25 was reviewed. The TAR indicated, Cleanse with [normal saline (NS)], pat dry and apply dressing to right hand every shift for rash to right hand. Order date: 11/19/25. [discontinued (D/C)] date: 12/8/25. The TAR indicated on 12/4/25, for the night shift administration time, there was no licensed staff initials in the box to demonstrate the wound care was provided as ordered. The DON stated LVN 2 was assigned to Resident 2 during the night shift and LVN 2 should have checked and initialed the box on 12/4/25 to indicate that the wound care was provided and it was not. The DON stated, If LVN 2 did not document that the wound care was provided, LVN 2 did not provide the wound care.During a review of Resident 3's AR, dated 4/1/26, the AR indicated Resident 3 had a history of Hypertensive Heart (a chronic condition caused by high blood pressure which forces the left ventricle to work harder, causing it to thicken and stiffen which may progress to heart failure), Dementia (a decline in mental ability severe enough to interfere with daily life, characterized by the loss of cognitive functions such as thinking, remembering, reasoning, and behavioral changes), Diabetes Mellitus Type 2, Malignant Neoplasm of Prostate (a cancerous tumor that forms in the tissues of the prostate gland), and Presence of Cardiac Pacemaker (a small, battery-operated medical device implanted under the skin usually near the collarbone to treat abnormal heart rhythms by delivering low-energy electrical pulses).During a concurrent interview and record review on 4/1/26 at 12:49 p.m. with the DON, Resident 3's TAR, dated 1/1/26 to 1/31/26 was reviewed. The TAR indicated, Skin Tear with flap site: Left dorsal hand [back of hand]: Cleanse with NS, apply steri-strips [a sterile, breathable adhesive strips used as a non-invasive alternative to stitches or staples for closing small, shallow cuts and surgical incisions] and cover with dry dressing. Change dressing every day, leave steri-strips in place [for seven (x 7)] days. Order date: 1/17/26. The TAR indicated on 1/21/26, for the night shift administration time, there was no licensed staff initials in the box to demonstrate the wound care was provided as ordered. The DON stated LVN 2 was assigned to Resident 3 during the night shift and LVN 2 should have checked and initialed the box on 1/21/26 to indicate that the wound care was provided for the night shift and it was not. The DON stated, If LVN 2 did not document that the wound care was provided, LVN 2 did not provide the wound care.During a review of Resident 4's AR, dated 4/1/26, the AR indicated Resident 4 had a history of Paraplegia (a medical condition characterized by partial or complete paralysis of the lower half of the body), Diabetes Mellitus Type 2, Hypertensive Chronic Kidney Disease (a medical condition where long-term, uncontrolled high blood pressure damages the small blood vessels, in the kidneys, leading to progressive kidney impairment), Severe Morbid Obesity (a chronic health condition defined by a body mass index [BMI] of 40 or higher with obesity-related complications) and Malignant Neoplasm of Large Intestine (a cancerous tumor that develops in the tissues of the colon or rectum).During a concurrent interview and record review on 4/1/26 at 12:49 p.m. with the DON, Resident 4's TAR, dated 1/1/26 to 1/31/26 was reviewed. The TAR indicated, Rash peri-anal [the area of skin and tissue immediately surrounding the anus, located between the buttocks]: apply [brand name] powder [an antifungal medication designed for external use to treat skin infections] to rash on peri-anal every shift and as needed after incontinence [involuntary, accidental leakage of urine or feces due to loss of bladder or bowel control] episodes until healed. Order date: 11/19/26. The TAR indicated on 1/21/26, for the night shift administration time, there was no licensed staff initials in the box to demonstrate the wound care was provided as ordered. The TAR indicated [Moisture-Associated Skin Damage (MASD)]: apply [brand name-(menthol and zinc oxide)-a moisture barrier ointment primarily composed of calamine, zinc oxide, and menthol] ointment to coccyx [tailbone] every shift and [as needed (PRN)] after incontinence episodes every shift. for MASD to Coccyx Clean coccyx with NS pat dry, do not rub, apply [brand name-menthol and zinc oxide]ointment until healed. Order date: 1/5/26. The DON stated LVN 2 was assigned to Resident 4 during the night shift and LVN 2 should have checked and initialed the box on 1/21/26 to indicate that the wound care was provided for the night shift and it was not. The DON stated, If LVN 2 did not document that the wound care was provided, LVN 2 did not provide the wound care.During a review of Resident 5's AR, dated 4/1/26, the AR indicated Resident 5 had a history of Congestive Heart Failure (a chronic, progressive condition where the heart muscle cannot pump blood efficiently enough to meet the body's needs), COPD, Diabetes Mellitus Type 2, Severe Morbid Obesity, Benign Neoplasm of Cranial Nerves (a non-cancerous, typically slow-growing tumor that arises from the cells of one of the 12 pairs of cranial nerves. These nerves connect the brain directly to various parts of the head, neck, and torso, controlling functions like hearing, balance, facial movement and sensation), Schizoaffective Disorder (a chronic mental health condition characterized by a combination of schizophrenia symptoms such as hallucinations or delusions and major mood disorder), Dependence on Respirator, and Dependence on Supplemental Oxygen.During a concurrent interview and record review on 4/1/26 at 12:49 p.m. with the DON, Resident 5's TAR, dated 1/1/26 to 1/31/26 was reviewed. The TAR indicated, Cleanse abdominal folds with soap and water, pat dry, apply [brand name] powder-an antifungal medication used to treat skin infections caused by Candida yeast. Monitor and report [medical doctor (MD)] for worsening every shift for fungal rash for 14 days. Order date: 1/20/26. The TAR indicated on 1/21/26, for the night shift administration time, there was no licensed staff initials in the box to demonstrate the wound care was provided as ordered. The DON stated LVN 2 was assigned to Resident 5 during the night shift and LVN 2 should have checked and initialed the box on 1/21/26 to indicate that the wound care was provided for the night shift and it was not. The DON stated, If LVN 2 did not document that the wound care was provided, LVN 2 did not provide the wound care.LVN 1 and LVN 2 were not available for interview.During an interview on 4/1/26 at 12:43 p.m. with LVN 3, LVN 3 stated it was standard of practice to follow the physician's wound care order and to document after the wound care was provided as ordered. LVN 3 stated if the wound care provided was not documented, the wound care was not provided. LVN 3 stated documentation of wound care was required to indicate continuity of care and to reflect the wound care the residents received. LVN 3 stated if wound care was not provided as ordered, then possible infection could result and slow down the healing process.During an interview on 4/1/26 at 1:15 p.m. with the DON, the DON stated it was standard of practice to document the wound care provided as ordered. The DON stated complete and accurate documentation was required to reflect the wound care the residents received. The DON stated it was standard of practice to follow the physician's order for wound care to prevent infection and promote wound healing.During an interview on 4/1/26 at 1:20 p.m. with the Administrator (ADM), the ADM stated complete and accurate documentation was required to reflect the care provided. The ADM stated if staff did not provide documentation that the wound care was completed, then the wound care was not completed. The ADM stated it was standard of practice to follow the physician's wound treatment order to ensure wound healing and prevent infection.During a review of the facility's P&P titled, Charting and Documentation, undated, the P&P indicated, Definition of Record: The resident's clinical record is an account of treatment, care, response to care, signs, symptoms and progress of the resident's condition. It also includes data needed for identification and communication with family/responsible party. Importance and Use of the Record: Provides a multidisciplinary record of the physical and mental status of the resident.

Based on interview and record review, the facility failed to follow the policy and procedure (P&P) titled, Admission, Transfer, Discharge and Bed-Holds, for one of three sampled residents (Resident 1) when Resident 1 (a veteran - someone who has served in a nation's armed forces) was denied admission for rehabilitation services based on payment source. This failure had the potential to delay recovery for Resident 1 following an Esophagogastroduodenoscopy (EGD - a medical procedure used to examine the lining of the esophagus, stomach, and the first part of the small intestine), Robotic Ivor [NAME] Esophagectomy (a minimally invasive surgical procedure with the use of a surgical robot to remove a portion of the esophagus to treat cancer) and Exploratory Laparotomy (a surgical procedure involving a large incision in the abdomen to visually examine the abdominal organs to identify the cause of unexplained symptoms or injuries).During an interview on 8/26/25 at 11:01 a.m. with [Hospital A] Social Worker (SW), the SW stated Resident 1 was referred to the facility on 8/5/25 for rehabilitation services for 20 days. The SW stated on 8/5/25 he spoke with the facility's Business Office Manager (BOM) and the BOM informed him the facility was unable to admit Resident 1 because [Hospital A] did not bill Medicare (the federal health insurance program for U.S. citizens and permanent legal residents, age [AGE] and older, people with disabilities and End-Stage Renal Disease (a severe condition where the kidneys have permanently lost most of their function) for the required three midnight stay (a Medicare Part A regulation requiring a patient to have a minimum of three consecutive nights of inpatient hospital care before they are eligible for covered services). The SW stated [Hospital A] billed VA (United States Department of Veterans Affairs - a cabinet-level agency of the U.S. government responsible for providing comprehensive benefits, healthcare, and support services to military veterans and their families) directly for services, not Medicare. During a review of Resident 1's [Hospital A] Demographic (HD), undated, the HD indicated, [name of Resident 1]. POS (Period of Service): Vietnam ERA. admitted : 7/11/25. discharged : 8/6/25. Health Insurance Information: Medicare Part A Effective 2/1/13. Medicare Part B Effective 2/1/13. Tricare (the U.S. military's health insurance plan providing coverage to service members, retirees, and their families) Effective 1/1/25.During a review of Resident 1's [Hospital A] Discharge Summary (DS), dated 8/6/25, the DS indicated, THORACIC SURGERY (surgical procedures performed on the organs and structures within the chest cavity). DISCHARGE SUMMARY. DATE OF OPERATION: 7/11/25. PREOPERATIVE DIAGNOSIS: Esophageal cancer (a disease in which malignant cells form in the tissues lining the hollow muscular tube that transports food and liquids from the throat to the stomach). PROCEDURES PERFORMED: 1. EGD 2. Robotic Ivor [NAME] esophagectomy. 3. Exploratory laparotomy. Diagnoses/Active Problems Managed this Hospitalization: . (Resident 1) treated with the above procedure, which the patient tolerated well. He continued to do well and on POD#20 (post-operative day 20), he was transferred to the floor. Inpatient rehab recommendations are for SNF (skilled nursing facility - a place that offers medical and therapeutic services that can only be performed safely and effectively by or under the supervision of licensed, trained health professionals to address complex medical needs and facilitate recovery after an illness, injury, or surgery). A suitable facility has been found, all necessary arrangements have been made, and the patient will be discharged .During an interview on 8/27/25 at 9:28 a.m. with the admission Services Manager (ASM), the ASM stated when the facility received a referral for admission, the admission staff reviewed the referral to ensure the facility could provide the services required. The ASM stated the admission staff would verify the residents' primary insurance, secondary insurance and copay. The ASM stated a three midnight stay at a general acute care hospital with an inpatient status was required for Medicare to cover skilled nursing services (medical and therapeutic services that can only be performed safely and effectively by or under the supervision of licensed, trained health professionals to address complex medical needs and facilitate recovery after an illness, injury, or surgery). The ASM stated Medicare would not cover skilled nursing services if there was no record of the three midnight stay at a general acute care hospital. During an interview on 8/27/25 at 9:45 a.m. with the BOM, the BOM stated when the facility received a referral for admission, the referral was reviewed to verify payment source. If a resident had no payment source, the resident was given a private option to pay. The BOM stated the admission staff would interview the resident or the resident's family member to agree on a payment plan. The BOM stated she spoke to the SW on 8/5/25 regarding the referral. The BOM stated she explained the three midnight stay qualifying requirement for Medicare coverage to the SW. The BOM stated since [Hospital A] did not bill Medicare for the three midnight stay requirement, Medicare will not cover services provided at the facility. The BOM stated she requested Resident 1's admission classification (status) to support services provided at [Hospital A] but the SW did not provide the information, therefore, the facility was unable to admit Resident 1. During a concurrent interview and record review on 8/27/25 at 10:45 a.m. with the BOM, the facility's P&P titled, Admission, Transfer, Discharge and Bed-Holds, dated 2016 was reviewed. The P&P indicated, . The facility provides equal access to quality care and opportunity for admission and does not limit, transfer or discharge prospective or current residents based upon race, creed, national origin, sex, religion, handicap, ancestry, marital or veteran status, sexual orientation or payment source. The BOM stated admission was not based on payment source. The BOM stated the facility should have offered Resident 1 with a letter of agreement (LOA - a legally binding admission contract that outlines the terms of residency, services, and financial obligations). The BOM stated she should have followed through with the SW and Resident 1 should have been admitted . During an interview on 8/27/25 at 11:10 a.m. with the Director of Nursing (DON), the DON stated during the referral process, admission staff would consult with nursing staff to ensure the facility could provide the clinical service the resident required. The DON stated the facility could not deny admission based on the payment source. The DON stated Resident 1 should have been admitted .During an interview on 8/27/25 at 11:15 a.m. with the Administrator (ADM), the ADM stated the facility should admit the resident if the facility could provide the services the resident required. The ADM stated there was a missed opportunity to admit Resident 1 due to miscommunication between the BOM and the SW. The ADM stated the BOM did not know the referral was made from a VA general acute care hospital. The ADM stated the BOM should have clarified the required information with the SW. The ADM stated the facility should have admitted Resident 1 based on a LOA. The ADM stated admission was not based on the payment source. During a review of the facility's P&P titled, Admission, Transfer, Discharge and Bed-Holds, dated 2016, the P&P indicated, Purpose: To provide uniform guidelines for admission, transfer, discharge and bed-holds in compliance with state and federal guidelines. To promote equal access to quality care and facilitate continuity with care transitions. Policy: The facility provides equal access to quality care and opportunity for admission and does not limit, transfer or discharge prospective or current residents based upon race, creed, national origin, sex, religion, handicap, ancestry, marital or veteran status, sexual orientation or payment source. admission: .The facility does not request or require residents or potential residents to waive their rights to Medicare or Medicaid (a joint federal and state health insurance program that provides free or low-cost health coverage to low-income U.S. citizens and permanent legal residents), nor does it request or require oral or written assurance that residents or potential residents are not eligible for, or will not apply for Medicare or Medicaid benefits. The facility does not request or require a third party guarantee of payment to the facility as a condition of admission or expedited admission, or continued stay in the facility; however, the facility does require a resident representative who has legal access to the resident's income or available resources to sign a contract of assurance (without incurring personal financial liability), for payment from the resident's income or resources.

Based on observation, interview, and record review, the facility failed to provide required treatment and services to one of five residents (Resident 20), when Resident 20 did not receive restorative nursing assistant (RNA - helps patient regain physical skills through therapeutic care including mobility exercises, dressing, eating and bathing) services ordered by the physical therapist (PT-a person qualified to treat disease, injury or deformity by physical methods such as massage, heat treatment and exercise) once PT was discontinued on 3/6/24. Resident 20 did not receive range of motion (ROM- full movement potential of a joint) treatment from 3/6/24, when Resident 20 was discharged from PT, until 2/4/25, when Resident 20 was reevaluated by an occupational therapist (OT - healthcare professional who helps individuals improve their ability to perform activities of daily living [ADL]), a time lapse of 10 months and 29 days. These failures by PT to coordinate with RNA services to continue Resident 20's exercise treatments, potentially contributed to Resident 20 developing decreased ROM of the right hand leading to a contracture (a stiffening/shortening at any joint, that reduces the joint's ROM). Findings: During a concurrent observation and interview on 2/3/25 at 2:34 p.m. with Resident 20 and Resident 20's responsible party (RP - health care decision maker) in Resident 20's room, Resident 20's right hand was observed to have slight movement of the middle finger, while the other three fingers and thumb remained in a bent position and did not move. The RP stated, I visit my wife every single day and am here from 7 a.m. to 3 p.m. The RP stated Resident 20's right hand has worsened since admission. The RP stated no ROM had been done since the Resident was discharged from physical therapy in March of 2024. The RP stated he did not know why PT was no longer provided but the RP had informed staff a few months ago in a meeting about wanting treatment for Resident 20's right hand. The RP stated Resident 20's right hand was more bent than when she came into the facility, and she could no longer extend four fingers. During a review of Resident 20's Admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/5/25, the AR indicated Resident 20 was admitted to the facility on [DATE] with a diagnosis of hemiplegia (total loss of the ability to move the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (when blood flow to the brain is interrupted, causing brain cells to die) affecting left non-dominant side and encephalopathy (a change in how the brain functions and leads to declining ability to reason and concentrate). During a review of Doctor of Medicine/Nurse Practitioner/Physician's Assistant Progress Note (MD/NP/PA), dated 1/22/25, the MD/NP/PA Progress Note indicated, . [Resident 20] has a history of multiple strokes with right side weakness . [History] of stroke [blood flow to the brain is interrupted leading to brain cell damage and death] with right hemiparesis . During a review of Resident 20's Care Plan (CP), dated 1/30/24, the CP indicated, Self-Care Deficit as Evidence by: Needs maximal to dependent assistance with [activities of daily living (ADL)] [related to] multiple medical conditions, *With [diagnosis] of CVA [cerebrovascular accident- known as a stroke, where blood flow to the brain is interrupted] [with/left] SIDED WEAKNESS With impaired [right lower extremity (limbs of the body, such as the arms and legs)/bilateral upper extremity (RLE/BUE)] ROM. Date initiated: 1/30/24 . Revision on 2/6/25 . During a concurrent interview and record review on 2/7/25 at 10:02 a.m. with the Administrator (ADM), Resident 20's CP, dated 1/30/24 was reviewed. The CP indicated, .Interventions .Transfer: Two- person physical assistance required .Locomotion [movement or the ability to move from one place to another]- One- person physical assist required as needed .Bathing - One- person physical assist required . The ADM stated this CP is current. The ADM stated the CP did not state to perform ROM, but locomotion would be considered movement with raising of arms. During a review of Resident 20's Minimum Data Set (MDS - a resident assessment tool), dated 7/19/24, the MDS indicated Resident 20's Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 3 out of 15 (0-7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, 13-15 cognitively intact) which indicated resident had a severe cognitive impairment. During a review of Resident 20's N Adv- Skilled Evaluation - V 16 (Evaluation), dated 1/31/24, the Evaluation indicated, the right hand was normal with no weakness, tremors (involuntary, rhythmic shaking movements that can affect various parts of the body including the hands), numbness or tingling. During a review of Resident 20's PT Evaluation, dated 1/31/24, the PT Evaluation indicated, .Assessment summary .without skilled therapeutic intervention [a goal-oriented treatment that is tailored to a resident's needs and performed by a licensed therapist], the patient is at risk for further decline in function, decreased ability to return to prior living environment and increased dependency upon caregivers . The PT Evaluation indicated, Reason for Referral: Patient referred to PT due to new onset of increased need for assistance from others, decrease in functional mobility, compromised physical exertion level during activity, functional limitation with ambulation [ability to walk from one place to another, either independently or with the help of a device] and decrease in strength . The PT Evaluation indicated the ROM for both lower extremities were within functional limits (WFL) and strength for bilateral lower extremities (BLE) was impaired but did not indicate the ROM and strength for bilateral upper extremities (BUE). During a review of Resident 20's Physical Therapy PT Discharge Summary, dated 3/6/24, the Physical Therapy PT Discharge Summary indicated, . Prognosis to Maintain [current level of function] = Good with strong family support, good with consistent staff follow-through . During a review of Resident 20's Occupational Therapy OT Evaluation, dated 1/31/24, the Occupational Therapy OT Evaluation indicated, Resident 20's baseline (starting point) for upper body dressing was, Max A (51-75% assist- [PT and resident each put in about half of the effort]), Section GG: Substantial/Maximal Assist [level of assistance where a patient needs a significant amount of help to complete a task] . The Occupational Therapy OT Evaluation indicated for section musculoskeletal [having to do with muscles, bones, tendons, ligaments, joints and cartilage] ROM, [upper extremity (UE)] ROM: [right upper extremity (RUE)] ROM= Impaired . The Occupational Therapy OT Evaluation indicated, .without skilled therapeutic intervention, this patient is at risk for rehospitalization , decreased ability to return to prior level of function . decrease in level of mobility, falls, further decline in function, increased dependency upon caregivers and decreased participation in functional tasks . The Occupational Therapy OT Evaluation did not indicate ROM specifically for right hand and right fingers. During a review of Resident 20's Occupational Therapy OT Discharge Summary, dated 3/6/24, the Occupational Therapy OT Discharge Summary indicated, . Progress & Response to Treatment: Patient responded positively to passive techniques to stimulate functional performance and enhance safety to prevent further decline . Restorative Programs. Restorative Program Established/Trained = Restorative Range of Motion Program. Range of Motion Program Established/Trained: UE ROM [performed ROM] exercises for shoulder flexion [a bending movement around a joint in a limb that decreases the angle between the bones of the limb at the joint]/extension [movement of a joint that increases the angle between the bones involved], abduction [movement of a body part away from the midline of the body], elbow flexion/extension, wrist flexion/extension, [finger] flexion . During a review of Resident 20's Occupational Therapy OT Discharge Recertification, dated 3/6/24, the Occupational Therapy OT Discharge Recertification indicated, .Communication. Collaboration/Transition plan: Reviewed patient's plan of treatment and treatment services with interdisciplinary team members . During a review of Resident 20's Progress Note (PN), dated 3/1/24, the PN indicated, .Functional: Able to move all extremities. Upper extremity ROM: No Impairment Physical Therapy Resident continues to participate in therapy as ordered. Occupational therapy: Resident continues to participate in therapy as ordered . During a review of Resident 20's Restorative Therapy Referral - V 1, dated 3/6/24, the Restorative Therapy Referral - V 1 indicated, .D. RNA Program. 1. Current Problems: Patient is at elevated risk of loss of UE/ ([lower extremity (LE)] ROM and inability to tolerate upright activity. 2. Goals: Maintain current UE/LE ROM and tolerance to upright activity. 3. Approaches: Right/Left upper and lower extremity PROM to tolerance all planes [a flat surface, a cut through the body] 3 sets[group of repetitions of an exercise performed consecutively without stopping] [times] 10 [repetitions] [up in chair (UIC)] via [patient lift - a mechanical device used to lift and/or transfer a person) daily [times] 1 or to tolerance Position [right] UE with pillow between body and UE . The Restorative Therapy Referral - V 1 indicated check marks for both boxes stating, Program reviewed with RNA and training completed and RAI [Resident Assessment Instrument- tool that helps nursing home staff assess a resident's needs and strengths]/MDS made aware of transfer of care. During a review of Resident 20's Interdisciplinary team (IDT) Assessment & Progress Note - V 3 (IDT Assessment), dated 4/24/24, the IDT Assessment indicated, Restorative Care/ PT/OT (occupational therapy)/ST (speech therapy) . 2. Functional ROM limitations . check marked for both sides-upper extremity. The IDT Assessment indicated no checkmark for current PT, OT and ST, and no checkmarks for current RNA programs including .1. Ambulation/locomotion 3. Splint [an external device used to immobilize an injury or joint /Contracture management 5. ROM 2. ADL 4. Dining . The IDT Assessment indicated, . [Resident 20] Requires maximal to dependent assist with ADL'S needs . During a review of Resident 20's IDT Assessment & Progress Note - V 3 (IDT Assessment), dated 7/12/24, the IDT Assessment indicated, Restorative Care/ PT/OT/ST . 2. Functional ROM limitations . check marked placed for, .1. None-upper extremity 2. None-lower extremity . The IDT Assessment indicated no checkmark for current PT, OT and ST, and no checkmarks for current RNA programs including .1. Ambulation/locomotion 3. Splint/Contracture management 5. ROM 2. ADL 4. Dining . During a review of Resident 20's IDT Assessment & Progress Note - V 4 (IDT Assessment), dated 10/11/24, the IDT Assessment indicated, Restorative Care/ PT/OT/ST . 2. Functional ROM limitations . check marked for both sides-upper extremity. The IDT Assessment indicated no checkmark for current PT, OT and ST, and no checkmarks for current RNA programs including .1. Ambulation/locomotion 3. Splint/Contracture management 5. ROM 2. ADL 4. Dining . The IDT Assessment indicated, . [Resident 20] Requires maximal to dependent assist with ADL'S needs . During a review of IDT Assessment & Progress Note - V 4 (IDT Assessment), dated 1/9/25, the IDT Assessment indicated, Restorative Care/ PT/OT/ST . 2. Functional ROM limitations . check marked for, 2. None-Lower Extremity . 5. Both sides Upper Extremity . The IDT Assessment indicated no checkmark for current PT, OT and ST, and no checkmarks for current RNA programs including .1. Ambulation/locomotion 3. Splint/Contracture management 5. ROM 2. ADL 4. Dining . The IDT Assessment indicated, .5. New Referrals for PT/OT [evaluation] and [treatment] . During an interview on 2/6/25 at 9:11 a.m. with Restorative Nursing Assistant (RNA) 1, RNA 1 stated, there was no RNA program for Resident 20 and a restorative therapy referral form was never received from a PT. RNA 1 stated the process of transitioning a resident from PT to the RNA program was the PT would create the restorative therapy referral form that included the RNA treatment. RNA 1 stated this form would then be printed out by the PT, provided to and reviewed with the RNA. RNA 1 stated the PT would provide instructions if needed and both the PT and RNA would sign the form and keep a copy. The RNA would then present the copy to the MDS Coordinator (a nurse who manages the assessment process for long-term care patients) to upload into Point Click Care (PCC- online charting system). RNA 1 stated once uploaded, the form was given back to the RNA and the form was stored in a binder in the RNA office. RNA 1 was unable to locate a copy of the restorative therapy referral form that would have been completed and signed by an RNA and PT on 3/6/24 for Resident 20. During a concurrent interview and record review on 2/6/25 at 9:50 a.m. with Physical Therapist (PT) 1, Resident 20's Restorative Therapy Referral - V 1, dated 3/6/24 was reviewed. The Restorative Therapy Referral - V 1 indicated an established RNA program that specified therapy treatments to be conducted by an RNA with Resident 20.The Restorative Therapy Referral - V 1 indicated the RNA program, was reviewed with RNA and training completed . and .RAI/MDS was made aware of the transfer of care . The Restorative Therapy Referral - V 1 indicated the form was electronically signed by the physical therapist on 3/6/24 and is seen in the resident's medical record. PT 1 stated this form was signed on 3/6/24 by a temporary PT that is no longer at the facility. PT stated there is no signature by the RNA on this form. PT 1 stated there was a physical therapy evaluation done on 2/5/25 for Resident 20. During an interview on 2/6/25 at 10:00 a.m. with Occupational Therapist (OT) 1, OT 1 stated an occupational therapy evaluation was conducted for Resident 20 on 2/4/25. OT 1 stated, I saw a new developing contracture on the resident's right hand. OT 1 stated splinting (medical procedure that involves immobilizing an injured area with a supportive device) would be done for this contracture. OT 1 stated Resident 20 will be fitted for a splint (a rigid or flexible device that maintains in position a displaced or movable part) and one would be placed. During a review of Resident 20's MD/NP/PA Progress Note dated 1/22/25, the MD/NP/PA Progress Note indicated, . No new concern. Husband at bedside wondering if there is treatment for [Resident 20's] right hand contracture . The MD/NP/PA Progress Note indicated in the musculoskeletal category, box for negative and box for contractures were check marked and indicated .mild right-hand contracture . The MD/NP/PA Progress Note indicated in the comments section, . Right hand contracture: continue to place a rolled towel in her hand . During an interview on 2/6/25 at 10:09 a.m. with the Assistant Director of Rehab (ADOR), the ADOR stated she was unable to locate the restorative therapy referral form in the records kept in her office for Resident 20 from 3/6/24. The ADOR stated currently there was a real change of condition conducted on 1/27/24 for Resident 20. The ADOR stated the current plan for Resident 20 was to have PT and OT services done and once these services are completed, Resident 20 would be placed in the RNA program. The ADOR stated a splint for Resident 20's RUE wrist for finger flexion will be ordered once the resident is fitted for one. The ADOR stated, I do see there is a significant change of condition for resident in development of a contracture. During a review of Resident 20's Rehabilitation Referral, dated 1/27/25, the Rehabilitation Referral indicated for section splinting/contracture management, contracture upper (contracture found on RUE) was check marked. The Rehabilitation Referral indicated for section physical care/mobility skills box for weakness upper/lower extremities was check marked and box for limited ROM was check marked. The Rehabilitation Referral indicated, Comments: PT/OT eval for BUE/BLE strengthening. During a concurrent interview and record review on 2/6/25 at 10:30 a.m. with the MDS Coordinator, the MDS Coordinator stated there was no RNA program done for Resident 20 when the resident was discharge from PT in March of 2024 and was unable to locate the Restorative Therapy Referral - V 1 form completed on 3/6/24. The MDS Coordinator stated the expectation was for the RNA to be informed by the PT of the restorative program, the form signed by both the RNA and PT and the form presented to MDS Coordinator to upload into PCC. The MDS Coordinator stated this process was not done and it should have been. The MDS Coordinator stated Resident 20's RP informed her, sometime in January of 2025, of Resident 20's right hand and observed it to appear different and placed an order for a PT and OT evaluation on 1/10/25. The MDS Coordinator stated, there should have been an order for ROM done by the RNA. During a review of Resident 20's Order Details, dated 1/10/25, indicated an order for, Occupational Therapy Evaluation and Treatment was placed on 1/10/25 by the MDS Coordinator and signed by the MD on 1/14/25. During a review of Resident 20's Order Details, dated 1/10/25, indicated an order for Physical Therapy Evaluation and Treat was placed on 1/10/25 by the MDS Coordinator and signed by the MD on 1/14/25. During a review of Resident 20's Occupational Therapy PT Evaluation, dated 2/4/25, the Occupational Therapy PT Evaluation indicated, . RUE ROM. Hand = Impaired (Contractures developing in R [right] hand) . The Occupational Therapy PT Evaluation indicated, .RUE strength = Impaired . The Occupational Therapy PT Evaluation indicated, . Reason for Skilled Services: Patient requires skilled occupational therapy services at the prescribed frequency and duration to address the following: splinting in R hand in order to enhance this patient's quality of life by improving hand ROM. Due to the documented deficits (lacking something necessary or not meeting a standard) and the patient's complicated medical history, without skilled therapeutic intervention, this patient is at risk for contracture(s) . The Occupational Therapy PT Evaluation did not specifically mention evaluation of the fingers on the right hand. During a review of Resident 20's Physical Therapy PT Evaluation, dated 2/5/25, the Physical Therapy PT Evaluation indicated, Reason for Referral: Patient referred to PT due to new onset of decrease in functional mobility, decreased postural alignment, decrease in strength and ROM . The Physical Therapy PT Evaluation indicated ROM for the right lower extremity (RLE) is impaired and the left lower extremity (LLE) is WFL but did not indicate ROM for both upper extremities. The Physical Therapy PT Evaluation indicated strength for both RLE and LLE was impaired but did not indicate strength for both upper extremities. During an interview on 2/6/25 at 1:40 p.m. with the ADOR, the ADOR stated the Director of Rehab (DOR) oversaw a resident's transition from PT to the RNA program and oversight was not done for Resident 20. The ADOR stated the purpose of performing the RNA program was for the resident to maintain their current level of function once discharged from PT or OT services. The ADOR stated Resident 20 may have developed a contracture because the RNA program had not been done. During an interview on 2/6/25 at 2:03 p.m. with the Director of Nursing (DON), the DON stated there was no policy in place for the process of transitioning a resident from PT to the RNA program. During an interview on 2/7/25 at 1:39 p.m. with Resident 20's RP, the RP stated he noticed Resident 20's 4 fingers and right hand started to bend in June of 2024. The RP stated Resident 20 would tell him she was unable to straighten out her fingers when he would ask her to. The RP stated he notified staff about Resident 20's right hand in a meeting held about 3 months ago and in the following meeting he brought it up again because nothing had been done. The RP stated one of the social workers suggested placing a towel in Resident 20's right hand but stated, I felt like it wouldn't help because I don't want her hand like in a fist, I want it straightened out. During an interview on 2/7/25 at 5:00 p.m. with the DON, the DON stated there was a failure by PT for not following the process of transitioning a resident from PT services to the RNA program. The DON stated the process was broken. The DON stated the importance of following the process was to make sure that the recommendation made by the PT was followed especially if the resident was not in rehab and for maintenance by the RNA, CNAs, and nurses. The DON stated she wanted the residents to maintain ADLs. The DON stated, we failed to follow the recommendation [by the PT]. During a review of the facility's policy and procedure (P&P) titled, Nursing Rehab/Restorative Care Program, (undated), the P&P indicated, The primary goal . is to ensure that all residents receive care and services that promote their ability to live and function as independently as possible; to maintain and/or improve function and prevent decline . Members of various clinical disciplines and support services use their observational and assessment skills to identify each resident's functional strengths, weaknesses and needs .For residents in a RNA program, monthly progress notes by the Restorative Nurse Aide provide specifics on delivery of Nursing Rehab and/or Restorative activities and the resident's response to them (how they are progressing toward their goals). The progress notes are signed off by restorative nurse or by state requirements . During a review of the facility's Job Description (JD) titled, Job Description/Performance Evaluation RNA, dated 11/13/17, the JD indicated, .The primary purpose of this position is to assist in performing restorative nursing procedures that maximize the resident's existing abilities, emphasize independence, minimize the negative effects of disability with an attitude of realistic optimism .Meets with administration, nursing staff, therapy department, as well as other related departments in planning restorative care. Maintains restorative care standards . Maintains treatment grids, care plans and progress notes as required . During a review of the facility's JD titled, .Rehabilitation Job Description for Physical Therapist, dated 12/8/15, the JD indicated, . The Physical Therapist identifies the need for and makes referral(s) to other disciplines to address the comprehensive needs of the patients. They implement individualized therapy programs designed to restore, reinforce, and enhance performance. In addition, the Physical Therapist instructs, educates and trains patients and caregivers in those skills and functions essential for promoting independence and productively, in order to diminish or correct pathology [the study of disease, including its causes, effects and progression]. They direct activities to promote and maintain health . Responsibilities/Accountabilities . 4. Makes referrals to other disciplines and agencies in order to address the comprehensive needs of the patient. 5. Consults with other members of the rehabilitation team to select the most appropriate therapeutic regimen consistent with the needs and capabilities of each patient .11 .completes all related documentation and record keeping regarding these services .15. Performs routine reexamination as needed/required to modify/progress plan of treatment . During a review of the facility's JD titled, .Rehabilitation Job Description for Assistant Director of Rehab PT (DRAP), dated 2/20/23, the JD indicated, .This position also assists in integration of rehabilitation services in all settings .Responsibilities/Accountabilities .1. Fills in for the Director of Rehab in their absence . 6. Assists in management of therapy staff . During a review of the facility's JD titled, .Rehabilitation Job Description for Director of Rehab PT (DRGP), dated 2/20/23, the JD indicated, .This position also assists in integration of rehabilitation services in all settings. The Director of Rehab PT ensures that the highest standard of rehabilitation services is delivered and maintained . 2. Provides direct patient care. 3. Monitors the standard of clinical services being delivered and maintained in all sites and ensures an ethical and compliant product is being delivered . During a review of the facility's JD titled, Job Description/Performance Evaluation MDS Coordinator, dated 11/13/17, the JD indicated, The primary purpose of this position is to manage the MDS function and processes to: (1) maximize clinical outcomes for patients and residents, assuring resident safety and (2) ensure timely, accurate and complete clinical and support documentation . The JD was current during the time of Resident 20's care.

Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) did not develop pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) when Resident 1 was assessed as a moderate risk for developing pressure ulcers and the nursing care plan of daily and weekly skin assessments was not implemented from 1/6/24 to 1/19/24 for early recognition of skin changes and implementation of appropriate interventions to prevent pressure ulcer. These failures resulted in Resident 1 to develop a preventable Stage 3 (full thickness skin loss involving damage or death of the deepest layer of the skin that may extend down to, but not through, underlying connective tissues) pressure ulcer to the sacrum (located at the bottom of the spine, near the tail bone or coccyx) area. Findings: During a review of the clinical record for Resident 1, the Admission Record (record containing resident demographic information), undated, the Admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included Acute Respiratory Failure (a serious condition that makes it difficult to breathe), Generalized Muscle Weakness, Hypertension (high blood pressure), Mild Cognitive Impairment (decline in memory and thinking), Pneumonia (lung infection caused by bacteria), and Morbid Obesity (a complex disease involving appetite regulation and energy consumption). During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool used to identify resident mental and physical functional level) assessment dated [DATE], the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS-assessment of cognitive status for memory and judgement) assessment score of 9 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderate impairment, and 00-07 indicates severe impairment) indicating Resident 1 had moderate cognitive deficits. During a review of the facility policy and procedure (P&P) titled Skin Integrity dated 8/1/14, the P&P indicated, . Residents identified to be at risk for skin breakdown (pressure ulcers) will have a routine assessment and interdisciplinary (IDT) care plan process implemented to maintain and/or improve skin integrity . 2. New admission residents will have a skin assessment on admission then weekly for three weeks . 4. Communication by Certified Nurse Assistant (CNA) to licensed nurse utilizing a skin condition worksheet or comparable document . 15. Weekly head to toe assessment will be completed of all residents by a Licensed nurse . During a phone interview on 2/2/24, at 1:00 p.m., with General Acute Care Medical Social Worker (MSW), MSW stated she filed a complaint to the local Ombudsman (advocates for nursing home residents) office and the California Department of Public Health (CDPH, a government agency for the State of California in charge of protecting the public's health and helping shape positive health outcomes for individuals, families and communities) on 1/29/24 regarding Resident 1's facility-acquired pressure ulcer. MSW stated Resident 1 was transferred to Skilled Nursing Facility (SNF, a place where trained nurses in a medical setting are providing care to patients to continue recovering after an illness, injury or surgery) on 1/6/24 for rehabilitation and with no pressure ulcers or open skin. MSW stated Resident 1 was readmitted to acute hospital on 1/25/24 due to abnormal vital signs (clinical data, such as pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) and with stage 3 pressure ulcer to her sacrum area. MSW stated she was concerned about the quality of care being provided by the facility to its residents. During a phone interview on 2/4/24, at 11:14 a.m., with Certified Nurse Aide (CNA) 1, CNA 1 stated he was the assigned CNA to care for Resident 1 on 1/19/24, from 3:00 p.m. to 11:30 p.m. CNA 1 stated, I'm a new CNA and it was my first time to work in that nursing unit and to care for [Resident 1]. She does not move much. She stayed in her bed for the duration of my shift. She has a urinary catheter [a flexible tube used to empty the bladder and collect urine in a drainage bag]. CNA 1 stated at approximately 9:00 p.m., he went to Resident 1's room to check and change her disposable brief. CNA 1 stated, She [Resident 1] had a bowel movement and while doing peri-care, I noticed an open area to her sacrum area. I immediately reported it to [RN 1]. The nurse came to the room and I assisted her [RN 1] by holding [Resident 1]'s back while she's assessing and measuring the wound. CNA 1 stated he does not recall receiving a report from the morning CNA regarding [Resident 1] having a pressure ulcer on her sacrum area. CNA 1 stated the task of checking Resident 1's skin was not listed on her care plan. CNA 1 stated he was not aware of the care plan intervention of assessing Resident 1's skin twice a day. During a concurrent interview and record review on 2/5/24, at 7:25 p.m., with Registered Nurse (RN) 1, RN 1 stated she was the license nurse assigned to care for Resident 1 on 1/6/24. Resident 1's Admission Note (AN), dated 1/6/24 was reviewed. The AN indicated, . 18:41 [6:41 p.m.] . 14. Skin note: Rash to perianal area [area between the genitals and anus], laceration [cut] to left medial [towards the middle] high, bruises to right dorsum [back] hand, swelling to left lateral malleolus [bone located at the ankle], swelling to right medial malleolus . RN 1 stated she was unable to find a documentation of Resident 1 having pressure ulcer to her sacrum area on admission. During a concurrent interview and record review on 2/5/24, at 7:39 p.m., with RN 1, Resident 1's Nursing Progress Note (NPN) and Change in Condition Report (COC), dated 1/19/24 were reviewed. RN 1 stated she was the assigned RN to care for Resident 1 on 1/19/24, from 3:00 p.m. to 11:30 p.m. The NPN indicated, . 22:19 [10:19 p.m.] . CNA informed the writer that resident has [pressure] ulcer on her back. Writer went into the room and assessed the resident . The COC indicated, . 22:29 [10:29 p.m.] . pressure injury on sacrum, and three to five small bones fuse to create the coccyx] . this start on: 01/19/2024 . RN 1 stated she provided nursing care to Resident 1 since admission, and she was not aware of Resident 1 having a pressure ulcer to her sacrum area. RN 1 stated the morning nurse did not mention Resident 1 having a pressure ulcer to her sacrum area during change of shift report. During a concurrent interview and record review on 2/5/24, at 7:46 p.m., with RN 1, Resident 1's Skin and Wound Evaluation, dated 1/20/24 was reviewed. The evaluation indicated, . 01:38 [1:38 a.m.] . Type: Pressure . Stage: Stage 3: Full-thickness skin loss . Location: Sacrum, Medical . Exact Date: 01/19/2024 . Wound Measurements: Area 36.4 cm (centimeter, unit of measurement) . Length 8.5 cm . Width 5.9 cm . RN 1 stated Resident 1's sacrum pressure ulcer was first discovered on 1/19/23 by [CNA 1]. RN 1 stated a stage 3 pressure ulcer was impossible to develop within a couple of hours. RN 1 stated Resident 1's skin was not assessed daily and should have been assessed. During a concurrent interview and record review on 2/5/24, at 7:52 p.m., with RN 1, Resident 1's Nursing Care Plan (CP), dated 1/7/24 was reviewed. The CP indicated, . Focus: Potential for impaired skin integrity related to impaired mobility . Interventions . Observe skin integrity during am/pm [morning/afternoon] care . Date Initiated: 1/6/24 . Evaluate Skin Weekly . Date Initiated: 1/6/24 . RN 1 stated she was unable to find documentation a skin assessment was done during morning and afternoon care from 1/7/24 to 1/19/24. RN 1 stated she was unable to find documentation of weekly skin assessment from 1/7/24 to 1/19/24. RN 1 stated the facility failed to assess Resident 1's skin integrity twice a day and weekly which resulted to the late recognition of a stage 3 pressure ulcer to her sacrum area. During a concurrent interview and record review on 2/6/24, at 10:45 a.m., with the Nursing Supervisor/Assistant Director of Nursing (ADON) 1, Resident 1's Nursing Care Plan (CP), dated 1/7/24 was reviewed. ADON 1 stated she was unable to find documentation a skin assessment was done during morning and afternoon care from 1/7/24 to 1/19/24. ADON 1 stated she was unable to find documentation of weekly skin assessment from 1/7/24 to 1/19/24. ADON 1 stated CNAs and licensed nurses were expected to implement Resident 1's skin integrity care plan and it was not done. During a concurrent interview and record review on 2/6/24, at 10:51 a.m., with the ADON 2, Resident 1's CNA Task Description, undated was reviewed. The document indicated, . Task List . Roll Left & [and] Right every shift . Sit to Lying every shift . ADON 2 stated she was unable to find a specific task to check Resident 1's skin during morning and afternoon care. ADON 2 stated the facility failed to implement Resident 1's skin integrity care plan and did not assess Resident 1's skin twice a day and weekly which resulted to stage 3 pressure ulcer to her sacrum area. ADON 2 stated she and [ADON 1] were the designated clinical leaders for RNs, License Vocational Nurse (LVNs) and CNAs. ADON 2 stated she and [ADON 1] failed to ensure clinical staff were implementing Resident 1's skin integrity care plan. During an interview on 2/6/24, at 11:46 a.m., with the Director of Nursing (DON), the DON stated Resident 1's nursing care plan interventions to prevent skin breakdown should have been implemented on admission and it was not done. The DON stated the facility failed to follow the P&P on Skin Integrity which contributed to Resident 1's development of stage 3 sacrum pressure ulcer. During a review of Resident 1's clinical record titled, BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK, dated 1/6/24, at 6:44 p.m., the document indicated, . 3. ACTIVITY . Bedfast: Confined to bed . 4. MOBILITY . Very Limited. Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently . 6. FRICTION & [and] SHEAR . Problem: Requires moderate to maximum assistance in moving . Score 13 . [AT RISK 15-18, MODERATE RISK 13-14, HIGH RISK 10-12, VERY HIGH RISK 9 or below] . During a review of the facility policy and procedure (P&P) titled Prevention of Pressure Ulcer undated, the P&P indicated, . BASIC RESPONSIBILITY: Licensed Nurse and Nursing Assistant . 20. Asses for risk of pressure ulcer development . 28. Establish a turning and positioning schedule in bed and chair to meet the resident's needs . Documentation may include . Preventive measures used . Condition of the resident's skin . Goal: List MEASURABLE goal(s) to be accomplished . During a review of the facility's document titled, Job Description . Certified Nursing Assistant (CNA), undated, the document indicated, . Maintain and use current, appropriate clinical knowledge of all required nursing policies and procedures . Provide the clinical and support services needed to meet all physical and psychosocial needs of the residents . Improve and maintain skin integrity and general health and comfort including: Provides skin care interventions as per the plan of care . During a review of the facility's document titled, Job Description . Registered Nurse (RN), undated, the document indicated, . The primary purpose of this position is to function as a collaborative member of the IDT, provide patient quality care, optimal clinical outcomes . Utilizes professional standards in performing assessment and monitoring in accordance with scope of licensure . Develops, implements, evaluates, and updates plans of care accordingly . During a review of the facility's document titled, Job Description . Nursing Supervisor, undated, the document indicated, . The primary purpose of this position is to manage nursing department services on a day-to-day basis to achieve the identified clinical and operational results and assuring resident safety . Conduct clinical assessments; use critical thinking and coordinate professional standards of care . Develop, review, and revise care plans to accurately reflect Resident needs . Supervise nursing staff to maximize clinical outcomes and operations effectives . During a review of professional reference document titled Pressure Injury Prevention Points dated 2016, retrieved from https://npuap.org/page/PreventionPoints, the document indicated, Consider bedfast and chairfast individuals to be at risk for development of pressure injury . Develop a plan of care based on the areas of risk, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, repositioning and the support surface . Inspect the skin at least daily for signs of pressure injury . Assess pressure points, such as the sacrum, coccyx, buttocks . Turn and reposition all individuals at risk for pressure injury . Continue to reposition an individual when placed on any support surfaces . Use a pressure redistributing chair cushion for individuals sitting in chairs or wheelchairs . Reposition weak or immobile .

Based on interview, and record review clinical record, and professional reference review, the facility failed to implement a comprehensive systemic approach to ensure residents maintained acceptable parameters of nutritional and hydration status (desirable body weight range) and did not experience unplanned severe weight loss (a loss of greater than 5% [percent] of weight in one month's time) and dehydration (a condition where the body loses too much water and other fluids to carry out normal organ functions) for one of three residents (Resident 1) when the Registered Dietician (RD) did not accurately assess the nutritional status of Resident 1 and develop and implement interventions meant to address unintended weight loss in accordance with professional standards and facility policy and procedure. The interdisciplinary team (IDT, healthcare that integrates multiple disciplines through collaboration) did not develop and implement effective interventions to address the unintended weight loss and did not pursue a course of action to consult other healthcare professionals to address the clinical decline of Resident 1 in accordance with facility policy and procedure. These failures resulted in Resident 1's harm when he lost 33 pounds (lbs) in 44 days, 65.7 % weight loss. Resident was transferred and admitted to the Acute Care Hospital (ACH) 1 for hypovolemic shock (a life threatening condition in which severe blood or fluid loss makes the heart unable to pump enough blood to the body that can cause many organs to stop working). Resident 1 was transferred from ACH 1 to ACH 2 where he was admitted for Failure to Thrive (FTT - described as a syndrome manifested by weight loss greater than 5% baseline, decreased appetite, poor nutrition, and inactivity often accompanied by dehydration). Resident 1 expired at ACH 2 due to multiple organ failure secondary to severe protein calorie malnutrition. Findings: During a review of Resident 1's Admission Record (AR) dated [DATE], the AR indicated, diagnosis information included fracture of neck of right femur, acute post-hemorrhagic anemia (condition that develops when you lose a large amount of blood quickly), type 1 diabetes mellitus (chronic condition in which the pancreas produces little or no insulin, Insulin is a hormone needed to allow sugar to enter cells to produce energy) with proliferative diabetic retinopathy without macular edema of the left eye (new blood vessels grow in your retinas and into the gel-like fluid that fills your eyes), type 1 diabetes mellitus .type 1 diabetes mellitus with other diabetic kidney complications, hyperlipidemia (A condition in which there are high levels of fat particles (lipids) in the blood), major depressive disorder, muscle weakness and difficulty walking. The AR indicated Resident 1 was his own Responsible Party (RP, health decision maker). During a review of Resident 1's History and Physical Exam (H&P) dated [DATE] at 4:52 p.m., the H&P indicated, .HPI: At baseline, patient lives with a roommate in a single- story home, he is ambulatory and independent without assistive devices and uses a cane sometime for ambulation. Patient has history of diabetes and in past he had episodes of hypoglycemia (low blood sugar). Patient sustained an accidental fall in the kitchen that could be associated with low blood sugar. Following the fall patient had significant pain in left hip and he was brought by emergency room for evaluation. Patient was noted to have left femoral neck fracture; orthopedic consultation was obtained. Patient was taken to operating room and underwent left hip pinning procedure. Postoperatively, the pain was controlled with oral medications. Patient needed further short- term inpatient rehab so h was transferred to skilled nursing facility Neurologic AAOX3 [alert and oriented], generalized weakness .no focal deficit .Prognosis: Fair . Rehabilitative Potential Fair . Resident aware of medical condition, understands right and admission agreement: yes PLAN: short term physical therapy and occupational therapy pain management . During a review of Resident 1's Admission Nursing Assessment (ANA), dated [DATE], the assessment indicated Resident 1 was admitted to the facility with a weight of 141.8 lbs. The ANA indicated, Resident 1 was admitted for physical therapy and occupational therapy (PT/OT) and was admitted from the Acute Care hospital (ACH) with a diagnosis of right femoral neck fracture and hypoglycemia. The ANA indicated, Resident 1 had unsteady gait and poor balance, history of falls within the last 30 days and was independent with cognitive skills and decision making. The ANA indicated, an activities of daily living (ADL) care plan was initiated. The ADL care plan indicated, Resident 1 required one person physical assistance for bed mobility, Resident 1 was independent when eating, Resident 1 was a one person physical assist with toilet use, Resident 1 was a one person physical assistance for transfers and Resident 1 was one person physical assist with bathing. During a review of Resident 1's Physician Orders (PO) dated [DATE], the PO indicated, .Order [Brand name of nutritional drink] .two times a day 4 oz [ounces] .start date [DATE] .Order Snacks BID [twice a day] between meals .two times a day . start date [DATE] .Order MD [medical doctor] determines that Resident has the Mental Capacity to make Healthcare decisions as per History and Physical or Transfer orders or preferred intensity of care .start date [DATE] CCHO [consistent carbohydrate] diet, Regular texture, Regular/Thin consistency .start date [DATE] .Order Sertraline[Medication used to treat depression] HCL Tablet . Give 75 mg by mouth . start date [DATE] . During a review of Resident 1's Weight and Vitals Summary (WVS), dated [DATE], the WVS indicated, the following weights were obtained: [DATE], 141.8, Lbs (Standing) [DATE], 142.6, Lbs (Standing), 0.8 Lbs weight gain from [DATE]. [DATE], 141.5, Lbs (Standing), 1.1 Lbs weight loss from [DATE]. [DATE], 137.2, Lbs (Standing), 4.3 Lbs weight loss from [DATE]. [DATE], 138.6, Lbs (Standing), 1.4 Lbs weight loss from [DATE]. [DATE], 127.2, Lbs (Standing), 11.4 Lbs weight loss from [DATE]. [DATE], 126, Lbs (Standing), 1.2 Lbs weight gain from [DATE]. [DATE], 121.8, Lbs (Standing), 4.2 Lbs weight loss from [DATE]. [DATE], 114.2 Lbs (Standing), 7.6 Lbs weight loss from [DATE]. [DATE], 109.6 Lbs (Standing), 4.6 Lbs weight loss from [DATE]. During an interview on [DATE] at 10:22 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was Resident 1's nurse and was the nurse who sent him to the hospital on [DATE]. LVN 1 stated Resident 1 was only answering yes and no questions and was not socializing as he used to. LVN 1 stated Resident 1 required encouragement to eat and CNA's assisted Resident 1 with meals. LVN 1 stated Resident 1 required assistance transferring out of his wheelchair and required 2 CNA's. During a concurrent interview and record review on [DATE], at 10:22 a.m., with LVN 1, Resident 1's SBAR Communication Form dated [DATE] was reviewed. The SBAR indicated Resident 1 was sent out to the ACH for Altered Mental Status (confusion or decreased alertness that may be a symptom of a serious illness particularly in older adults that may be caused by infections, health problems, or malnutrition). During an interview on [DATE], at 10:35 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1's meal intake fluctuated and he would refuse meals and sometimes only ate his snacks. CNA 1 stated on good days Resident 1 ate ,d+[DATE] % of a meal and on bad days he ate ,d+[DATE] % of his meals. CNA 1 stated she would provide Resident 1 with his ADL care that included shaving, brushing his teeth and providing bed baths and showers. CNA 1 stated Resident 1 ate independently and required encouragement to eat. CNA 1 stated Resident 1 was withdrawn (reserved) and sometimes he would like to participate in activities. CNA 1 stated there were days Resident 1 would not want to get out of bed and needed encouragement. During an interview on [DATE], at 10:55 a.m., with CNA 2, CNA 2 stated, Resident 1 had poor meal intake of about 25%. CNA 2 stated Resident 1 ate independently with supervision because he needed encouragement to eat and drink. During a concurrent interview and record review, on [DATE], at 11:01 a.m., with the Registered Dietician (RD), Resident 1's Nutritional assessment dated [DATE], was reviewed. The Nutritional Assessment indicated a total score of 3 out of 14 possible points (where a score of ,d+[DATE] indicated normal nutritional status, ,d+[DATE] indicated at risk for Malnutrition, and ,d+[DATE] indicated Malnutrition). The RD stated Resident 1 was admitted to the facility with a score that indicated malnourishment. The RD stated no recommendations were made to prevent further weight loss. The RD stated she could have ordered snacks, shakes, or a fortified diet upon admission to prevent weight loss but did not know why she did not do so. During a concurrent interview and record review, on [DATE], at 11:01 a.m., with the RD, Resident 1's Weights and Vitals Summary dated [DATE] was reviewed. The summary indicated Resident 1 weighed 137.2 lbs. and had lost 5.4. lbs. (3.78%) from the previous weight of 142.6 lbs. on [DATE] (loss in 2 days). The RD stated a 5 lb. weight loss was a significant loss. The RD stated there were no interventions done because she calculated a 3 lb. weight loss, not 5 lbs. During a review of the professional reference titled Academy of Nutrition and Dietetics (Academy)/ American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) clinical characteristics that the clinician can obtain and document to support a diagnosis of malnutrition from the Journal of the Academy of Nutrition and Dietetics, dated [DATE], volume 112 number 5, the document indicated weight loss can be interpreted as follows: In the context of Acute illness or injury a weight loss of ,d+[DATE]% in 1 week or 5 % in 1 month is moderate malnutrition. A loss of > (greater than) 2 % in 1 week or >5% in 1 month is severe malnutrition. In the context of chronic illness, a weight loss of 5% in 1 month or 7.5% in 3 months is moderate malnutrition. A loss of >5% in 1 month or 7.5% in 3 months is severe malnutrition. During a concurrent interview and record review, on [DATE], at 11:01 a.m., with the RD, Resident 1's Weights and Vitals Summary dated [DATE] and [DATE] were reviewed. The summary indicated Resident 1 weighed 127.2 lbs. and had lost 11.4 lbs. (8.24%) from the previous weight of 138.3 lbs. on [DATE] (loss in 7 days). Resident 1 had lost 15.4 lbs. (10.79%) from the previous weight of 142.6 lbs. on [DATE] (loss in 15 days). The RD stated, the Interdisciplinary Team (IDT) met on [DATE] and she recommended starting Resident 1 on snacks two times a day between meals. The RD stated she was not aware how much of the snacks Resident 1 consumed and did not evaluate the percentage of snack. The RD stated the Certified Nurse Assistants (CNA's) recorded the percentage of snack consumption in the clinical record. Resident 1's Weights and Vitals Summary dated [DATE] indicated Resident 1 weighed 121.8 lbs. and had lost 5.4 lbs. (4.24%) from the previous weight of 127.2 lbs. on [DATE] (loss in 14 days). Resident 1 lost 20.8 lbs. (14.58%) from the previous weight of 142.6 lbs. on [DATE] (loss in 20 days). The RD stated the IDT met on [DATE] to evaluate the medication Sertraline (an antidepressant that could stimulate the appetite) that Resident 1 started on [DATE]. The RD stated the antidepressant would take about six weeks to work and was not sure if the medication was effective. The RD stated no other interventions were recommended for the weight loss. The RD stated she could have ordered an appetite stimulant for Resident 1 but did not. During a review of the professional reference titled, .Sertraline . Mayo Clinic, Mayo Foundation for Medical Education and Research (MFMER), dated [DATE], indicated, . Some side effects may occur . Check with your health care professional if any of the following side effects continue or are bothersome .More common . decreased appetite or weight loss . During a concurrent interview and record review, on [DATE], at 11:01 a.m., with the RD, Resident 1's Weights and Vitals Summary dated [DATE] was reviewed. The summary indicated Resident 1 was 114.2 lbs. and had lost 7.6 lbs. (6.23%) from the previous weight of 121.8 lbs. on [DATE] (loss in 7 days). Resident 1 had lost 28.4 lbs. (19.91%) from the previous weight of 142.6 lbs. on [DATE] (loss in 36 days). The RD stated the IDT met on [DATE] and she recommended Resident 1 start on shakes two times a day between meals. The RD stated she did not evaluate how much of the shakes Resident 1 consumed. The RD stated the nurses recorded the resident's shake consumption in the clinical record. The RD stated she was part of the IDT but was not responsible to evaluate the effectiveness of Resident 1's weight loss interventions. The RD stated she did not know who evaluated the effectiveness of the weight loss interventions. During a concurrent interview and record review, on [DATE], at 11:01 a.m., with the RD, Resident 1's Weights and Vitals Summary dated [DATE] was reviewed. The summary indicated Resident 1 was 109.6 lbs. and had lost 4.6 lbs. (4.02%) from the previous weight of 114.2 lbs. on [DATE] (loss in 7 days). Resident 1 had lost 33 lbs. (23.14%) from the previous weight of 142.6 lbs. on [DATE] (loss in 44 days). The RD stated the IDT met on [DATE] and recommended a previous intervention of weekly weights. The RD stated she did not personally follow up with Resident 1 and had the Dietary Supervisor do the follow up. The RD stated she did not know what to do for Resident 1's weight loss and did not have any more follow ups done. During a concurrent interview and record review, on [DATE], at 11:01 a.m., with the RD, Resident 1's Activities of Daily Living (ADL) - Eating [and] Amount Taken and the Clinical Interdisciplinary Assessment, record dated [DATE] to [DATE] was reviewed. The record indicated Resident 1's meal intake fluctuated and continuously decreased from [DATE] to [DATE]. The RD stated Resident 1's meal intake averaged between 40% to 78% on the following dates of calculation: 70% on [DATE]; 78% on [DATE]; 65% [DATE]; 59% on [DATE]; and 40% on [DATE]. The RD stated Resident 1 began to refuse some of his meals starting on [DATE]. During a review or Resident 1's Clinical Interdisciplinary assessment dated [DATE], [DATE], [DATE], [DATE] and [DATE] indicated, Resident 1 had an average meal intake a follows: 70% average meal intake from [DATE] to [DATE]; 78% average meal intake from [DATE] to [DATE]; 65% average meal intake from [DATE] to [DATE]; 59% average meal intake from [DATE] to [DATE]; and 40% average meal intake from [DATE] to [DATE]. During a concurrent interview and record review, on [DATE], at 11:01 a.m., with the RD, the facility's Policy and Procedure (P&P) titled, Weight Management Standard, dated ,d+[DATE] was reviewed. The P&P indicated, . A resident that is eating well but continues to lose weight may be offered: a. Large portions b. Snacks between meals c. Fortified diet - if albumin or prealbumin levels are low or protein needs are increased d. High Protein Nourishment - some residents are not able to consume large amounts of food or a satisfied with the amount of food being served, so they prefer to drink extra calories. A resident that is not eating well and continues to lose weight may be offered: a. RNA feeding program b. Three small meals and three snacks between meals c. Enriched diet d. Med pass supplement . The RD stated Resident 1 was on a Controlled Carbohydrate diet (CCHO - helps diabetics keep their carbohydrate consumption at a steady level). The RD stated no diet adjustments were made. The RD continued she does not know why she did not liberalize (diet that allows diabetics make choices with more variety throughout the day without increasing blood sugar levels) or fortify (diet that has a higher nutrient density without increasing portion size) Resident 1's diet. During a concurrent interview and record review, on [DATE], at 11:01 a.m., with the RD, the facility's Policy and Procedure (P&P) titled, Weight Management Standard, dated ,d+[DATE] was reviewed. The P&P indicated, .Phase III . If supplements are utilized labs may be ordered to monitor nutritional status . Follow up labs may be ordered to verify ability to maintain nutritional status without supplements .: The RD stated Resident 1 had no nutritional labs ordered during his stay at the facility. The RD stated, albumin (measures protein made by the liver, helps keep fluid in the bloodstream) and prealbumin (a test that evaluates protein in the blood and is a preferred indicator for protein malnutrition) are labs that can be ordered for residents who are malnourished. The RD stated she does not know why she did not request to order nutritional labs for Resident 1. During an interview with the DON, on [DATE], at 9:52 a.m., the DON stated the doctor had been notified of Resident 1's weight loss on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The DON stated the doctor responded to all notifications with No New Orders. During an interview on [DATE], at 11:43 a.m., with the Director of Nursing (DON), the DON stated it is the IDT and nursing responsibility to evaluate if Resident 1's weight loss interventions were effective. The DON stated, if the interventions were not effective then a different plan should have been initiated. The DON stated, the labs obtained at the ACH for Resident 1 on [DATE] did not include nutritional labs. The DON stated, the RD should have known if ordering lab tests for albumin or prealbumin were appropriate for Resident 1. During a review of the clinical records titled, Clinical Interdisciplinary Assessment by the IDT, dated [DATE], [DATE], [DATE], [DATE], and [DATE], all the reviews indicated Resident 1 was identified by the IDT to have a significant unplanned and unanticipated weight loss at each review. The IDT reviews indicated Resident 1 had trended a continuous decline in food intake and weight loss. The IDT reviews indicated no consults to other health professionals such as the Speech Therapist (ST), Occupational Therapist (OT), Gastrointestinal (GI), Pharmacist (RPh) or Dental providers were recommended or done. Resident 1 had snacks and shakes added to his diet and there were no indications of any evaluation for of effectiveness for these interventions, nor were there any indications if the IDT reviewed the records. There was no indication of any evaluation of other risk factors that could have attributed to Resident 1's decline in meal intake and severe weight loss. There was no escalation of interventions per the facility's P&P on Weight Management. During a review of Job Description/Performance Evaluation, dated [DATE], the Job description indicated, a Registered Dietician job duties are to, Evaluate the nutritional care of residents and document in the medical record. Using the Company formulary, recommends dietary interventions according to the status of the resident . Provides monthly review and documentation for residents with weight loss . and others considered at high risk. Observes and assesses residents to monitor food acceptance and nutritional status. Provides nutritional education for residents, families and care givers as needed .Comply with all covenant care policies, procedures, and standards. Demonstrate key competencies as required by the position and in accordance with State/Federal regulations . During a review of Resident 1's ACH 1 Discharge Summary dated [DATE], the Discharge Summary indicated, .Active/Final Diagnosis Shock most likely hypovolemic . had evidence of ketoacidosis (a serious complication of diabetes that occurs when the body produces high levels of blood acids) likely secondary to him not getting nutrition. Initially patient was treated in the line of septic shock with [intravenous] fluid . He was treated with volume resuscitation (rapid fluid infusion to maintain intravascular [inside blood vessels] volume . During a review of Resident 1's ACH 2 Discharge Summary dated [DATE], the Discharge Summary indicated, Reason for Hospital admission (Admitting Diagnosis): failure to thrive (according to the article Creative Nutrition: Solutions for Failure to Thrive Patients by B. [NAME], RD, LD Aging Well Vol. 3 No.4 P.8, FTT is described as a syndrome manifested by weight loss greater than 5% baseline, decreased appetite, poor nutrition, and inactivity often accompanied by dehydration . may result from physical and emotional deprivation, poor appetite, poor diet, or medical problems . All of these combined can easily lead to inadequate intake, malnutrition, unintended weight loss, weakness, functional decline, and other complicating factors . FTT is not a normal consequence of aging . For older patients exhibiting an unintended reduction of food intake, unintended weight loss . the term failure to thrive should trigger a thorough evaluation to determine reversible underlying causes . Undernutrition or Malnutrition. One of the most common symptoms of FTT is unintended weight loss that can result in undernutrition or protein energy malnutrition if left untreated. It is important to quickly and accurately identify older adults at risk of malnutrition . Easily treatable causes of FTT such as . poor nutritional intake should be addressed immediately . Medical Nutrition Therapy . One of the most important nutrition interventions is to ensure adequate calorie and protein intake .) at custodial care facility . Family stated he would not want to survive with any degree of disability. He has a POLST dated 2011 indicating DNR, Comfort Care, no trial of tube feeding. On [DATE] he had clearly continued to decline .and expired . During a review of Resident 1's ACH 2 Death Summary dated [DATE], the Death Summary indicated, . Immediate Cause of Death: Multiple organ failure . B. Due to: Severe protein calorie malnutrition . Time interval between onset and death: weeks . During a review of the facility's policy and procedure titled, Weight Management Standard, dated ,d+[DATE], the P&P indicated, .Residents identified to be at risk for weight variance, will have routine assessment and care plan interventions . The objective of this process is to assess, and manage weight variances, to determine appropriate referrals and/or interventions to achieve the best possible clinical outcomes . Assessment process is initiated on admission and continues at a minimum of monthly with intervention and care plan implementation as variance is identified . Licensed nurse, IDT and/or RD complete an assessment which may include a review of meal intake records, medication changes, physical assessment for declines, special equipment needs (utensils), pain psychosocial issues. IDT may coordinate Walking Rounds in order to better assess contributing factors to significant weight variance: questioning resident and/or family members to gain further insights and approaches. Review to identify potential casual factors of loss/gain, need for significant change in condition assessment and referral for continued assessment and intervention. Assess impact which may include: Medication that alters taste or appetite, Medication that causes fluid loss/gain, Vision problems, Communication issues, Dental problems, Chewing/Texture problems, swallowing problems, Decreased cognition, Psychological problems such as anxiety or depression . Intake does not meet nutritional needs . Reduced intake, Dehydration Risk . Decline in self-feeding, Resident needs further assistance or oversight during meals . Calorie or other dietary restrictions, Disease related conditions . Verify food is seasoned and palatable per resident, Verify food meets cultural or regional variations , Evaluate need for six smaller meals vs. standard three; smaller vs. larger portions, Re-evaluate placement in dining room and need for greater assistance/supervision, Re-evaluate in-room assistance level required . Implement meal fortification/ enriched/ enhanced program, Remove restrictions and liberalize diet . During a review of professional reference titled, Practice Paper of the American Dietetic Association, dated 2010, indicated , . In older adults, a 5% or more unplanned weight loss in 30 days often results in protein-energy undernutrition as critical lean body mass is lost . that may trigger sarcopenia [a condition characterized by loss of skeletal muscle mass and function] and functional decline [a loss of independence in self-care capabilities and deterioration in mobility and in activities of daily living]. (Practice Paper of the American Dietetic Association: Individualized Nutrition Approaches for Older Adults in Health Care Communities, [DATE] Journal of the American Dietetic Association) . During a review of professional reference titled, Involuntary Weight Loss can lead to Muscle Wasting . Depression and an increased rate of Disease Complications (www.aafp.org/afp American Family Physician). Dated [DATE], indicated, . Various studies demonstrated a strong correlation between weight loss and morbidity (the condition of suffering from a disease or medical condition) and mortality. One study showed that nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of diagnoses or cause of death. In another study, institutionalized elderly patients who lost five percent of their body weight in one month were found to be four times more likely to die within one year . During a review of a professional reference publication titled, Nutrition Care of the Older Adult from the Academy of Nutrition and Dietetics, dated 2016, indicated, . The goal of Medical Nutrition Therapy is to maintain or restore the individual's usual body weight . During a review of professional reference titled, The Academy of Nutrition and Dietetics Evidence Analysis Library regarding Unintended Weight Loss for Older Adults Evidence-Based Nutrition Practice Guidelines dated ,d+[DATE], indicated, . The Registered Dietitian should monitor and evaluate weekly body weights of older adults with unintended weight loss, until body weight has stabilized, to determine effectiveness of medical nutrition therapy (MNT) . During a professional reference reviewed retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2892745/pdf/nihms156446.pdf, Patterns of Weight Change Preceding hospitalization for Heart, dated [DATE], indicated, . Increases in body weight are associated with hospitalization for heart failure and begin at least [one] week before admission. Daily information about patients' body weight identifies a high-risk period during which interventions to avert decompensated heart failure that necessitates hospitalization for Heart Failure . Frequent monitoring of heart failure patients' clinical status, specifically their body weights, can alert clinicians to the early stages of heart failure decompensation. By focusing on weight changes, clinicians would be well positioned to implement interventions that could prevent decompensation of heart failure that necessitates hospitalization .

Based on interview and record review, the facility failed to ensure two of six sampled residents (Resident 1 and Resident 3) were provided with wound treatment in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Licensed Nurses (LNs) failed to perform Resident 1's physician prescribed wound care for four consecutive days of .cleanse S/P (status post [MEDICAL RECORD OR PHYSICIAN ORDER] .; and 2. LNs failed to perform Resident 3's day shift wound care on 12/1/20, 12/3/20, 12/4/20, 12/5/20, 12/6/20, 12/7/20 and evening shift on 12/4/20 and 12/7/20 and the weekly wound assessment on 12/2/20. These failures resulted in Resident 1's wound worsening in depth, exposing bone in the wound bed; Resident 1 experienced increased pain and was stressed and Resident 3's wounds worsened and had the potential for pain and infection. Findings: 1. During a review of Resident 1's Admission Record (a document containing demographic information), undated, the Admission Record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical functional level) assessment, dated 10/3/20, the MDS indicated Resident 3's Brief Interview for Mental Status (BIMS) assessment score was 15 (0-6 severe cognitive (pertaining to reasoning memory and judgement) deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit). During an interview on 12/9/20, at 1:56 p.m., with Resident 1, Resident 1 stated, the nurses did not perform the wound care to her left knee according to her physician orders. Resident 1 stated she was supposed to have wound care to her left knee twice daily. Resident 1 reviewed a notebook she kept at bedside and stated the wound care was only done once daily on 12/5/20, 12/6/20 and 12/7/20. Resident 1 stated her dates may be off because every day in the facility was the same. During a review of Resident 1's Physician Orders, dated December 2020, the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent interview and record review, on 12/9/20, at 3:47 p.m., with the Treatment Nurse (TN), Resident 1's TAR (Treatment Administration Record), dated December 2020 was reviewed. Resident 1's TAR indicated, on 12/3/20, 12/4/20, 12/5/20 and 12/6/20 day shift, there were no licensed staff initials in the boxes for Resident 1's left knee wound care to demonstrate the wound care was performed. The TN stated if the documentation was not in the TAR, the treatment had not been done. The TN stated the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] During a concurrent interview and record review, on 2/10/21, at 12:56 p.m., with the TN, Resident 1's Wound Assessment[s] (an evaluation of wound progress and need for treatment change), dated 12/2/20 and 12/9/20, were reviewed. The 12/2/20 wound assessment indicated Resident 1's wound had 2 small openings, measuring 0.5 centimeters (cm-unit of measurement) by 0.5 cm and the other measured 0.2 cm by 0.2 cm with no depth. The 12/9/20 wound assessment indicated, the wound had 2 openings, measuring 1 cm by 0.5 cm each with exposed bone and slough (dead tissue that needs to be removed from the wound for healing to take place) in the wound bed. The TN stated the missed wound care caused the wound to worsen. The TN stated Resident 1's physician did a tele-visit (physician visit performed via video) on 12/9/20 to evaluate the wound and the physician started Resident 1 on oral antibiotics because the wound had worsened. During a concurrent interview and record review on 3/3/21, at 11:07 a.m., with the Director of Nurses (DON), Resident 1's TAR, dated December 2020 was reviewed. The TAR indicated, Resident 1's wound care was not performed on the day shift as ordered on 12/3/20, 12/4/20, 12/5/20 and 12/6/20. The DON stated after the missed treatments, Resident 1's wound became larger and deeper. The DON stated when the treatment nurse was off, the station charge nurses were responsible to perform wound care. During a concurrent interview and record review on 6/16/21, at 3:50 p.m., with the TN, Resident 1's electronic medical record (EMR) was reviewed. Resident 1's MAR (Medication Administration Record) indicated, Resident 1 was prescribed intravenous (IV-into the vein) antibiotics from 10/1/20 until it was discontinued on 11/5/20, on 11/6/20. Resident 1 was prescribed oral antibiotics from 11/6/20 until 12/2/20. The TN reviewed the MARs dated 10/2020, 11/2020, 12/2020 and stated Resident 1 did not have an antibiotic prescribed from 12/4/20 until 12/9/20. The TN stated Resident 1's wound assessment indicated she had scant amount of purulent drainage (thick and milky discharge from a wound; it often indicates an infection) which indicated the wound was infected. During a telephone interview on 6/17/21, at 10:50 a.m., with Resident 1, Resident 1 stated, when the nurses did not perform the wound care to her knee twice a day according to the physician orders, it was very stressful for her and she had increased pain. During an interview on 3/8/21, with the Director of Nursing (DON), the DON stated she was unable to locate a Policy and Procedure (P&P) specific to following physician orders. The DON stated the facility followed the licensed nurse's job description. The DON provided a copy of the licensed nurse's job description. During a review of the facility's document titled Job Description/Performance Evaluation, dated 11/13/17, the job description indicated, job title LVN/LPN [licensed vocational or licensed practical nurse] . provides accurate assessment, over-sight, and monitoring of patients for quality medical management and early detection of changes in condition . utilizes professional standards in performing basic assessment and clinical monitoring . implements and maintains established policies and procedures relative to skin care treatments . properly prepares and administers medications and treatments . complies with professional standards, policies & procedures . principles for administering medications, treatments . During a professional reference review, retrieved from Lippincott Manual of Nursing Practice 10th Edition, dated 2014, page 16-17 indicated, Standards of practice General Principles . 1 The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable .b. These standards provide patients with a means of measuring the quality of care they receive .5. A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation . Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record . Failure to formulate or follow the nursing care plan . During a professional review titled, Does a Nurse Always Have to follow a Doctor's Orders? undated, retrieved from https://www.registerednursing.org/does-nurse-always-follow-doctors-orders/ indicated, .nurses cannot just randomly decide which order to follow and which not to follow. Unless there is a safety concern or an order that conflicts with personal or religious beliefs, failing to carry out orders can be grounds for discipline by the employer as well as the board of nursing, as it could be deemed 'neglect . 2. During a review of Resident 3's Admission Record, indicated, Resident 3 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 3's MDS assessment, dated 1/21/21, the MDS assessment indicated Resident 3's BIMS assessment score of 15. During a review of Resident 3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . every day and evening shift for ulcers . During a concurrent interview and record review on 12/9/20, at 3:47 p.m., with the TN, Resident 3's TAR, dated December 2020 was reviewed. The TAR indicated, there were no licensed staff initials in the box for Resident 3's wound care on day shift 12/1/20, 12/3/20, 12/5/20, 12/6/20 and day and evening shift on 12/4/20 and 12/7/20 to demonstrate wound care was performed. The TN stated there was no documentation on the TAR that indicated Resident 3 received wound care to his lower legs. During a review of Resident 3's wound assessment, dated 11/25/20, the wound assessment indicated, .type . stasis .epithelial (cells laid together in sheets with the cells tightly connective to one another) tissue present (pink) . drainage type . bloody . amount scant [very little] . improving . During a review of Resident 3's wound assessment, dated 12/11/20, the wound assessment indicated, .epithelial tissue present (pink) . moist . drainage type . bloody . amount small . evaluated wound progress . worsening . During a review Resident 3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . app [apply] to b/l [bilateral-(both)] lower legs ulcers topically every day and evening shift for ulcers . During a concurrent interview and record review on 2/10/21, at 12:56 p.m., with the TN, Resident 3's wound assessments and physician orders, were reviewed. The TN reviewed Resident 3's electronic medical record and stated she was unable to find a wound assessment performed the first week of December [2020]. The TN stated Resident 3's wounds were not assessed for 2 weeks. The TN stated licensed nurses should have performed a wound assessment on 12/2/21 according to the facility's policy. The TN compared the wound assessments dated 11/25/20 and 12/11/20 and stated the wounds had an increased amount of drainage and became moist between the assessments. The TN stated the change of condition was missed. The TN reviewed Resident 3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The TN stated Resident 3 had DM and was at a higher risk for infection. During a review of Resident 3's careplan, dated 2/17/20, the careplan indicated, .stasis [CONDITION(S)] (term used to describe skin irritation) to both lower extremities . skin breakdown will develop .evaluate skin weekly .observe skin integrity during am/pm care . During an interview on 3/3/21, at 10:18 a.m., with FM 1, FM 1 stated Resident 3 was her father. FM 1 stated Resident 3 tested positive for COVID-19 (a serious, contagious respiratory [Lung] infection transmitted from person to person) and was moved from his normal room into the COVID-19 unit the last week of November 2020 and did not return to his usual room until the second week of December 2020. FM 1 stated when Resident 3 had COVID-19, the nurses in the COVID-19 unit were not paying attention to his leg wounds and the wounds had gotten worse. FM 1 stated she called and notified Resident 3's physician the wounds had gotten worse. FM 1 stated after she spoke with the physician, Resident 3's wound care was done as ordered and his legs started to improve. During an interview on 3/3/21, at 11:07 p.m., with the DON, the DON stated Resident 3 missed several wound treatments from 12/1/20-12/7/20. The DON stated wound assessments must be done weekly to determine if there were any significant changes from week to week. The DON stated Resident 3 had Diabetes Mellitus which placed him at high risk for serious complications such as a skin infection, pain and poor healing. During an interview on 3/8/21, with the DON, the DON stated she was unable to locate a P&P specific to following physician orders. The DON stated the facility followed the licensed nurse's job description. The DON provided a copy of the licensed nurse's job description. During a review of the facility's document titled Job Description/Performance Evaluation, dated 11/13/17, the job description indicated, job title LVN/LPN . provides accurate assessment, over-sight, and monitoring of patients for quality medical management and early detection of changes in condition . utilizes professional standards in performing basic assessment and clinical monitoring . implements and maintains established policies and procedures relative to skin care treatments . properly prepares and administers medications and treatments . complies with professional standards, policies & procedures . principles for administering medications, treatments . During a review of the facility's P&P titled, Skin Integrity Standard dated July 2018, the P&P indicated, .patients identified to be at risk for skin breakdown . will have a routine assessment . a weekly comprehensive 'head to toe' assessment conducted by licensed nurse . During a professional reference review, retrieved from a website https://medlineplus.gov/ency/patientinstructions/ 4.htm, titled Venous ulcers [wounds caused by poor blood circulation]-self care, undated, indicated, .venous ulcers (open sores) can occur when the veins in your legs do not push blood back up to your heart as well as they should . signs and symptoms . blood pools in the veins of the lower leg, fluid and blood cells leak out into the skin . wound care . always keep the wound clean and bandaged to prevent infection . your provider will tell you how often you need to change the dressing . keep the dressing and the skin around it dry . try not to get healthy tissue around the wound too wet . this can soften the health[y] tissue, causing the wound to get bigger . signs of infection . more drainage than before . bleeding . During a professional reference review, retrieved from Lippincott Manual of Nursing Practice 10th Edition, dated 2014, page 16-17 indicated, Standards of practice General Principles . 1 The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable .b. These standards provide patients with a means of measuring the quality of care they receive .5. A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation . Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record . Failure to formulate or follow the nursing care plan . During a professional review titled, Does a Nurse Always Have to follow a Doctor's Orders? undated, retrieved from https://www.registerednursing.org/does-nurse-always-follow-doctors-orders/ indicated, .nurses cannot just randomly decide which order to follow and which not to follow. Unless there is a safety concern or an order that conflicts with personal or religious beliefs, failing to carry out orders can be grounds for discipline by the employer as well as the board of nursing, as it could be deemed 'neglect .