Every finding on record at Pacifica Hospital of the Valley DP SNF

Based on interview and record review, the facility failed to review and update their facility assessment at least annually. This deficient practice had the potential to result in residents not receiving necessary care and services in a timely manner due to the facility's failure to evaluate the resident population and identify the resources needed to provide appropriate care and services.Findings: During a concurrent interview and record review on 2/11/2026 at 8:25 a.m. with the Director of Staff Development (DSD), the document titled Facility Assessment Tool, updated 2/9/2026, was reviewed. The DSD stated the document Facility Assessment Tool was used to create a facility assessment during the week of 2/9/2026. During a concurrent interview and record review on 2/11/2026 at 3:34 p.m. with the Director of Nursing (DON) and DSD, the DSD and DON were unable to provide the previous facility assessment document or the date it was completed or last reviewed. The DSD stated he was not sure if a facility assessment had been completed in 2025. The DSD stated a staff member that last worked in the facility in 2024 was in charge of completing the facility assessment and no one had access to the last version of the facility assessment at this time. The DSD stated the facility did not have a policy or procedure regarding how and when to conduct a facility assessment. The DON stated the facility assessment should be completed regularly and should involve input from residents and their families so the residents can feel like they have a voice and the facility can be assessed as a whole. During an interview on 2/12/2026 at 11:22 a.m. with the DSD, the DSD stated the facility assessment should be updated yearly in case there are new issues or concerns so the facility can address and accommodate them.

Based on interview and record review, the facility failed to electronically submit staffing information based on payroll data to the Centers for Medicare & Medicaid Services (CMS) in the third quarter (4/1/2025-6/1/2025) of 2025. The deficient practice had the potential to not provide the required staffing to ensure residents' care and safety. Findings: During a concurrent interview and record review on 2/12/2026 at 11:40 a.m., with the Staffing Coordinator (SC), the 2025 Payroll-Based Journal (PBJ) Staffing Report for quarter 1 (10/1/2024-12/31/2024), quarter 2 (1/1/2025-3/31/2025), quarter 3 (4/1/2025-6/20/2025), and quarter 4 (7/1/2025-8/30/2025) were reviewed. The 2025 PBJ Staffing Report for quarter 3 was triggered for failing to submit data for the quarter. The SC stated it is a requirement to submit PBJ data quarterly. During an interview with Director of Staff Development (DSD) on 2/12/2026 at 12:08 p.m., the DSD stated the initial PBJ data submitted to CMS for quarter 3 did not go through because of an issue with the data file sent. The DSD stated the facility fixed the problem and resubmitted it, but it missed the deadline. The DSD stated the purpose of submitting PBJ data is to provide the number of staffing hours taking care of the residents. The DSD explained that when PBJ data is not submitted, the facility fails to show compliance with staffing hours which affects the facility's Centers for Medicare & Medicaid Services (CMS) star rating (evaluation of the quality and performance of nursing homes to help consumers compare facilities). During an interview on 2/12/2026 at 12:25 p.m., with the Director of Nursing (DON), the DON stated the facility does not have a policy regarding submission of PBJ staffing.

Based on interview and record review, the facility failed to maintain documentation and demonstrate evidence of an ongoing quality assurance and performance improvement (QAPI) program. This deficient practice increased the risk of failing to identify areas in which the facility needed to improve which had the potential to negatively impact the care residents received as well as their quality of life. Findings: During a concurrent interview and record review on 2/12/2026 at 11:22 a.m. with the Director of Nursing (DON) and Director of Staff Development (DSD), the facility's QAPI Minutes, dated 11/25/2025, 12/16/2025, and 1/29/2026, were reviewed. The DON stated these were the only documented QAPI meetings from the past year, as she started doing QAPI again after she was hired in the fall of 2025. The DON stated the importance of a well-developed QAPI program is to give department leaders time to discuss issues, identify potential gaps in care, and brainstorm ideas to implement in order to improve care for the residents. The DSD stated before the current DON started in the fall of 2025, there was a QAPI program, but it was not documented properly and there were only sign in sheets showing the staff that was present. The DSD stated the QAPI meetings should be documented so they know what they have discussed before in previous meetings and can continue to act on it. During a review of the facility's policy and procedure (P&P) titled, Quality Assurance and Performance Improvement (QAPI) Committee 2025, last reviewed 1/29/2026, the P&P indicated one goal of the QAPI committee is to establish, maintain, and oversee organizational systems and processes to support the delivery of quality of care and services. The P&P further indicated the committee shall maintain minutes of all meetings that include the date and time the committee met, the names of committee members present and absent, a summary of the reports and findings, a summary of any approaches and action plans to be implemented, conclusions and recommendations from the committee, and the time the meeting adjourned.

Based on observation, interview, and record review, the facility failed to ensure staff followed transmission-based precautions (rules to prevent spreading infections) in accordance with facility policy and infection prevention standards to prevent the spread of infection, when the facility failed to ensure: 1.Licensed Vocational Nurse (LVN) 3 removed soiled gloves before pressing the call light reset button while giving morning care to Resident 55 who was on Enhanced Barrier Precautions (infection control steps requiring staff to wear gowns and gloves during high-contact care [like bathing, dressing, or changing catheters] for residents with, or at high risk of having, hard-to-treat germs) and did not pour visibly contaminated fluids into the shared sink in Resident 55's room. 2. Resident 22 did not have multiple disposable face masks hanging from the wheelchair or touching its wheels. 3. Infection outcomes were documented in the infection surveillance logs (a record-keeping tool used by nursing homes to track, analyze, and manage infections among residents). 4. Infection surveillance data is analysis (the ongoing, systematic collection and review of disease reports to track, understand, and stop the spread of infections) conducted and reports are generated at least quarterly, following facility policies and procedures (P&P). 5. The facility's Water Management Program ([WMP] - a written, step-by-step plan for buildings to ensure their water system was safe, clean, and efficient) was implemented and maintained as written. 6. Resident 13's bubble humidifier (a medical device that includes a plastic bottle partially filled with distilled water to add moisture to supplemental oxygen given to residents) was changed on 2/6/2026 as scheduled per physician orders. These failures placed residents, staff, and visitors at risk for exposure to and transmission of infectious organisms, incomplete monitoring and follow up of infections, missed trends or outbreaks due to lack of surveillance data analysis, contamination of equipment and unsafe water conditions. Findings: 1. During a review of Resident 55's Patient Registration Form, the Patient Registration Form indicated that Resident 55 was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE]. During a review of the History and Physical (H&P) dated 4/2/2025, the H&P indicated Resident 55 was admitted to the facility with diagnoses including chronic traumatic encephalopathy following head injury (permanent brain damage that happens after many head injuries), history of seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), tracheostomy (a surgically created hole in the neck that leads directly into the windpipe to help a person breathe), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 55's Minimum Data Set ([MDS] - a resident assessment tool) dated 12/18/2025, the MDS indicated Resident 55 was comatose. Resident 55 was dependent (helper does all the effort) from staff with all activities of daily living (ADL), such as oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. The MDS indicated that Resident 55 was dependent with roll left and right (ability to roll from laying on back to left and right side and return to laying on back on the bed). During a concurrent observation and interview on 2/9/2026 at 10:17 a.m. with LVN 3 in Resident 55's room, observed LVN 3 and LVN 4 providing morning care to Resident 55. While doing so, Resident 55's head activated the touch pad call light (an alerting device for nurses or other nursing personnel to assist a patient when in need). LVN 3 was observed pressing the call light reset button without changing soiled gloves and then continuing morning care. LVN 3 stated that touching the call light reset button with contaminated gloves could lead to cross-contamination and spread of infection to residents, staff, and visitors. During a concurrent observation and interview on 2/9/2026 at 10:25 a.m. with LVN 3 in Resident 55's room, LVN 3 was observed disposing of visibly contaminated fluids into a shared sink after completing Resident 55's morning care. LVN 3 stated that disposing of contaminated water into a shared sink could contaminate the sink and surrounding surfaces, potentially spreading pathogens and increasing the risk of cross-contamination for residents, staff, and visitors. 2. During a review of Resident 22's Patient Registration Form, the Patient Registration Form indicated that Resident 22 was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE]. During a review of the H&P dated 7/11/2025, the H&P indicated Resident 22 was admitted to the facility with diagnoses including chronic respiratory failure, tracheostomy, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 22's MDS dated [DATE], the MDS indicated Resident 22 was cognitively intact with little to no cognitive impairment. The MDS indicated Resident 22 was independent (resident completes the activity by themselves with no assistance from a helper) with oral hygiene, upped body dressing, lower body dressing, putting on/taking off footwear, personal hygiene. The MDS indicated the resident requires substantial/maximal assistance (helper does more than half the effort) with shower/bath. During a concurrent observation and interview on 2/10/2026 at 10:42 a.m. with Resident 22, Resident 22 was observed self-propelling in a wheelchair with multiple disposable face mask hanging from the wheelchair break handle. The masks were coming into contact with the wheelchair wheels. Resident 22 stated he takes extra disposable face masks from the nurses' station and keeps them on his wheelchair. Resident 22 further stated he changes masks frequently due to excessive mucus related to his tracheotomy. During an interview on 2/10/2026 at 10:45 a.m. with Registered Nurse (RN) 3, RN 3 stated disposable masks should not be hung on the wheelchair brake handle or touch the wheelchair wheels. RN 3 stated this could contaminate the masks. RN 3 further stated using potentially contaminated masks could increase the risk of infection for the resident. 3. During a concurrent interview and record review on 2/11/2026 at 11:15 a.m. with Infection Preventionist (IP), the facility's Infection Surveillance Logs indicated no documentation of outcomes for identified infections. IP stated that outcomes for identified infections should be documented int the infection surveillance log to ensure interventions and treatments are effective. 4.During a subsequent interview and record review on 2/11/2026 at 11:30 a.m. with IP, the IP stated she was unfamiliar with the Infection Surveillance Analysis and Reports and was not aware that Surveillance Analysis needed to be completed. Record review indicated the facility had no documented Infection Surveillance Analysis Reports. 5. During a concurrent interview and record review on 2/12/2026 at 8:00 a.m. with Plant Operator Director (POD), the POD stated water temperatures are checked daily. The POD stated chlorine residual levels were not tested in the facility. The POD further stated the facility did not maintain a schedule for water testing and the facility did not have logs for water testing and the results as indicated in the facility's WMP. The POD stated failure to routinely test and document water quality, including chlorine residuals, may allow the growth and spread of waterborne pathogens (bacteria, viruses, or parasites found in contaminated water), which could place residents, staff and visitors at risk for waterborne infections (illnesses caused by bacteria, viruses, or parasites from human or animal waste that contaminate drinking or recreational water). During an interview on 2/12/2026 at 3:00 p.m. with Director of Nursing (DON), the DON stated the call light reset button was considered a high touch surface. The DON stated pressing the call light reset button with soiled gloves could lead to contamination of the surface and increase the risk of cross-contamination and the spread of pathogens to residents, staff and visitors. During a subsequent interview with DON on 2/12/2026 at 3:00 p.m., the DON stated disposing contaminated water into a resident's sink can contaminate the sink basin and surrounding surfaces. The DON stated that subsequent use of the contaminated sink for hand hygiene or resident care could expose residents and staff to pathogens, increase the risk of infections, leading to serious complications. The DON stated that infection surveillance logs should track the outcome, treatment response and follow up for each identified infection. The DON further stated without documenting infection outcomes in the surveillance logs the facility would not be able to determine if treatments are effective, if proper infection control processes are being followed, or if resident care interventions are meeting the residents' needs. The DON stated that it was the facility's policy to analyze infection surveillance data and generate reports and trends. The DON stated that failure to analyze surveillance data could affect the facility's ability to identify infection patterns or trends. The DON was uncertain about how often the surveillance data should be analyzed. The DON stated failure to follow the facility's WMP could compromise water quality, allow bacterial growth including Legionella (a type of bacteria found in water that can cause a severe, pneumonia-like lung infection), and result in residents being exposed to contaminated water, increasing the risk of waterborne infections. During a review of facility's P&P titled, Personal Protective Equipment (PPE) dated October 2025, the P&P indicated, Gloves shall be removed immediately and hands washed after each task was completed. If gloves are not removed, contamination of the environment, other patients, or other body sites on the same patient can occur. During a review of facility's P&P titled, Infection Control Plan 2025, dated May 2025, the P&P indicated, The Infection Preventionist will be responsible for data collection, evaluation and follow up. Surveillance data will be collected and recorded in the appropriate fashion. The Infection Preventionist will analyze and present the surveillance data to the Infection Control Committee and appropriate medical staff committees at least quarterly. During a review of facility's P&P titled, Isolation Precautions, dated May 2025, the P&P indicated, Use Standard Precautions for the care of all patients. Handle used patient care equipment soiled with blood, body fluids, secretions and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing and transfer of microorganisms to other patients and environments. During a review of facility's WMP, dated January 2024, the WMP indicated, Control measures and limits have been established to limit growth and spread of Legionella, such as maintaining domestic hot water temperatures in the storage tanks, hot water return temperatures, frequent flushing of hot water faucets and Pacifica Hospital - Water Management Plan (January 2024 updated) Page 9 of 13 showers in low-use area, maintaining chemicals in cooling tower to inhibit bacteria growth, monitoring hot water temperatures at distal locations throughout all buildings, and monitoring residual monochloramine levels in the cold water distal locations. 6. During a review of Resident 13's admission Record (the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted Resident 13 to the facility on [DATE]. During a review of the History and Physical (H&P) Note completed on 9/21/2023, the H&P indicated Resident 13 was admitted to the facility with diagnosis that included chronic hypoxemic respiratory failure (a long-term condition where the lungs cannot sufficiently transfer oxygen into the blood), cerebral vascular accident (CVA –stroke, loss of blood flow to a part of the brain), and post percutaneous endoscopic gastrostomy (PEG – medical device inserted into the stomach to provide essential nutrition, fluids, and medication or require long term feeding). The H&P indicated Resident 13 is unable to make decisions. During a review of Resident 13's Minimum Data Set (MDS – a resident assessment tool), dated 12/19/2025, the MDS indicated Resident 13 rarely/never able to make self-understood and rarely/never able to understand others. The MDS indicated Resident 13 was dependent (helper does all of the effort) with oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. During an observation on 2/9/2026 at 8:33 a.m. at Resident 13's bedside, a bubble humidifier dated 2/4 was observed connected to Resident 13's oxygen tubing. During an interview on 2/9/2026 at 11:13 a.m. with Respiratory Therapist (RT), RT 1 stated the date on the bubble humidifier indicates when it was last changed. RT 1 stated that Resident 13's bubble humidifier was dated 2/4, indicating that it was last changed on 2/4/2026 and had not been changed on 2/6/2026 as scheduled per physician orders. During a review of Resident 13's Order Summary Report, dated 2/11/2026, the Order Summary Report indicated a physician's order on 12/18/2023 to change the bubble humidifier in the morning every Monday, Wednesday, and Friday. During a review of Resident 13's MAR dated February 2026, the MAR indicated that on 2/6/2026 for the 9 am administration time, there were staff initials in the box for the order to change bubble humidifier in the morning of every Monday, Wednesday, and Friday, indicating the task had been completed. During an interview on 2/12/2026 at 11:19 a.m. with RT 2, RT 2 stated he documented on Resident 13's MAR on 2/6/2026 at 9am that he changed the bubble humidifier before he went to Resident 13's bedside to perform the task. RT 2 explained that when he went to Resident 13's bedside, Resident 13 was occupied and receiving care from another staff. RT 2 stated he did not change the bubble humidifier and meant to return later but forgot. RT 2 stated, It slipped my mind. RT 2 stated the bubble humidifier was not changed at all on 2/6/2026 as ordered. RT 2 stated it is important to change the bubble nebulizer regularly as scheduled to prevent bacterial or any other unwanted growth. During a review of the facility's P&P titled, Infection Control Plan 2025 last reviewed 1/29/2026, the P&P indicated, the facility is to maintain a comprehensive and effective program of surveillance, prevention, and control of infection .The organization will employ a coordinated process to reduce the risks of endemic, and epidemic, or healthcare-related infections(s) in patients and healthcare workers.Risk Mitigation: Practices to Decrease the Risk of Transmission.Adherence to appropriate infection prevention measures (e.g. hand hygiene, barrier precautions, aseptic techniques).

Based on observation, interview, and record review, the facility failed to provide care in a manner that promoted dignity and respect for four out of four sampled residents (Residents 1, 30, 49, and 64) when: 1. The facility failed to ensure Resident 1's Foley catheter (a specific type of tube inserted into the bladder to help drain urine) collection bag (designed to collect urine drained from the bladder via catheter) was covered with a dignity bag (a bag used to cover and hold the catheter drainage/collection bag, so it is not visible). 2. The facility failed to ensure a Restorative Nursing Assistant (RNA 1) knocked or requested permission before entering Resident 30's room. 3. LVN 2 failed to provide privacy while administering medications through Resident 49's gastrostomy tube (g-tube, a medical device inserted directly into the stomach through the abdomen to deliver nutrition, fluids, and medication). 4. The facility failed to honor Resident 64's right to be informed and involved in his care planning, when the resident was not provided with ongoing information regarding the status of his requested transfer to another facility. These deficient practices violated the residents' rights to be treated with respect and dignity and had the potential to negatively affect the residents' sense of self-worth and self-esteem. Findings: 1. During a review of Resident 1's admission Record (the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted Resident 1 to the facility on [DATE]. During a review of the History and Physical (H&P) report completed on 12/1/2025, the H&P indicated Resident 1 was admitted to the facility with diagnoses that included acute hypoxemic respiratory failure (a medical emergency where the lungs suddenly cannot transfer enough oxygen into the bloodstream to preserve normal organ function), diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and history of urinary tract infection (UTI – an infection of the urinary system, which includes the kidneys, ureters, bladder and urethra). During a review of Resident 1's Minimum Data Set (MDS – a resident assessment tool), dated 12/12/2025, the MDS indicated Resident 1 rarely/never able to make self-understood and rarely/never able to understand others. The MDS indicated Resident 1's cognitive skills for decision making are severely impaired (never/rarely made decisions). The MDS indicated Resident 1 was dependent (helper does all of the effort) with oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. During an observation on 2/10/2026 at 4:05 p.m., Resident 1's Foley catheter collection bag was attached to the side of the bed rail, with the urine visible inside. The urine collection bag was observed to be attached to a dignity bag, with the collection bag placed outside of the dignity bag. During a concurrent observation and interview on 2/10/2026 at 4:10 p.m. with Licensed Vocational Nurse (LVN) 1 in Resident 1's room, LVN 1 stated the urine collection bag observed outside the dignity bag should be inside the dignity bag. LVN 1 explained the purpose of the dignity bag is to hide the urine draining from the resident from other people's view. LVN 1 stated that privacy is a resident's right and the dignity bag provides privacy. During a review of Resident 1's Order Summary Report, dated 2/11/2026, the Order Summary Report indicated a physician's order on 11/29/2025 for Foley catheter size 16x10 every shift for wound management During an interview on 2/12/2026 at 12:25 p.m. with the Director of Nursing (DON), the DON stated that dignity bags are expected to be used for all residents with foley catheters. During a review of the facility's P&P titled, Patient's Rights - Residents last reviewed 1/29/2026, the P&P indicated, It is the policy of the Patient Care Services, Subacute Units, to have policies and procedures on residents' rights to ensure that each resident is able to fully exercise his or her rights as resident and as a citizen. Ensuring that residents are afforded these rights contribute to their quality of life and this to the overall quality of care provided in the facility.5. This facility shall treat each resident with consideration, respect, and full recognition of his/her dignity and individuality. 2. During a review of Resident 30's Patient Registration Form, the Patient Registration Form indicated the facility admitted the resident on 8/28/2021. During a review of Resident 30's History and Physical (H&P) dated 2/9/2026, the H&P indicated Resident 30 had the diagnoses of tracheostomy (surgically created opening in the front of the neck leading directly into the trachea [windpipe] to help a person breathe) with ventilator (a machine that helps you breathe) dependence and cerebral vascular accident (CVA-stroke, loss of blood flow to a part of the brain). The H&P further indicated Resident 30 was unable to make his own decisions. During a review of Resident 30's MDS, the MDS indicated the resident rarely/never understood others and rarely/never made themselves understood. The MDS further indicated Resident 30 was completely dependent (helper does all the effort) on staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During an observation and interview on 2/9/26 at 9:57 a.m., in the hallway near the entrance of Resident 30's room with RNA 1, RNA 1 was observed entering Resident 30`s room without knocking on the door and asking permission to go in. At this time Resident 30 was on his bed. Upon exiting the room and when interviewed, RNA 1 stated she forgot to knock on the resident's room and stated that she should have knocked and asked permission to go in since this is the resident's home and they deserve privacy. During an interview on 2/10/26 at 11:26 a.m. with the Director of Nursing (DON), the DON stated that anyone entering a resident`s room must knock and ask permission prior to entering the resident`s room. The DON stated resident`s privacy should be respected to avoid embarrassment. The DON stated that residents should be treated with respect and dignity. During a review of the facility`s policy and procedure (P&P) titled Patient's Rights - Residents, last reviewed on 1/29/2026, the P&P indicated that the facility shall treat each resident with respect and full recognition of dignity and staff will knock prior to entering the room. 3. During a review of Resident 49's Patient Registration Form, the Patient Registration Form indicated the facility admitted the resident on 2/18/2022. During a review of Resident 49's History and Physical (H&P), dated 7/11/2025, the H&P indicated Resident 49 had diagnoses including, but not limited to, chronic (long-term) respiratory failure (a condition where the lungs cannot release enough oxygen into the blood), was dependent on a ventilator (a medical device to help support or replace breathing), and required a g-tube to receive nutrition. The H&P further indicated Resident 49 had an impaired mental status and was unable to make decisions. During a review of Resident 49's Minimum Data Set (MDS – a resident assessment tool), dated 11/14/2025, the MDS indicated Resident 49 was in a persistent vegetative state (a disorder of consciousness following severe brain injury where the person is awake but completely unaware of themselves or their environment) and was dependent (helper does all of the effort) for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a concurrent observation and interview on 2/11/2026 at 8:45 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 entered Resident 49's shared room to administer medications via her g-tube. LVN 2 closed the resident's curtain to the resident's left side but left the foot of the bed and the resident's right side exposed. LVN 2 then lifted the resident's gown exposing her abdomen and g-tube and began administering medications. LVN 2 stated the resident should have been provided privacy during medication administration. LVN 2 stated residents should be given privacy because it is one of their basic rights. During an interview on 2/11/2026 at 3:34 p.m. with the Director of Nursing (DON) and Director of Staff Development (DSD), the DON stated the resident should have been provided privacy during medication administration. The DON stated residents have the right to privacy, and they may not want anyone else to know they have a g-tube. The DSD stated residents deserve dignity and should be given privacy when being exposed. During a review of the facility's policy and procedure (P&P) titled, Patient's Rights - Residents, last reviewed 1/29/2026, the P&P indicated the facility shall treat each resident with consideration, respect, and full recognition of his/her dignity and individuality. The P&P further indicated all treatments and personal care are given in privacy. 4. During a review of Resident 64's Patient Registration Form, the Patient Registration Form indicated the facility originally admitted the resident on 4/18/2025 and readmitted to the facility on [DATE]. During a review of Resident 55's H&P dated 4/2/2025, the H&P indicated Resident 55 was admitted to the facility with diagnoses including chronic respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), history of deep venous thrombosis ([DVT] - a serious medical condition where a blood clot forms in a deep vein), history of pulmonary embolism (a sudden, often life-threatening blockage in one or more arteries in the lungs). During a review of Resident 64's MDS, the MDS indicated Resident 64 was cognitively intact (able to make clear decisions). The MDS indicated that Resident 64 was dependent (helper does all the effort) from staff with toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated that Resident 64 was dependent with sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed) and chair/bed-to-chair transfer (he ability to transfer to and from a bed to a chair (or wheelchair). During an interview on 2/9/2026 at 9:30 a.m. with Resident 64, Resident 64 expressed dissatisfaction with the lack of communication regarding his care plan and transfer process. Resident 64 stated that he informed the social worker of his request to be transferred to a facility closer to his family approximately two months ago. Resident 64 stated he had not received any updates or information about the status of his request. During a concurrent interview and record review on 2/10/2026 at 3:35 p.m. with Social Worker (SW) 1, Resident 64's Social Service Notes for January and February 2026 were reviewed. The Social Service Notes indicated no documentation that Resident 64 was provided with information about the transfer referrals and was updated on the status of the transfer process. SW 1 stated the transfer process in progress had not been communicated to Resident 64. SW 1 stated it is Resident 64's right to be informed and updated regarding his care plan. During an interview on 2/12/2026 at 3:00 p.m. with Director of Nursing (DON), the DON stated it was the facility's policy to review and communicate care plan updates with residents and resident representatives. The DON stated residents have the right to be informed, and that staff were expected to discuss care plan updates and obtain the residents' input when changes occur. The DON further stated that residents and their families should be involved in care planning and kept aware of progress of all aspects of care. During a review of facility's policies and procedures (P&P) titled, Patient's Rights – Residents dated December 2025, the P&P indicated, This facility shall recognize and respect individuality of each resident and encourage expression of capabilities and independence. Therefore, compliance with the Federal and State regulations for residents' rights shall be maintained and utilized to enhance the comfort and wellbeing of each patient. Failure to ensure these rights will not be tolerated by facility management.

Based on observation, interview, and record review, the facility failed to provide an environment that was free from accident hazards for three of four residents (Residents 44, 29 and 55) reviewed under the accident care area by failing to: a. Provide upper bed rail padding for Resident 44, who had a history of seizures (a sudden surge of abnormal electrical activity in the brain, leading to a range of symptoms like muscle spasms, loss of consciousness). b. Apply bed side rail padding for seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) precautions as ordered by the physician for Resident 29. c. Ensure implementation of appropriate seizure precautions for Resident 55 with a documented history seizure disorder, as Resident 55 was observed with side rail up without padding and had no order for padded side rails. These deficient practices placed Residents 44, 29 and 55 at risk of injury and trauma during seizures. Findings: a. During a review of Resident 44's Patient Registration Form, the Patient Registration Form indicated the facility admitted Resident 44 on 3/27/2025. During a review of Resident 44's History and Physical (H&P), dated 1/26/2026, the H&P indicated Resident 44's had diagnoses including seizures assessment plan included seizures and tracheostomy (surgically created opening in the front of the neck leading directly into the trachea [windpipe] to help a person breathe). The H&P further states Resident 44 was unable to make his own decisions. During a review of Resident 44's Minimum Data Set (MDS – an assessment and care screening tool) dated 11/20/2025, the MDS indicated the resident rarely/never understood others and rarely/never made themselves understood. The MDS further indicated Resident 44 was completely dependent (helper does all the effort) on facility staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 44's Physician's Order printed on 2/11/2026, the Physician's Order indicated an order dated 5/20/2025, for bilateral padded side rails up at all times. During an observation on 2/9/2026 at 9:26 a.m. in Resident 44's room, Resident 44 was lying in bed with his eyes closed. The upper bed rails on Resident 44's bed were made of metal and were not padded. During a concurrent observation and interview on 2/9/2026 at 9:33 a.m. in Resident 44's room with Registered Nurse (RN 1), RN 1 stated Resident 44's bed did not have the necessary padding on his bedrails to keep him safe during a seizure. RN 1 stated the padding is to protect the resident's head and body from the uncontrolled shaking from seizures. During an interview on 2/9/2026 at 1:45 p.m. with the Director of Nursing (DON), the DON stated the facility staff did not follow the physician's instructions to apply padding to Resident 44's side rails and without them Resident 44 could sustain injuries if he had seizure. During a review of the facility provided Policy and Procedure (P&P) titled, Seizure Precautions last reviewed on 1/29/2026, the P&P indicates to provide a safe environment and pad side rails as indicated. b. During a review of Resident 29's Patient Registration Form, the Patient Registration Form indicated Resident 29 was admitted to the facility on [DATE]. During a review of the H&P report dated 12/10/2025, the H&P indicated Resident 29 was admitted to the facility with diagnoses including chronic respiratory failure with hypoxia (a condition where there's not enough oxygen or too much carbon dioxide in your body), seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), traumatic subdural hemorrhage (a head injury causes blood vessels to tear and leak blood between the brain and its outer covering), dysphagia (difficulty swallowing). During a review of Resident 29's MDS dated [DATE], the MDS indicated Resident 29 had moderate cognitive impairment (decisions poor; cues/supervision required). The MDS indicated Resident 29 was dependent (helper does all the effort) from staff with all activities of daily living (ADL), such as oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. The MDS indicated that Resident 29 was dependent with chair/bed-to-chair transfer (the ability to transfer to and from a bed to a chair (or wheelchair). During a review of Resident 29's Order Summary Report dated 5/5/2024, the Order Summary Report indicated physician order for bilateral (two sides) padded side rails at all times every shift. During a concurrent observation and interview on 2/10/2026 at 2:04 p.m. with Licensed Vocational Nurse (LVN) 6 in Resident 29's room, Resident 29's bed was observed with all 4side rails up with no padding. LVN 6 stated Resident 29 was at risk for seizures. LVN 6 stated Resident 29 was at risk for seizures, and that lack of padding could result in head injury or trauma during a seizure. c. During a review of Resident 55's Patient Registration Form, the Patient Registration Form indicated that Resident 55 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. During a review of the H&P dated 4/2/2025, the H&P indicated Resident 55 was admitted to the facility with diagnoses including chronic traumatic encephalopathy following head injury (permanent brain damage that happens after many head injuries), history of seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), tracheostomy (a surgically created hole in the neck that leads directly into the windpipe to help a person breathe), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 55's MDS dated [DATE], the MDS indicated Resident 55 was comatose. Resident 55 was dependent from staff with all ADLs, such as oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. The MDS indicated that Resident 55 was dependent with roll left and right (ability to roll from laying on back to left and right side and return to lying on back on the bed). During a concurrent interview and record review on 2/10/2026 at 2:08 p.m. with LVN 6 of Resident 55's Care Plan Report dated 6/20/2026 indicated bilateral padded side rails were to remain up all times for seizure precautions. However, the Physician Order Summary did not indicate documentation of an order to maintain padded side rails up at all times for seizure precautions. LVN 6 stated Resident 55 had a history of seizure disorder. During a concurrent observation and interview on 2/10/2026 at 2:10 p.m. with LVN 6 in Resident 55's room, Resident 55's bed observed having 4 siderails up with no padding on any of the siderails. LVN 6 stated without an order and padding in place, Resident 55 could be at increased risk for head injury or trauma in the event of seizures. During an interview on 2/12/2026 at 3:00 p.m. with Director of Nursing (DON), the DON stated that Residents 29, 44, and 55 were on seizure precautions. The DON stated that seizure precautions should follow the physician's orders and individualized assessments. The DON stated that failure to follow ordered interventions and implement seizure precautions, including padded side rails when indicated, could place residents at serious risk of harm. The DON added that unpadded side rails during a seizure could cause injuries such as head trauma, fractures, skin breakdown or even death. During a review of the facility's policy and procedure (P&P) titled, Seizure Precautions, reviewed/revised on December 2025, the P&P indicated, It is the policy of the facility to provide preventative measures prior to and during seizure activity to prevent resident injury to the extent possible. Identify residents with potential for seizure activity on the resident's care plan. Provide safe environment. Pad side rails as indicated.

Based on observation, interview, and record review the facility failed to safely use side rails for five of six sampled residents (Resident 6, 8, 24, 29, 55) by failing to: 1.Having a physician's order for Resident 55 and Resident 6's use of side rails and follow the physician's order for bilateral side rails up at all times, when all four side rails were observed up. 2. Assess Residents 6, 8, 24, 29, and 55 for risk of entrapment from bed rails prior to installation and obtain informed consent prior to use of side rails. These deficient practices had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning, psychosocial harm (mental, emotional, or physical injuries caused by social factors, or stressful interactions, rather than physical accidents), physical harm and risk for entrapment (getting stuck). Findings: a. During a review of Resident 6's Patient Registration Form, the Registration Form indicated the facility admitted the resident on 6/3/2022. During a review of Resident 6's History and Physical (H&P), dated 1/26/2026, the H&P indicated Resident 6 had diagnoses including tracheostomy (surgically created opening in the front of the neck leading directly into the trachea [windpipe] to help a person breathe). and dysphagia (difficulty swallowing). The H&P further indicated Resident 6 did not have the capacity to make his own decisions. During a review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/8/2026, the MDS indicated Resident 6 had some cognitive decline but is able to make himself understood and understand others. During a review of Resident 6's Order Summary Report, the report included and order dated 6/3/2026 for bilateral side rails up at all times every shift. During a review of Resident 6's Side Rails Care Plan (CP), initiated on 6/27/2026, the CP had an intervention to use side rails as indicated. During an observation on 2/9/2026, at 9:58 a.m., inside Resident 6's room, Resident 6 was sitting up in bed with four side rails up (upper and lower). During a concurrent observation and interview on 2/9/2026, at 10:33 a.m., inside Resident 6's room with Registered Nurse (RN 1), RN 1 looked at the bed rails and stated four side rails are up, but that she believed it should be only two. During a concurrent interview and record review on 2/9/2026 at 1:05 p.m. with RN 1, RN 1 reviewed Resident 6's electronic and paper medical record. RN 1 stated there was an order for only bilateral (two) side rails up and all four should not have been up for Resident 6's safety. RN 1 searched and stated there was not a consent for the use of bed rails or an assessment for entrapment. RN 1 stated residents should be assessed for entrapment to prevent injuries, and the responsible party should have the opportunity to consent for the use of side rails after being informed of the risks and benefits prior to use. During an interview on 2/10/2026, at 10:08 a.m., with the Director of Nursing (DON), the DON stated prior to installation of the side rails on the resident's bed they should have had a physician's order, consent for the use of the bedrail, and assessment for entrapment, to ensure appropriate use and safe use of the bedrail for the residents. During a review of the facility's recent policy and procedure (P&P) titled, Side Rail Assessment, last reviewed on 1/29/2026, the P&P indicated a siderail assessment was to be completed every 3 months. During a review of the facility's recent policy and procedure (P&P) titled, Informed Consent, last reviewed on 1/29/2026, the P&P indicated there must be a signed a signed consent for all treatments and procedures. During a review of the facility's recent policy and procedure (P&P) titled, Orders, Physicians, last reviewed on 1/29/2026, the P&P indicated accuracy must be assured with all physician's orders. b. During a review of the History and Physical (H&P) dated 12/19/2025, the H&P indicated Resident 8 was admitted with diagnoses including cardiopulmonary arrest (a medical emergency where the heart suddenly stops beating, stopping blood flow to the brain and body), respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), encephalopathy (damage or disease that affects the brain), hypertension (high blood pressure), Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). Resident 8 was comatose (a state of deep, prolonged unconsciousness where a person cannot be awakened, fails to respond to light, sound, or pain, and does not move voluntarily) and totally unresponsive to verbal and painful stimuli. During a review of Resident 8's Minimum Data Set ([MDS] - a resident assessment tool) dated 12/24/2025, the MDS indicated Resident 8 was comatose. Resident 8 was dependent (helper does all the effort) from staff with all activities of daily living (ADL), such as oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. The MDS indicated that Resident 8 was dependent with rolling left and right (ability to roll from laying on back to left and right side and return to lying back on the bed). During an observation on 2/9/2026, at 12:10 p.m., in Resident 8's room, Resident 8 was lying down in bed with four side rails up (upper and lower). During a review of Resident 8's Order Summary Report dated 2/26/2025, the Order Summary Report indicated physician order for bilateral (two sides) side rails up at all times every shift. During a concurrent observation and interview on 2/10/2026 at 2:10 p.m. with Licensed Vocational Nurse (LVN) 6 and Registered Nurse (RN) 4 in Resident 8's room, Resident 8's bed was observed having four side rails up. LVN 6 stated four side rails were up to prevent Resident 8 from falling. c. During a review of Resident 24's Patient Registration Form, the Patient Registration Form indicated Resident 24 was admitted to the facility on [DATE]. During a review of Resident 24's H&P dated 10/13/2025, the H&P indicated Resident 24 was admitted to the facility with diagnoses including traumatic encephalopathy following head injury(permanent brain damage that happens after many head injuries), history of respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), permanent tracheostomy (a surgically created hole in the neck that leads directly into the windpipe to help a person breathe), seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). The H&P indicated Resident 24 was awake, responsive, able to verbalize slightly. During a review of Resident 24's Minimum Data Set ([MDS] - a resident assessment tool) dated 12/4/2025, the MDS indicated Resident 24 had moderately impaired cognitive skills (decisions poor; cues/supervision required). The MDS indicated Resident 24 was dependent (helper does all the effort) from staff with all activities of daily living (ADL), such as oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. The MDS indicated that Resident 24 was dependent with roll left and right (ability to roll from laying on back to left and right side and return to laying on back on the bed). During an observation on 2/9/2026, at 12:15 p.m., in Resident 24's room, Resident 24 was lying down in bed with four side rails up (upper and lower). During a review of Resident 24's Order Summary Report dated 12/22/2025, the Order Summary Report indicated a physician order for bilateral padded side rails for seizure precautions every shift. During a concurrent observation and interview on 2/10/2026 at 2:04 p.m. with LVN 6 and RN 4 in Resident 24's room, Resident 24's bed was observed having 4 side rails up with no padding. LVN 6 stated four side rails were up to prevent Resident 24 from falling. LVN 6 stated Resident 24 was at risk for seizures, and that lack of padding could result in head injury or trauma during a seizure episode. d. During a review of Resident 29's Patient Registration Form, the Patient Registration Form indicated Resident 29 was admitted to the facility on [DATE]. During a review of the H&P report dated 12/10/2025, the H&P indicated Resident 29 was admitted to the facility with diagnoses including chronic respiratory failure with hypoxia (a condition where there's not enough oxygen or too much carbon dioxide in your body), seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), traumatic subdural hemorrhage (a head injury causes blood vessels to tear and leak blood between the brain and its outer covering), dysphagia (difficulty swallowing). During a review of Resident 29's MDS dated [DATE], the MDS indicated Resident 29 had moderate cognitive impairment. The MDS indicated Resident 29 was dependent from staff with all ADL, such as oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. The MDS indicated that Resident 29 was dependent with chair/bed-to-chair transfer. During an observation on 2/9/2026, at 12:20 p.m., in Resident 29's room, Resident 29 was lying down in bed with four side rails up (upper and lower) with no padding. During a review of Resident 29's Order Summary Report dated 5/5/2024, the Order Summary Report indicated physician order for bilateral (two sides) padded side rails at all times every shift. During a concurrent observation and interview on 2/10/2026 at 2:04 p.m. with Licensed Vocational Nurse (LVN) 6 in Resident 29's room, Resident 29's bed was observed with all 4 side rails up with no padding. LVN 6 stated four side rails were up to prevent Resident 29 from falling. LVN 6 stated Resident 29 was at risk for seizures, and that lack of padding could result in head injury or trauma during a seizure. e. During a review of Resident 55's Patient Registration Form, the Patient Registration Form indicated that Resident 55 was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE]. During a review of the H&P dated 4/2/2025, the H&P indicated Resident 55 was admitted to the facility with diagnoses including chronic traumatic encephalopathy following head injury (permanent brain damage that happens after many head injuries), history of seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), tracheostomy (a surgically created hole in the neck that leads directly into the windpipe to help a person breathe), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 55's MDS dated [DATE], the MDS indicated Resident 55 was comatose. Resident 55 was dependent from staff with all ADLs, such as oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. The MDS indicated that Resident 55 was dependent with roll left and right (ability to roll from laying on back to left and right side and return to lying on back on the bed). During an observation on 2/9/2026, at 12:20 p.m., in Resident 55's room, Resident 55 was lying down in bed with four side rails up (upper and lower) with no padding. During a concurrent interview and record review on 2/10/2026 at 2:06 p.m. with LVN 6 of Resident 55's Care Plan Report dated 6/20/2026, the Crae Plan Report indicated bilateral padded side rails were to remain up all times for seizure precautions. However, the Physician Order Summary did not indicate documentation of an order to maintain padded side rails up at all times for seizure precautions. LVN 6 stated Resident 55 had a history of seizure disorder. During a concurrent observation and interview on 2/10/2026 at 2:07 p.m. with LVN 6 in Resident 55's room, Resident 55's bed was observed having 4 siderails up with no padding on any of the siderails. LVN 6 stated without an order and padding in place, Resident 55 could be at increased risk for head injury or trauma in the event of seizures. During a concurrent interview and record review on 2/10/2026 at 2:10 p.m. with RN 4, RN 4 reviewed Resident 24, Resident 8, Resident 29 and Resident 55's electronic and paper medical records. RN 4 stated there was an order for bilateral padded side rails up for seizure precautions and having four side rails raised without padding was not according to the physician's order for Resident 24 ,8 , 29 and 55. RN 4 stated there was no documented entrapment risk assessment and no documented consent for the use of bed rails. RN 4 stated this practice had the potential to place Resident 24,8, 29 and 55 at risk for injury and entrapment. RN 4 further stated residents/RP should have the opportunity to consent for side rails to ensure the benefits outweigh the risks. During an interview on 2/12/2026 at 3:00 p.m. with Director of Nursing (DON), the DON stated side rails must have doctors order before they are used. The DON stated that if a physician's order indicates bilateral side rails, staff should not raise all four side rails by default. Using all four side rails considered a restraint. The DON stated it was not acceptable to maintain side rails up at all times without documented consent from the residents or RP. Residents/RPs must be aware of possible risks, benefits, and other available options. The DON added that the facility must assess residents for entrapment risk or admission, at lease quarterly, and on an ongoing basis. If residents become trapped between mattress and the side rail, it can lead to serious harms and even death. During a review of the facility's recent policy and procedure (P&P) titled, Side Rail Assessment, last reviewed on 1/29/2026, the P&P indicated a siderail assessment was to be completed every 3 months. During a review of the facility's policy and procedure (P&P) titled, Informed Consent for Procedures and Treatments, reviewed in December 2025, the P&P indicated there must be a signed consent for all treatments and procedures. During a review of the facility's P&P titled, Orders, Physicians, reviewed in December 2025, the P&P indicated accuracy must be assured with all physician's orders.

Based on observation, interview, and record review the facility failed to: 1.Have immediate access to controlled substances ([CS] - medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as narcotics or Controlled Medication [CM]) and medication emergency kit ([eKIT] - kit containing medications needed to be used during emergencies) stored in the refrigerator in one (1) of two (2) observed Medication Rooms (Medication Room Subacute 2.) 2. Include the verifying signatures of two (2) licensed nurses on the Facility Medication Destruction Form observed in Medication Room Subacute 2, for four (4) of four (4) sampled records. As a result, control and accountability of medications disposition (process of returning and/or destroying unused medications) did not follow state and federal regulations and facility policy and procedures. 3. Reconcile (the process of comparing transactions and activity to supporting documentation) two (2) medication eKITs containing CSs for February 2026, in two (2) of two (2) inspected Medication Rooms (Medication Room Subacute 2 and Medication Room Subacute 3.) As a result, control and accountability of CSs did not follow state and federal regulations and facility policy and procedures. 4.Complete an accurate CS reconciliation at shift change on 2/9/2026 in one (1) of three (3) observed Medication Carts (Medication Cart Subacute 2 Cart 2.) As a result, control and accountability of CSs did not follow facility policy and procedures. These deficient practices increased the opportunity for medication diversion (the transfer of a medication from a lawful to an unlawful channel of distribution or use,) and increased the risk that residents in the facility could have accidental exposure to harmful medications and delayed medication treatment during emergencies possibly leading to physical and psychosocial harm, and hospitalization. Findings: During a concurrent observation and interview on 2/9/2026 at 11:30 a.m., with Registered Nurse (1), in Medication Room Subacute 2, RN 4 could not open the double locks on a plastic clear rectangular container inside the refrigerator. RN 4 stated the container with the double lock contained CSs for several residents and an eKIT. RN 4 asked several other nurses to open the locks but none of the keys opened the container. The pharmacy department and engineering departments were called to assist in opening the container. During a concurrent record review and interview on 2/9/2026 at 11:40 a.m., with RN 4, in Medication Room Subacute 2, RN 4 reviewed four (4) Facility Medication Destruction Form records dated 1/2/2026 and 2/9/2026. RN 4 stated RN 4 was unable to locate the signatures or names of the licensed nurses on the four (4) logged disposition records. RN 4 stated that licensed nurses failed to follow state requirements and facility policy of signing the logs with a witness when disposing medications. During a review of Facility Medication Destruction Form, dated 1/2/2026, 1/2/2026, 2/9/2026 and 2/9/2026, the four (4) forms indicated the prepared by, checked by and verified by sections were empty, not signed or identified who completed the destruction of the listed medications. During an observation on 2/9/2026 at 12:08 p.m., in Medication Room Subacute 2, the Director of Pharmacy (DOP) arrived and stated that the DOP does not have keys to the plastic container inside the refrigerator. During an observation on 2/9/2026 at 12:25 p.m., in Medication Room Subacute 2, the Engineering department arrived and stated that Engineering department does not have keys to the container. During an observation and concurrent interview on 2/9/2026 at 12:30 p.m., with Registered Nurse (RN) 4, in Medication Room Subacute 2, there was one (1) medication eKIT stored in the refrigerator and labeled 2, containing CSs without an accountability log for the reconciliation of CS inventory at every shift change for February 2026. During a concurrent interview, RN 4 stated that all CSs, including medication eKITs containing CSs should be reconciled at every shift. RN 4 stated the eKIT labeled 2 containing CSs in Medication Room Subacute 2 was not reconciled at every shift in February 2026, and it was important to account for all CSs to ensure accountability and prevent CS diversion. During a concurrent record review and interview on 2/9/2026 at 12:40 p.m., with Licensed Vocational Nurse (4), LVN 4 reviewed the Floor Narcotic Release log in Medication Cart Subacute Cart 2. LVN 4 stated the Floor Narcotic Release log was the facility's CS accountability record was used for the daily CS reconciliation (review of inventory by 2 people to identify discrepancies) at each shift change and signed with the on-coming and retiring (out-going) nurses, after completing all CS inventory, including refrigerated CSs. LVN 4 stated that LVN 4 (on-coming) and LVN 5 (out-going) could not open the locked plastic clear rectangular container containing CSs inside the refrigerator, and as a result could not verify the count of the CSs inside the refrigerator. LVN 4 stated that LVN 4 and LVN 5 signed the log at 7 a.m. on 2/9/2026 for Medication Cart Subacute Cart 2 without verifying the CS inventory count in the refrigerator. LVN 4 stated that accurate CS reconciliation was important to know the amount of medications available, and if not done properly it can lead to delayed medication treatment and harm residents by not treating their condition requiring hospitalization and leading to possible death. During a review of the Floor Narcotic Release log labeled Cart 2, the log indicated LVN 4 and LVN 5 signed for the completion of the CS reconciliation on 2/9/2026 at 7 a.m. and indicated that the narcotic counts were accurate and that there were no shortages or overages. During an observation on 2/9/2026 at 1 p.m., with RN 4 in Medication Room Subacute 2, the plastic clear rectangular container inside the refrigerator was open. RN 4 stated the keys would get stuck but after several attempts the locks opened. RN 4 acknowledged the following medications were stored inside the container: midazolam (a CS used for seizures [sudden, uncontrolled body movements caused by abnormal electrical activity in the brain leading to loss of muscle control and shaking]) 5mg/ml one (1) ml vial for Resident 11 midazolam 5mg/ml one (1) ml vial for Resident 43 midazolam 5mg/ml one (1) ml vial for Resident 44 midazolam 5mg/ml one (1) ml vial for Resident 49 midazolam 5mg/ml one (1) ml vial for Resident 55 eKIT labeled 24 containing Ativan (a CS used for seizure and anxiety) 2mg/ml one (1) ml vial for facility stock. During a concurrent interview, RN 4 stated it was important to have access to critical medications to provide immediate care to residents. RN 4 stated the facility could not open the locks to the plastic container inside the refrigerator on 2/9/2026 between 11:30 a.m. and 1 p.m. RN 4 stated midazolam and Ativan were used for seizures and need to be administered immediately upon a physician's order. RN 4 stated seizure was considered an emergency and not having timely access to midazolam and Ativan could lead to delay in care and harm Resident 11, 43, 44, 49, 55 and others experiencing seizures, by not controlling the seizure, and leading to hospitalization and/or potential death. During an observation and concurrent interview on 2/9/2026 at 1:57 p.m., with RN 2, in Medication Room Subacute 3 there was one (1) medication eKIT stored in the refrigerator and labeled 24, containing CSs without an accountability log for the reconciliation of CS inventory at every shift change for February 2026. During a concurrent interview, RN 2 stated that all CSs, including medication eKITs containing CSs, should be reconciled at every shift. RN 2 stated the eKIT labeled 24 containing CSs in Medication Room Subacute 3 was not reconciled at every shift in February 2026, and it was important to account for all CSs to ensure accountability and prevent CS diversion. During an interview on 2/9/2026 at 3:45 p.m., with the Director of Nursing (DON,) the DON stated that medication eKITs containing CSs needed to be counted and reconciled at every shift change to ensure accountability and prevent CS diversion. The DON stated the eKITs labeled 2 and 24 containing CSs in Medication Room Subacute 2 and 3 were not reconciled at every shift in February 2026. The DON stated that the facility will immediately implement an accountability log for reconciliation of eKits containing CSs. During the same interview, the DON stated that LVN 4 and LVN 5 failed to notify the DON that the keys do not unlock the clear plastic container inside the refrigerator in Medication [NAME] Subacute 2 that day (2/9/2026) at 7 a.m. The DON stated, as a result LVN 4 and LVN 5 failed to complete a physical inventory and reconciliation of the CSs at shift change but documented that the reconciliation was completed with no discrepancies. The DON stated it was important to complete an actual physical count of all CSs and reconcile at each shift change to prevent CS diversions, and to know the amount of medications available for residents to prevent delay in care and harm such as hospitalizations and death. During the same interview, the DON reviewed the four (4) Facility Medication Destruction Form records dated 1/2/2026 and 2/9/2026. The DON stated the DON was unable to locate the witness signatures on the logs. The DON stated licensed nurses failed to include the signatures of witnesses when destroying medications. The DON stated it was important to verify and sign these logs with witnesses to prevent medication diversions and accidental exposure to residents. During a review of the Policy and Procedures (P&P,) titled Controlled Medication Storage, last reviewed 1/29/2026, the P&P indicated: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substance are subject to special handling, storage, disposal and record keeping in the facility in accordance with federal, state and other applicable laws and regulations. The DON and the consultant pharmacist shall maintain facility's compliance with federal and state laws and regulations in the handling of controlled medications. At each shift change, a physical inventory of all controlled medications shall be conducted by two licensed nurses and is documented on the controlled substance accountability record. During a review of the Policy and Procedures (P&P,) titled Emergency Pharmacy Services/Emergency Kits, last reviewed 1/29/2026, the P&P indicated: A locked and sealed emergency supply shall be maintained at one or more designated areas Emergency controlled substances are kept in a sealed, portable container. Refrigerated emergency supplies are kept in a sealed, portable container. when an emergency or starter dose of a medication is needed, the nurse shall break the container seal and remove the required medication. During a review of facility's P&P, titled Discontinued Medications - Disposal, last reviewed 1/29/2026, the P&P indicated: b. With the exception of controlled substances, the facility should have at least two licensed nurses prepare the destruction of medications that would be picked up by a licensed reverse distributor like medical waste services. During a review of facility's P&P, titled Destruction of Medications - Non controlled, last reviewed 1/29/2026, the P&P indicated: All non-controlled medication will be properly recorded and prepared before its destruction and placement in a designated collection receptacle. d. Nurses will record all medications for destruction on the medications destruction record form and keep a copy at the facility. The following information will include: 1. Facility Name 2. Date of preparation 3. Name of the patient 4. Rx number 5. Medication name 6. Amount to be disposed 7. Who prepared the medications.

Based on observation, interview, and record review the facility failed to: Label one (1) open insulin (medication used to regulate blood sugar levels) Lantus (brand name insulin for glargine, a long-acting insulin) Solostar pen (a type of device containing insulin) stored at room temperature for Resident 4, in accordance with manufacturer's requirements in one (1) of three (3) inspected Medication Carts (Medication Cart Subacute 2 Cart 2.) Store eye drop and ear drop medications separately, in one (1) of three (3) inspected Medication Carts (Medication Cart Subacute 2 Cart 2.) These deficient practices increased the risk that Resident 4 could receive medication that had become ineffective or toxic due to inadequate storage, and labeling, experience medication adverse consequences (unwanted, uncomfortable, or dangerous effects that a medication may have) and increase the risk of contamination and receiving medications via the wrong route for residents in the facility, resulting in the negative impact to their health and well-being possibly leading to health complications, hospitalization, or death. Based on observation, interview, and record review the facility failed to: 1.Label one (1) open insulin (medication used to regulate blood sugar levels) Lantus (brand name insulin for glargine, a long-acting insulin) Solostar pen (a type of device containing insulin) stored at room temperature for Resident 4, in accordance with manufacturer's requirements in one (1) of three (3) inspected Medication Carts (Medication Cart Subacute 2 Cart 2.) 2. Store eye drop and ear drop medications separately, in one (1) of three (3) inspected Medication Carts (Medication Cart Subacute 2 Cart 2.) These deficient practices increased the risk that Resident 4 could receive medication that had become ineffective or toxic due to inadequate storage, and labeling, experience medication adverse consequences (unwanted, uncomfortable, or dangerous effects that a medication may have) and increase the risk of contamination and receiving medications via the wrong route for residents in the facility, resulting in the negative impact to their health and well-being possibly leading to health complications, hospitalization, or death. Findings: During an observation on [DATE] at 1:48 p.m., in Medication Cart Subacute 2 Cart 2 , and in the presence of Licensed Vocational Nurse (LVN) 3, the following medication was found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, or stored and labeled contrary to facility policies: -One (1) open and used insulin Lantus for Resident 4 was found stored at room temperature without a date indicating when storage or use at room temperature began. According to the manufacturer's product labeling, open Lantus Solostar insulin pens should be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 28 days of opening pen. Three (3) insulin Lantus Solostar pens, one (1) earwax softener drops, and one (1) lubricant eye drops were stored in the same bin/compartment of the medication cart. During a concurrent interview with LVN 3, LVN 3 stated insulin Lantus Solostar pen for Resident 4 was open, used, stored at room temperature, and not labeled with a date when use at room temperature began. LVN 3 stated insulin pen was considered a multi-dose (having more than one [1] dose) medication. LVN 3 stated according to manufacturer directions the Lantus pen needed to be discarded after 28 days of use, and after that day the insulin loses potency (the strength of medication) and considered expired. LVN 3 stated that LVN 3 was unaware when the insulin Lantus Solostar pen for Resident 4 was opened or stored at room temperature therefore unknown when it would expire. LVN 3 stated administering expired insulin in error will not be effective in keeping the blood sugar stable and can harm Resident 4 by causing high blood sugar levels, leading to shock and coma (a state of deep unconsciousness caused by injury or illness), hospitalization or even death. LVN 3 stated the Lantus Solostar pen needed to be removed from the medication cart and replaced with new ones from pharmacy to ensure expired insulin was not administered in error to Resident 4. During the same interview, LVN 3 stated that internally administered medications, such as oral tablets and injections, and externally administered medications, such as eye drops and ear drops, should be stored separately in their own sections/bins and not together, to prevent errors in wrong route administration and possible infections/contaminations. LVN 3 acknowledged one (1) medication bin containing three (3) insulin pens, one (1) ear drop and one (1) eye drop. LVN 3 stated the facility failed not to separate and store ear drops separate from eye drop medications. During an interview on [DATE] at 3:45 p.m., with the Director of Nursing (DON,) the DON stated the insulin Lantus Solostar pen for Resident 4 was not labeled with a date when the pen was first opened and used. The DON stated several LVN's failed to label the date the pen was opened and used. The DON stated without knowing when the Lantus Solostar pen was opened it was unknown when it would expire, increasing the risk of administration of expired insulin to Resident 4. The DON stated expired insulins have lost potency and effectiveness and when administered in error were not effective in controlling blood sugar levels leading to hyperglycemia (high blood sugar level) and adverse effects for Resident 4, potentially resulting in hospitalization due to Diabetic Ketoacidosis ([DKA] - a condition that develops when the body doesn't have enough insulin resulting in the buildup of acid in the blood to levels that can be life threatening.) The DON stated the Lantus Solostar pen needed to be replaced with a new one from pharmacy. During the same interview, the DON stated ear drops and eye drops should be stored separately to prevent wrong route administration, infections and contaminations. The DON stated the facility failed to store ear drop and eye drop medication in separate bins/compartments in Medication Cart Subacute 2 Cart 2. During a review of the facility's Policy & Procedures (P&P,) titled Storage of Medications, last reviewed [DATE], the P&P indicated Medications and biologicals shall be stored safely, securely, and properly, following manufacturer's recommendations of those of the supplier. e. Eye medications shall be kept separate from ear medications. ii. Once a refrigerated item such as multi-dose insulin vials are opened, the nurses write down the open date and it must be discarded according to storage table 1 below from the date open. If the refrigerated item is a unit dose item such as pens, then each individual pen may have its own date opened and be discarded according to storage table 1 from the date opened. During a review of the facility's appendix to Storage of Medications P&P titled Storage Table 1, last reviewed [DATE], the table indicated: Lantus (glargine) - Good for 28 days after opening or removing from refrigerator. During a review of manufacturer guideline, titled Highlights of Prescribing Information for Lantus, dated 6/2022, the guide listed the following: Only use your pen for up to 28 days after its first use. Throw away the LANTUS SoloStar pen you are using after 28 days, even if it still has insulin left in it.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when purchased bags of ice, still on their original packaging, were placed on top of the ice made by the ice maker and used for 14 of the 60 residents that eat and drink food prepared by the kitchen, These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) for 14 of the 60 medically compromised residents who received food from the kitchen. Findings: During an initial kitchen tour observation on 2/9/2026 at 7:42 a.m., observed three bags of purchased ice still in their original bags mixed with ice made by the ice maker. During a concurrent observation and interview with the Dietary Manager (DM) on 2/9/2026 at 7:44 a.m., the DM looked into the ice maker and stated there were three bags of ice mixed with the fresh ice made by the ice maker. The DM stated sometimes the ice maker does not work well and they have to purchase separate bags of ice but that the ice should have been removed from the bags to prevent cross contamination. During a review of the policy and procedure (P&P) titled, Ice Machine, last revised on 1/29/2026, the P&P indicated when ice comes in contact with food and beverages shall be from a sanitary source.

Based on observation, interview and record review, the facility failed to provide reasonable accommodation for resident needs and preferences for two of four sampled residents (Resident 24 and Resident 5) by failing to: Ensure Resident 5's call light (an alerting device that allows a resident to call for help) was within reach. 2. Ensure Resident 24 was provided with a push button call light despite Resident 24 having wrist contractures (a condition where the muscles, tendons, or skin around the wrist tighten, shorten, and scar, causing the joint to become stiff and locked in a bent position) that limited the ability to grasp and activate the call light. This deficient practice had the potential to prevent Resident 5 and Resident 24 from summoning assistance, placing the residents at risk for unmet needs and delayed care. Findings: 1.During a review of Resident 5's admission Record (the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted Resident 5 to the facility on 9/6/2025. During a review of the History and Physical (H&P) report completed on 9/8/2025, the H&P indicated Resident 5 was admitted to the facility with diagnosis that included chronic hypoxemic respiratory failure (a long-term condition where the lungs cannot sufficiently transfer oxygen into the blood), dependence on respirator/ventilator status (unable to breathe independently and requires a machine to help or fully take over a resident's breathing when they cannot do so on their own), and [NAME] Barre syndrome (a condition in which the body's system that protects from infection attack the nerves). The H&P stated Resident 5 was bedbound (confirmed to bed due to illness) state. During a review of Resident 5's Minimum Data Set (MDS – a resident assessment tool), dated 11/13/2025, the MDS indicated Resident 5 has the ability to express ideas and wants and understands (clear comprehension) others. The MDS indicated Resident 5 was dependent (Helper does all of the effort. Resident does none of the effort to complete the task) with eating, oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. The MDS indicated that Resident 5 is dependent for roll left and right (ability to roll from laying on back to left and right side and return to laying on back on the bed). During a concurrent observation and interview on 2/9/2026 at 10:10 a.m. with Resident 5, Resident 5 was lying in bed with a touch-activated call light (easy-to-activate communication device alerting staff when resident needs help) on the left side above his head. Resident 5 stated he taps the call light with his head when he needs help. Resident 5 stated he sometimes cannot reach it because of where it is placed. Resident 5 stated that he would verbally call out loud to get staff attention when unable to reach the call light. During a concurrent observation and interview on 2/9/2026 at 10:20 a.m. in Resident 5's room, the call light was observed on the left side above the resident's head, out of Resident 5's reach. LVN 8 stated the touch-activated call light is what Resident 5 uses to let staff know he needs help and should always be within reach of the resident. LVN 8 stated that without the call light, Resident 5 does not have a device to let staff know that he needs help. LVN stated because of this, staff will not know what may be going on with him and/or may miss something. During an interview on 2/12/2026 at 12:25 p.m. with the Director of Nursing (DON), the DON stated staff are expected to make sure call lights are always within residents' reach and responded to timely. The DON stated you never know what a resident is calling help for, and it may be an emergency, so it is important that residents have a call device within reach to call at all times. During a review of Resident 5's care plan (CP) titled, Risk for falls related to impaired mobility, incontinence of bowel, chronic respiratory failure on trach, muscle spasms, neuropathy, side effects of medications initiated 6/24/2023 the CP indicated an intervention ensure call light is available to resident. During a review of Resident 5's care plan (CP) titled, The resident has an alteration in musculoskeletal status muscle cramping of lower extremities, quadriplegia initiated 01/1/2024, the CP indicated an intervention be sure call light is within reach and respond promptly to all requests for assistance. During a review of Resident 5's care plan (CP) titled, Self-Care Deficit: Totally dependent with bed mobility, bathing, dressing, eating, transfer, toilet use and personal hygiene due to physical and medical condition. Resident uses adaptive call light initiated 01/09/2024, the CP indicated an intervention touch-activated call light, place the call light within easy reach of the patient's bedside. During a review of Resident 5's care plan (CP) titled, Side rail use for safety to prevent falls initiated 7/15/2025, the CP indicated an intervention place call light within reach and respond timely. During a review of the facility's P&P titled, Call Light System last reviewed 1/29/2026, the P&P indicated, It is the policy of this facility to provide each resident with a call system to enable them to request assistance. To provide a mechanism for residents to communicate to staff a need for assistance.Procedure: b. Make sure call cords are placed within the residents' reach at all times. 2. During a review of Resident 24's Patient Registration Form, the Patient Registration Form indicated Resident 24 was admitted to the facility on [DATE]. During a review of Resident 24's H&P, dated 10/13/2025, the H&P indicated Resident 24 was admitted to the facility with diagnoses including traumatic encephalopathy following head injury(permanent brain damage that happens after many head injuries), history of respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), permanent tracheostomy (a surgically created hole in the neck that leads directly into the windpipe to help a person breathe), seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). The H&P indicated Resident 24 was awake, responsive, able to verbalize slightly. During a review of Resident 24's MDS dated [DATE], the MDS indicated Resident 24 had moderately impaired cognitive skills (decisions poor; cues/supervision required). The MDS indicated Resident 24 was dependent (helper does all the effort) from staff with all activities of daily living (ADL), such as oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. The MDS indicated that Resident 24 was dependent with roll left and right (ability to roll from laying on back to left and right side and return to laying on back on the bed). During a concurrent observation and interview on 2/9/2026 at 10:37 a.m. with Resident 24 in Resident 24's room, observed standard push button call light tied to the right upper side rail, resting next to Resident 24's right shoulder. Resident 24's wrists and fingers were observed contracted bilaterally. Resident 24 stated he was calling for help by yelling for a nurse. Resident 24 stated he did not know where the call light was located or how to use it. During a concurrent observation and interview on 2/9/2026 at 10:52 a.m. with Licensed Vocational Nurse (LVN) 6, Resident 24 demonstrated his ability to move his arms but could not move his wrists and fingers. LVN 6 stated Resident 24 was able to move left hand fingers slightly. LVN 6 placed the standard push button call light in Resident 24's left hand. Resident 24 was unable to use the standard call light. LVN 6 stated not having a type of a call light that Resident 24 could use may prevent Resident 24 from calling for assistance, resulting in unmet needs and delayed care. During an interview on 2/12/2026 at 3:00 p.m. with Director of Nursing (DON), the DON stated staff were required to provide accommodation or alternative devices when residents were unable to use standard equipment. The DON stated residents being unable to use their call light to request assistance can lead to increased stress, unmet physiological needs, delayed care, and in increased risk for injuries. During a review of facility's Policies and Procedures (P&P), the P&P titled, Call light system dated October 2025, the P&P indicated, It is the policy of this facility to provide each resident with a call system to enable them to request assistance.

Based on interview and record review, the facility failed to follow its policy titled, Advance Directives, by not providing assistance with creating an advance directive (a legal document indicating resident preference on end-of-life treatment decisions) for two of four sampled residents (Residents 2 and 27) reviewed under the Advance Directive care area. This deficient practice resulted in Residents 2 and 27 not receiving assistance with creating advance directives, increasing the risk that the residents' wishes regarding their medical care would not be known or honored if they became unable to make or communicate their own decisions Findings: During a review of Resident 2's Patient Registration Form, the Patient Registration Form indicated the facility admitted the resident on 6/11/2022. During a review of Resident 2's History and Physical (H&P), dated 7/11/2025, the H&P indicated Resident 2 had diagnoses including, but not limited to, a history of assault with a spinal cord injury (damage to the bundle of nerves and nerve fibers that transmit signals between the brain and the body resulting in temporary or permanent loss of sensation and motor function) and chronic (long-term) respiratory failure (a condition where the lungs cannot release enough oxygen into the blood) with dependence on a ventilator (a medical device to help support or replace breathing). The H&P further indicated Resident 2 had an impaired mental status, was able to make his needs known, and was able to make some decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 12/11/2025, the MDS indicated Resident 2 was cognitively intact (able to think, learn, and remember clearly) and was dependent (helper does all of the effort) for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 27's Patient Registration Form, the Patient Registration Form indicated the facility admitted the resident on 9/19/2024. During a review of Resident 27's H&P, dated 5/21/2025, the H&P indicated Resident 27 had diagnoses including, but not limited to, chronic respiratory failure and seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) disorder. The H&P further indicated Resident 27 was alert and oriented (awake, responsive, and aware). During a review of Resident 27's MDS, dated [DATE], the MDS indicated Resident 27 was cognitively intact and was dependent for all ADLs except eating in which she required moderate assistance (helper does less than half of the effort). During a concurrent interview and record review on 2/12/2026 at 12:02 p.m. with Social Worker (SW) 1, reviewed Resident 2's Advance Health Care Directive Acknowledgement, dated 3/4/2025 and Resident 27's Advance Health Care Directive Acknowledgment, dated 2/12/2025. Resident 2's and Resident 27's Advance Health Care Directive Acknowledgements both indicated that the residents did not have an advance directive, but both residents' Advance Health Care Directive Acknowledgment indicated: However, I would like to discuss Advance Directives further: Nursing to refer for follow up. SW 1 stated there was no documentation of having met with either Resident 2 or 27 to follow up about an advance directive and neither have an advance directive on file now. SW 1 stated the usual process is for nursing to ask the resident if they have an advance directive when they are admitted , and if they do not, but want more information to refer them to social services so that a social services staff can provide education regarding making an advance directive, give them a blank one, and can contact the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) to help complete the advance directive. SW 1 stated it is important to meet with the resident and give them education regarding creating an advance directive, as this is their right and ensures staff are aware of their wishes and able to act accordingly if the resident becomes unable to make or communicate their own decisions. During a review of the facility's policy and procedure (P&P) titled, Advance Directives, last reviewed 1/29/2026, the P&P indicated if the resident indicates that he or she has not established an advance directive, the facility will offer assistance to establish one. The P&P indicated the resident will be given the option to accept or decline the assistance. The P&P indicated nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline the assistance.

Based on observation, interview and record review, the facility failed to provide care in accordance with professional standards for one (1) of one (1) sampled residents (Resident 26) investigated for gastrostomy tube ([G-tube] - a tube inserted through the belly that delivers nutrition and medications directly to the stomach) care by failing to flush the tube with the prescribed volume of water. This deficient practice increased the risk that Residents 26 could experience adverse effects (unwanted, unintended result) from lower volume of water, possibly leading to clogging of the G-tube and requiring procedures for declogging (removing a blockage) or replacement of the tube. Findings: During an observation on 2/9/2026 at 9:20 a.m. in Medication Cart 4, licensed vocational nurse (LVN) 7 was observed flushing Resident 26's G-tube with 25 milliliter ([ml] - a unit of measure of volume) followed by administering amiodarone (a medication used for middle cerebral artery (mca) occlusion (a blood clot blocking the largest brain artery, not allowing blood flow to major brain areas,) losartan (a medication used for high blood pressure,) polyethylene glycol 3350 (a medication used for constipation,) amlodipine (a medication used for high blood pressure,) docusate (a medication used for constipation,) ferrous sulfate (a medication used for anemia,) metoprolol (a medication used for high blood pressure,) magnesium oxide (a medication used for constipation,) via G-tube with 5 ml water flushes in between each medication, and flushing the G-tube with an additional 25 ml water after the last medication. During an interview on 2/9/2026 at 10:30 a.m., with LVN 7, LVN 7 stated flushing G-tube with water before and after medication administration was a standard of practice to prevent clogging the tube and ensuring medication has cleared the tube. LVN 7 stated the flushes usually range between 20 and 30 ml. LVN 7 stated LVN 7 decided to flush with 25 ml since it falls in between 20 and 30 ml. LVN 7 acknowledged the physician order for Resident 26 indicated to flush with 30 ml water before and after medication administration through the G-tube. LVN 7 stated LVN 7 failed to flush with the prescribed amount increasing the risk of clogging Resident 26's G-tube, requiring declogging or potential tube preplacement. During an interview on 2/9/2026 at 3:45 p.m., with the Director of Nursing (DON,) the DON stated flushing G-tube with water before and after medication administration and in between each medication was a standard of practice. The DON stated Resident 26's order indicated to flush before and after medication administration through the G-tube with 30 ml water. The DON stated LVN 7 failed to flush Resident 26's G-tube with 30 ml water that day (2/9/2026) during medication administration increasing the risk of clogging Resident 26's G-tube, requiring declogging or potential tube preplacement. During a review of Resident 26's History and Physical ([H&P] - a document containing resident health history, diagnosis and treatment plan,) dated 4/30/2025, the H&P indicated the facility originally admitted the resident to the facility on 3/24/2025 and re-admitted on [DATE] with diagnoses including respiratory distress, mca occlusion, and dysphagia (difficulty swallowing.) During a review of Resident 26's Order Summary Report, dated 2/9/2026, the report indicated Resident 26 was prescribed to Flush tube with 30 ml of water before and after medication administration pass, starting 5/3/2025. During a review of Resident 26's Medication Administration Record ([MAR] - a record of mediations administered to residents), for February 2026, the MAR indicated Resident 26 was prescribed Flush tube with 30 ml of water before and after medication administration pass, daytime and nighttime. During a review of Resident 26's Care Plan (a person-centered guide identifying a resident's health and daily needs,) dated 5/1/2025, the care plan indicated: The resident will remain free of side effects or complications related to tube feeding. The resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders. During a review of the facility's Policy & Procedures (P&P,) Medication Administration, last reviewed 1/29/2026, indicated: 10. Flush the tube with approximately 30 ml of water using a catheter tipped syringe. 15. Rinse medication cup and administer rinsing to assure complete dose 16. Flush tube with a minimum of 30 ml of water. During a review of the American Society for Parenteral and Enteral Nutrition (ASPEN) standards, titled ASPEN Safe Practices for Enteral Nutrition Therapy, dated January 2017, the guideline indicated: Feeding tubes (known as [NAME]) are prone to clogging for a variety of reasons. The risk of clogging may result from .insufficient water flushes. Develop protocols that call for proper flushing before and after medication administration .Develop protocols for proper administration of medications through an EAD, as well as appropriate water flushes and EAD reclogging procedures.

Based on observation, interview and record review the facility failed to provide preventative care for one of one sampled resident (Resident 64) by not applying sequential compression device (SCD-inflatable sleeves wrapped around the legs that automatically inflate and deflate to mimic muscle movement, increasing blood flow and preventing deep vein thrombosis [DVT-a condition where a blood clot [clump of blood cells in blood stream] forms in a deep vein]) at all times to prevent DVT as ordered by the physician. This deficient practice had the potential to increase the risk of developing blood clots, causing pain, poor blood circulation and serious harm to Resident 64's health. Findings: During a review of Resident 64's Patient Registration Form, the Patient Registration Form indicated that Resident 64 was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE]. During a review of the History and Physical (H&P) dated 4/2/2025, the H&P indicated Resident 55 was admitted to the facility with diagnoses including chronic respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), history of deep venous thrombosis ([DVT] - a serious medical condition where a blood clot forms in a deep vein), history of pulmonary embolism (a sudden, often life-threatening blockage in one or more arteries in the lungs). During a review of Resident 64's Minimum Data Set ([MDS] - a resident assessment tool) dated 12/24/2025, the MDS indicated Resident 64 was cognitively intact (able to make clear decisions). The MDS indicated that Resident 64 was dependent (helper does all the effort) from staff with toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated that Resident 64 was dependent with sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed) and chair/bed-to-chair transfer (he ability to transfer to and from a bed to a chair (or wheelchair). During an observation on 2/9/2026, at 9:30 a.m., in Resident 64's room, Resident 64 was lying down in bed with two side rails up. Observed SCD hanging over the footboard of Resident 64's bed. The SCD was not connected to Resident 64 and was off. During a review of Resident 64's Order Summary Report dated 1/29/2026, the Order Summary Report indicated the physician order for SCD on for DVT prophylaxis (prevention) at all times. During a concurrent observation and interview on 2/10/2026 at 2:45 p.m. with Registered Nurse (RN) 4, in Resident 64's room, the SCD was observed on Resident 64's bed hanging on the footboard. RN 4 stated the SCD was disconnected from Resident 64 and was turned off. RN 4 stated Resident 64 had a history of DVT. RN 4 emphasized the importance of using SCD for Resident 64 at all times. RN 4 stated not using SCD put Resident 64 at great risk for developing blood clots and lead to serious health problems. During a concurrent interview and record review on 2/10/2026 at 2:50 p.m. with RN 4, Resident 64's Care Plan Report did not indicate documentation for SCD use. RN 4 stated not developing a care plan for SCD use could lead to staff not using the SCD consistently, increasing the risk for Resident 64 developing blood clots. During an interview on 2/12/2026 at 3:00 p.m. with Director of Nursing (DON), the DON stated not applying SCD as ordered by physician for Resident 64 with a history of DVT can increase the risk of Resident 64 developing blood clots, which could lead to pulmonary embolism and other serious health problems. During a review of facility's Policies and Procedures (P&P), the P&P titled, Sequential Compression Device (SCD) Application and Management, dated December 2025, the P&P indicated, Nurses will remove sleeves every shift to look at skin and when bathing. Otherwise, SCD device and sleeves should remain in place.

Based on observation, interview and record review the facility failed to provide appropriate services, equipment and assistance to one of three residents (Resident 8) reviewed under the care area of Position/Mobility, to maintain or improve mobility by not applying ankle-foot orthosis ([AFO] - a brace made of plastic or metal to support the lower leg and foot) in accordance with the facility's splinting protocol (rules for temporary, rigid immobilization of a joint to prevent further damage, reduce pain, and protect soft tissue) and physician's order. This deficient practice had the potential to increase the risk for decreased Range of Motion ([ROM] - the full distance and direction a joint can move comfortably, measuring how far you can bend, straighten, or rotate it), discomfort and worsening of Resident 8's contractures (a permanent tightening or shortening of muscles, tendons, skin, or other tissues that causes joints to become stiff, deformed, and limited in movement). Findings: During a review of Resident 8's Patient Registration Form, the Patient Registration Form indicated that Resident 8 was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE]. During a review of the History and Physical (H&P) dated 12/19/2025, the H&P indicated Resident 8 was admitted with diagnoses including cardiopulmonary arrest (a medical emergency where the heart suddenly stops beating, stopping blood flow to the brain and body), respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), encephalopathy (damage or disease that affects the brain), hypertension (high blood pressure), diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing). Resident 8 was comatose (a state of deep, prolonged unconsciousness where a person cannot be awakened, fails to respond to light, sound, or pain, and does not move voluntarily) and totally unresponsive to verbal and painful stimuli. During a review of Resident 8's Minimum Data Set ([MDS] - a resident assessment tool) dated 12/24/2025, the MDS indicated Resident 8 was comatose. Resident 8 was dependent (helper does all the effort) from staff with all activities of daily living (ADL), such as oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. The MDS indicated that Resident 8 was dependent with rolling left and right (ability to roll from laying on back to left and right side and return to lying back on the bed). During an observation on 2/9/2026, at 9:26 a.m., in Resident 8's room, Resident 8 observed having bilateral (both sides) wrist and ankle contractures with no splints applied. During a concurrent interview and record review on 2/10/2026 at 10:50 a.m. with Registered Nurse (RN) 3, RN 3 reviewed Resident 8's electronic and paper medical records. RN 3 stated Order Summary Report dated 2/1/2026, indicated the physician ordered to continue Restorative Nursing Assistant (RNA)/Nursing program for application of bilateral AFOs per splinting protocol. RN 3 stated that per facility's splinting protocol, splints must be applied per physician's order, removed every 2 hours by RNA to check for skin integrity and blood circulation. During a concurrent observation and interview on 2/10/2026 at 10:55 a.m. with RN 3 in Resident 8's room, Resident 8 was observed not having splints applied to his ankles. RN 3 stated that not having the splints applied to Resident 8's feet and ankles as ordered by the physician could place the resident at risk for worsening contractures and reduce mobility. During an interview on 2/12/2026 at 3:00 p.m. with Director of Nursing (DON), the DON stated not applying splints as ordered by the physician was not acceptable practice. The DON stated not applying splinting can lead to worsening of contractures, increased muscle spasms and further loss of function. During a review of facility's Policies and Procedures (P&P), the P&P titled, Splint Application & Use, dated December 2025, the P&P indicated, Splints are to be worn according to the schedule determined by written order of the physician.

Based on observation, interview and record review, the facility failed to ensure residents who were incontinent (lacks voluntary control over urination) of bladder received appropriate treatment and services to prevent urinary tract infections (UTI- an infection in the bladder/urinary tract) for two of three sampled residents (Resident 1 and Resident 8) by failing to keep Resident 1 and Resident 8's urinary indwelling catheter (a tube inserted into the bladder to drain or collect urine) in a manner that prevents urine backflow. This deficient practice had the increased potential for Resident 1 and Resident 8 to develop catheter associated urinary tract infection (CAUTI - UTI developed in a resident with an indwelling catheter). Findings: a. During a review of Resident 1's admission Record (the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted Resident 1 to the facility on [DATE]. During a review of the History and Physical (H&P) report completed on 12/1/2025, the H&P indicated Resident 1 was admitted to the facility with diagnosis that included acute hypoxemic respiratory failure (a medical emergency where the lungs suddenly cannot transfer enough oxygen into the bloodstream to preserve normal organ function), diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and history of urinary tract infection (UTI – an infection of the urinary system, which includes the kidneys, ureters, bladder and urethra). During a review of Resident 1's Minimum Data Set (MDS – a resident assessment tool), dated 12/12/2025, the MDS indicated Resident 1 rarely/never able to make self-understood and rarely/never able to understand others. The MDS indicated Resident 1's cognitive skills for decision making are severely impaired (never/rarely made decisions). The MDS indicated Resident 1 was dependent (helper does all of the effort) with oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. During a review of Resident 1's Order Summary Report, dated 2/11/2026, the Order Summary Report indicated a physician's order on 11/29/2025 for Foley catheter size 16x10 every shift for wound management. During a concurrent observation and interview on 2/10/2026 at 4:10 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1 was lying down in bed with a urinary catheter bag hanging on the left side of the resident's bed frame with amber yellow liquid. Observed a dependent loop (is when a tubing dips downward and traps fluid, which can block proper drainage) with urine collecting in the catheter tubing close to the resident's urethral meatus (external opening at the end of the penis in male or above the vaginal opening in females where urine exits the body). Resident 1 had an empty leg strap (band that secures a catheter or drainage bag to the thigh or calf to ensure the bag stays in the correct position for drainage) on his left thigh without the catheter attached. LVN 1 stated the leg strap should be holding the catheter to prevent dislodgement and maintain the position of the catheter where the urine flows downward from when it empties from the resident's bladder. LVN 1 stated improper placement of urine catheter may cause urine to flow back to the resident and cause a UTI. LVN 1 also stated that there is a risk of it becoming clogged if urine cannot flow freely. During an interview on 2/12/2026 at 12:25 p.m. with the Director of Nursing (DON), the DON stated that urine catheter should be secured with a leg strap with the urinary catheter bag hanging below the level of the bladder. The DON emphasized that the catheter tubes should not be kinked or contain any dependent loops, as this may cause urine to flow back and potentially result in a urinary tract infection (UTI). During a review of Resident 1's care plan (CP) titled, The resident has indwelling urinary catheter indicated for wound management. At risk for urinary tract infection. At risk for urine backflow due to resident moving catheter, the CP indicated to apply leg strap as indicated and maintain proper alignment of indwelling catheter free of kinks. b. During a review of Resident 8's Patient Registration Form, the Patient Registration Form indicated that Resident 8 was originally admitted to the facility on [DATE], and readmitted to the facility on [DATE]. During a review Resident 8's H&P dated 12/19/2025, the H&P indicated Resident 8 was admitted with diagnoses including cardiopulmonary arrest (a medical emergency where the heart suddenly stops beating, stopping blood flow to the brain and body), respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), encephalopathy (damage or disease that affects the brain), hypertension (high blood pressure), and diabetes mellitus. Resident 8 was comatose (a state of deep, prolonged unconsciousness where a person cannot be awakened, fails to respond to light, sound, or pain, and does not move voluntarily) and totally unresponsive to verbal and painful stimuli. During a review of Resident 8's MDS dated [DATE], the MDS indicated Resident 8 was comatose. Resident 8 was dependent from staff with all activities of daily living (ADL), such as oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. The MDS indicated that Resident 8 was dependent with rolling left and right. During a concurrent observation and interview on 2/10/2026 at 10:55 a.m. with RN 3 in Resident 8's room, Resident 8 was observed to have suprapubic indwelling urinary catheter (urinary catheter inserted through the area just above the pubic bone) securely attached to Resident 8's left thigh then to the drainage tube (the tube connecting a urine catheter to a drainage bag) laid over a positioning wedge (a firm foam triangle used to support, stabilize, or elevate specific body parts while a person is in bed). RN 3 stated the tubing was above the level of Resident 8's bladder, and urine was visibly backing up toward the resident's body. RN 3 further stated this positioning of the tubing could increase the risk for UTIs and CAUTIs. During an interview on 2/12/2026 at 3:00 p.m. with the DON, the DON stated it was not acceptable practice for catheter tubing to be positioned above the level of residents' bladder level. The DON explained that the tubing must remain below bladder level and the drainage bag should not touch the floor. The DON further stated that positioning the tubing above the bladder can interfere with urine flow, potentially causing obstruction and increasing the risk of CAUTIs. During a review of the facility's P&P titled, Infection Control Plan 2025 last reviewed 1/29/2026, the P&P indicated, Pacifica Hospital of the Valley to maintain a comprehensive and effective program of surveillance, prevention, and control of infection.The organization will employ a coordinated process to reduce the risks of endemic and epidemic, or healthcare-associated infection(s) in patients and healthcare workers. Infection Prevention will be comprehensive and address issue(s) identified as epidemiologically significant and demographically sound. These issues include but are not limited to the following: Device-related infections, especially those associated with intravascular devices, urinary catheters, and ventilators.Risk Mitigation: Adherence to CDC guidelines and toolkits: Catheter-associated urinary tracts infections (CAUTI).

Based on observation, interview and record review, the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices for one of four sampled residents (Resident 13) when Respiratory Therapist 2 (RT 2) documented on the Medication Administration Record (MAR - a daily documentation record used by licensed staff to document medications and treatments given to a resident) that Resident 13's bubble humidifier (a medical device that includes a plastic bottle partially filled with distilled water to add moisture to supplemental oxygen given to residents) was changed when the bubble humidifier had not changed. This deficient practice resulted in inaccurate documentation in Resident 13's medical record. Findings: During a review of Resident 13's admission Record (the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted Resident 13 to the facility on [DATE]. During a review of the History and Physical (H&P) Note completed on 9/21/2023, the H&P indicated Resident 13 was admitted to the facility with diagnosis that included chronic hypoxemic respiratory failure (a long-term condition where the lungs cannot sufficiently transfer oxygen into the blood), cerebral vascular accident (CVA -stroke, loss of blood flow to a part of the brain), and post percutaneous endoscopic gastrostomy (PEG - medical device inserted into the stomach to provide essential nutrition, fluids, and medication or require long term feeding). The H&P indicated Resident 13 is unable to make decisions. During a review of Resident 13's Minimum Data Set (MDS - a resident assessment tool), dated 12/19/2025, the MDS indicated Resident 13 rarely/never able to make self-understood and rarely/never able to understand others. The MDS indicated Resident 13 was dependent (helper does all of the effort) with oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. During an observation on 2/9/2026 at 8:33 a.m. at Resident 13's bedside, a bubble humidifier dated 2/4 was observed connected to Resident 13's oxygen tubing. During an interview on 2/9/2026 at 11:13 a.m. with Respiratory Therapist (RT), RT 1 stated the date on the bubble humidifier indicates when it was last changed. RT 1 stated that Resident 13's bubble humidifier was dated 2/4, indicating that it was last changed on 2/4/2026 and had not been changed on 2/6/2026 as scheduled per physician orders. During a review of Resident 13's Order Summary Report, dated 2/11/2026, the Order Summary Report indicated a physician's order on 12/18/2023 to change the bubble humidifier in the morning every Monday, Wednesday, and Friday. During a review of Resident 13's MAR dated February 2026, the MAR indicated that on 2/6/2026 for the 9am administration time, there were staff initials in the box for the order to change bubble humidifier in the morning of every Monday, Wednesday, and Friday, indicating the task had been completed. During an interview on 2/12/2026 at 11:19 a.m. with RT 2, RT 2 stated he documented on Resident 13's MAR on 2/6/2026 at 9am that he changed the bubble humidifier before he went to Resident 13's bedside to perform the task. RT 2 explained that when he went to Resident 13's bedside, Resident 13 was occupied and receiving care from another staff. RT 2 stated he did not change the bubble humidifier and meant to return later but forgot. RT 2 stated, It slipped my mind. RT 2 stated that he should not have documented the bubble humidifier was changed as accuracy in MAR documentation is important because it informs the healthcare team of the completion status of the physician's orders. RT 2 stated that the inaccurate documentation on Resident 13's MAR implied the bubble nebulizer was changed, and it did not require another RT to perform the task, which resulted in Resident 13's bubble nebulizer not being changed at all on 2/6/2026. During an interview on 2/12/2026 at 3:35pm with the Director of Nursing (DON), the DON stated that documentation should be done only after the intervention has been performed. The DON stated that the task must first be completed, then documented. During a review of the facility's P&P titled, Oxygen Therapy last reviewed 1/29/2026, the P&P indicated, To deliver supplemental oxygen to aid the relief of tissue hypoxia or hypoxemia.Equipment:.Bubble humidifier or aerosol humidifier, if trach resident.Procedure: 6. Connect humidifier to outlet of flowmeter. Label with date opened.Documentation: Date and time oxygen therapy is in use. During a review of the facility's P&P titled, Medication Administration: last reviewed 1/29/2026, the P&P indicated, Ordering medications - Medications and treatments shall be administered only upon the written order of a person lawfully authorized to prescribe for and treat human illnesses.Administration - All medications and treatments shall be administered by licensed health care professionals as followed by state law.These policies and procedures are established to assure the most complete and accurate implementation of physicians' medication orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely and sanitary manner. General Policy a. All entries in the health record involving medications shall be made by licensed personnel.d. Documentation of medication doses administered shall be charted as soon as possible after administration to any individual resident.

Based on interview and record review, the facility failed to implement its protocol for Antibiotic Stewardship Program (a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics [medications that fight infections caused by bacteria]) for one of one sampled resident (Resident 8) by not completing an Antibiotic Time-Out (a scheduled check-up, treatment is paused to re-evaluate if the medication is still necessary, effective, or needs adjustment) between 48 to 96 hours of therapy initiation as indicated in facility's policies and procedures (P&P). This deficient practice had the potential to result in inappropriate or prolonged antibiotic use, increased risk of side effects (unwanted effects of medications), and antibiotic resistance (occurs when bacteria evolve to survive drugs designed to kill them, making infections difficult or impossible to treat). Findings: During a review of Resident 8's Patient Registration Form, the Patient Registration Form indicated that Resident 8 was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE]. During a review of the History and Physical (H&P) dated 12/19/2025, the H&P indicated Resident 8 was admitted with diagnoses including cardiopulmonary arrest (a medical emergency where the heart suddenly stops beating, stopping blood flow to the brain and body), respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), encephalopathy (damage or disease that affects the brain), hypertension (high blood pressure), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). Resident 8 was comatose (a state of deep, prolonged unconsciousness where a person cannot be awakened, fails to respond to light, sound, or pain, and does not move voluntarily) and totally unresponsive to verbal and painful stimuli. During a review of Resident 8's Minimum Data Set ([MDS] - a resident assessment tool) dated 12/24/2025, the MDS indicated Resident 8 was comatose. Resident 8 was dependent (helper does all the effort) from staff with all activities of daily living (ADL), such as oral hygiene, toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing. The MDS indicated that Resident 8 was dependent with rolling left and right (ability to roll from laying on back to left and right side and return to lying back on the bed). During a concurrent interview and record review on 2/11/2026 at 11:15 a.m. with the Infection Preventionist Nurse (IPN), the Resident 8's Order Summary Report dated 1/21/2026 indicated Physician order for Zosyn (an antibiotic medicine used to treat serous bacterial infections) solution 3-0.375 Gm/50 ml (unit of measurement) to be used 1 dose intravenously (through veins) every 8 hours for elevated white blood cells ([WBC] - a blood cell that helps attack infection or injury in the body) for 7 days. The IPN stated that it was the facility's policy to conduct antibiotic time-off within 48 to72 hours of antibiotic treatment initiation to assess if the treatment had been effective. The IPN reviewed Resident 8's electronic and paper medical records. The IPN stated there was no documentation of antibiotic time-off assessment. The IPN stated this could lead to unnecessary use of antibiotics, increased risk of side effects and antibiotic resistance. During an interview on 2/12/2026 at 3:00 p.m. with Director of Nursing (DON), the DON stated it was the facility's policy to perform and document an antibiotic time-out for Residents who are currently on antibiotics. Time out expected to be completed within two to four days of starting the antibiotic treatment. The DON stated if the time-out is not done or documented, staff may not know treatments efficiency, which can lead to inappropriate antibiotic use, increased risk of antibiotic resistance, and possible adverse reactions. During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship Program, reviewed/revised in January 2026, the P&P indicated the facility will utilize a process for completion of an Antibiotic Time-Out between 48 and 96 hours of therapy initiation.

Based on interview and record review, the facility failed to ensure one of one sampled Certified Nursing Assistant (CNA) reviewed for sufficient and competent nurse staffing was provided the required annual in-service training for dementia (a condition characterized by decline in mental ability such as memory, reasoning and communication) management. The deficient practice had the potential to negatively affect the quality of care received by residents with dementia. Findings: During a concurrent interview and record review on 2/12/2026 at 1:50 p.m. with the Human Resources Supervisor (HRS), Restorative Nursing Assistant (RNA- a CNA who has received additional training in restorative care) 2's employee file was reviewed. The HRS stated there was no record of RNA 2 having received dementia training in the last 12 months. During an interview on 2/12/2026 at 3:03 p.m. with the Director of Staff Development (DSD), the DSD stated he is responsible for ensuring required trainings are completed. The DSD stated that dementia training was not provided to RNAs in the last 12 months and will ensure dementia management training is provided annually moving forward. The DSD stated dementia training enhances staff knowledge about dementia and how to care for residents with this condition. The DSD stated that without proper dementia training, staff may misinterpret residents' behaviors and fail to implement appropriate interventions. The DSD stated that dementia management training equips staff with the necessary knowledge to provide effective care tailored to the specific needs of residents with dementia. During a review of the facility's P&P titled, Sub-Acute Staff Training last reviewed 1/29/2026, the P&P indicated, All Sub-acute staff must participate in initial orientation and annual in-service training.All staff are required to participate in regular in-service education.The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhance the resident's quality of life and quality of care and can demonstrate competency in the topic areas of the training.Required training topics include the following: (3) dementia management and resident abuse prevention.Training requirements are met prior to staff providing services to residents, annually, and as necessary based on the facility assessment.Completed training is documented by the staff development coordinator, or his or her designee and includes: the date and time of the training; the topic of the training; a summary of the competency assessment; and the hours of training completed

Based on interview and record review, the facility failed to ensure Resident 1's conservator was included in the decision to cancel a long-awaited medical appointment.This failure had the potential to result in Resident 1 to have a delay in his medical care due to the unplanned rescheduling. During a review of Resident 1's History and Physical (H&P), dated 6/8/2022, the H&P indicated Resident 1 admitted to the facility on [DATE] for long term care and management related head trauma (bodily injury) resulting in cerebral (relating to the brain) swelling (abnormal enlargement of a part of the body, typically as a result of an accumulation of fluid) and right temporal (portion of brain) contusion (bruising).During a review of Resident 1's Surgical Consult, dated 6/17/2025, the consult indicated the reason for consultation was for a skin lesion (type of wound) on his back related to dermatitis (skin inflammation).During a review of Sub Acute Appointment June 2025 calendar, dated June 2025, the calendar indicated, Resident 1 was scheduled for a dermatology appointment on 6/23/2025 at 3:00 PM.During a review of Resident 1's Letter of Conservatorship, dated 2/14/2023, the document indicated, Resident 1's conservator is his appointed conservator with exclusive authority to give consent for and to require the conservatee to receive medical treatment that the conservator in good faith based on medical advised determines to be necessary. During an interview on 7/1/2025 at 3:20 PM with the social worker (SW), the SW stated Resident 1 had a dermatology appointment scheduled for 6/23/2025 but she was instructed to cancel the appointment and transportation due to a lack of staff available to accompany Resident 1 to his appointment. The SW stated there was no communication with Resident 1's conservator prior to the decision to cancel his dermatology appointment; only notification of the need for rescheduling the appointment was sent to his conservator. During an interview on 7/1/2025 at 4:06 PM with the Director of Staff Development (DSD), the DSD stated, prior to cancelling Resident 1's dermatology appointment, the facility should have called Resident 1's conservator to notify them of the situation regarding low staffing and to present the available options to inquire on how they would like to proceed regarding Resident 1's care.During a concurrent interview and record review on 7/1/2025 at 4:10 PM with the DSD, Resident 1's California Standard admission Agreement For Skilled Nursing Facilities and Intermediate Care Facilities, dated 6/13/2025 was reviewed. The document indicated, Resident 1, including his conservator, have resident rights that include the right to:- effective communication and to participate in the development and implementation of your plan of care .- make decisions regarding medical care, and received as much information about any proposed treatment or procedure as you may need in order to give informed consent or to refuse a course of treatment .- reasonable continuity of care and to know in advance the time and location of appointments as well as the identity of the persons providing the care.The DSD stated the facility cancelling Resident 1's appointment prior to speaking to his conservator displayed the facility's lack of communication, which was a violation of Resident 1's resident rights. The DSD stated the importance of clear communication is to ensure the resident's needs are being met and that the conservator is included in the resident's plan of care.

Based on observation, interview, and record review, the facility failed to: 1. Maintain acceptable room temperature ranging from 71 to 81 degrees Fahrenheit ( F, unit of temperature) for 51 of 51 residents (Resident 1 to Resident 51) in the Sub-Acute (a medical facility that provides medical care to chronically ill patients who are medically stable) Unit. 2. Maintain the chiller (a cooling water circulation device that is connected to the air conditioning [A/C] system) for two of two chillers in working condition. 3. Monitor and record room temperatures in accordance with facility's policy and procedures, titled Daily Maintenance Log and Out of Range Temperatures, and Temperature Monitoring of Patient Room. 4. Ensure the rental chillers, which were used temporarily to replace the broken chillers of the air conditioner, were working properly. These deficient practices placed the 51 residents on the Sub-Acute Unit at risk for dehydration (excessive loss of body water) and/or heat stroke (internal body heat with complications involving the central nervous system that occur after exposure to high temperatures). On 6/15/2024 at 7:25 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death of a resident) situation for the facility's failure to provide a safe environment to the residents by failing to maintain an acceptable residents' rooms temperature range of 71 to 81 degrees Fahrenheit in the presence of the Chief Nursing Officer (CNO) 1. On 6/16/2024 at 2:16 p.m. and 3:45 p.m., the facility submitted an IJ Removal Plan (immediate action that includes all actions the entity has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely), which was not accepted. On 6/16/2024 at 4:12 p.m., the survey team conducted an exit conference with CNO 1 and exited the facility, with the IJ situation not removed. 6/18/2024 at 2:46 p.m., the facility submitted an IJ Removal Plan, which was not accepted. Findings: During an interview on 6/15/2024, at 2:11 p.m., with CNO 1, CNO 1 stated the chillers for the hospital went out yesterday on 6/14/2024 with no time identified. The hospital had vendors come and installed 2 rental chillers to use. The staff engineer checked the rental chillers after installation and the staff engineer stated everything was to be ok. The staff engineer did not check the temperature of the residents' rooms to confirm the temperature range was safe for patient care. During an interview on 6/15/2024, at 2:30 p.m., with House Supervisor (HS) 1, HS 1 stated, It feels very hot in the hospital. The engineer staff have been working on it today. During an interview on 6/15/2024, at 2:39 p.m., with Engineer Staff (ES) 1, ES 1 stated he was on duty today and the vendors were checking on the two rental chillers. The two rental chillers were running fine when ES 1 left the hospital at 1:15 pm today. ES 1 stated he told staff if they had issues with the temperature to call the on-call engineer staff. ES 1 stated 68 to 74 degrees Fahrenheit was a normal comfortable temperature range for the Sub Acute Unit. ES 1 did not know at this time if the two rental chillers were down. ES 1 stated it is important to keep the residents' rooms in running cool temperature. ES 1 stated he did not do a temperature log for today. ES 1 stated he did not have time to do the temperature log. During an interview on 6/15/2024, at 2:39 p.m., with Director of Operations (DO) 1, DO 1 stated the following: two rental chillers were installed at 4 am this morning and at 9 am, both rental chillers were running fine. DO 1 stated the engineer staff should be checking the chillers and temperature of the Sub Acute Unit daily. DO 1 stated the engineer staff should be checking and monitoring the temperature of the Sub Acute Unit after installation of the rental chillers. During an observation on 6/15/2024, at 3:34 p.m., on Sub Acute Unit on the 3rd Floor, rooms 340 to 344 were noted to have a hot temperature. During an interview on 6/15/2024, at 3:36 p.m., with Registered Nurse (RN) 2, RN 2 stated, Yesterday, called engineering department because temperature was hot, and they came. Today I called engineering department for the temperature, and they did not come. It has been hot today on the Sub Acute Unit. Did not provide cooling measures to the residents today. Not safe for residents to be in high temperature condition, they can have serious complications. During an observation on 6/15/2024, at 4:03 p.m., with Engineer Staff (ES) 1 on Sub Acute Unit on the 3rd Floor, ES 1 used a handheld thermometer (a non-contact thermometer temperature-sensing instrument) to obtain the temperature of rooms 340 to 344. The rooms had a temperature range of 77 to 82 degree per reading on the handheld thermometer. During an observation on 6/15/2024, at 4:46 p.m., with Engineer Staff (ES) 1 on the Sub Acute Unit 2nd Floor, ES 1 used a handheld thermometer to obtain temperature of rooms 340 to 344. The rooms had a temperature range of 77 to 82 degree per reading on the handheld thermometer. During an observation on 6/15/2024, at 5:50 p.m., with Engineer Staff (ES) 1 on Sub Acute Unit on 3rd Floor, ES 1 used a handheld thermometer to obtain temperature of rooms 340 to 344. The rooms had a temperature range of 77 to 82 degree per reading on the handheld thermometer. During an interview on 6/15/2024, at 5:57 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Today at 11 a.m., it started to be hot. The temperature feels hot. It is important for the temperature to be cool for residents, they can have problems if the rooms are very hot. During an interview on 6/15/2024, at 6:01 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, Nursing station temperature is really bad and felt really hot the whole start of my shift. The hospital air conditioning has always been a problem, we alerted the engineering department about the AC problem, but I think there are limited staff to get it done. Today is obvious hot on this Sub Acute Unit floor. It is not safe for residents to be in this hot air condition, they can have problems. During an interview on 6/15/2024, at 6:19 p.m., with CNO 1 and Engineer Staff (ES) 1, CNO 1 and ES 1 stated, The reason why the facility had problems with the two rental chillers because the vendor installed it incorrectly. Informed by the current vendor onsite who does not want to touch the work of another vendor. The water hoses of the rental chillers (was) installed incorrectly by the vendor. There is no estimated time for the vendor, who installed the chillers incorrectly, will be here. They are on their way as soon as possible to fix the issue. During a review of the facility's census dated 6/15/2024, the census indicated that there were 51 sub-acute residents in the facility. During a review of the facility's policy and procedure (P&P) titled, Contingency Plan for Failure of Air Conditioning System, revised on 2/2024, the P&P indicated, The Engineering Department shall have a contingency plan in place in the event of failure of the air-conditioning system. During a review of the facility's P&P titled, HVAC System, revised on 2/2024, the P&P indicated, Engineering Department personnel shall be trained in the preventative maintenance, location and safe operation of the HVAC system. During a review of the facility's P&P titled, Daily Maintenance Log and Out of Range Temperatures, revised on 2/2024, the P&P indicated, Engineering Department personnel will conduct daily rounds and monitor patient room temperatures that drop below or exceed above normal comfortable room temperature ranges. The facility was unable to provide records of residents' rooms temperature monitoring for the sub-acute. During a review of the facility's P&P titled, Temperature Monitoring of Patient Room, dated 10/2023, the P&P indicated, Purpose: This policy is to provide instructions on how to monitor and document temperatures that are required for assuring optimal conditions for patient rooms. Frequency: Temperatures of room air are monitored and documented each day manually by the Engineering Department. Acceptable Temperature Room Ranges 71 to 81 degrees

Based on observation, interview, and record review, the facility failed to maintain infection control practices to prevent spread of infection for two of 17 sampled residents (Residents 11 and 12). Resident 12, who tested negative for Methicillin Resistant Staphylococcus Aureus (MRSA is a micro-organism that is more difficult to treat than most strains of staphylococcus aureus, can infect surgical wounds, the bloodstream, the lungs or the urinary tract, and can be life-threatening), was sharing the same room (from January 1 to 8, 2016) as Resident 20 who tested positive for MRSA of the nares. On January 6, 2016, six days later, Resident 12 tested positive for MRSA of the nares. This deficient practice resulted in Resident 12 being positive for MRSA. Resident 11 was not screened for MRSA following his admission to the facility per the facility's policy and procedure. Resident 11 tested positive for [MEDICATION NAME]-Resistant [MEDICATION NAME] bacteria (VRE - bacteria live in our intestines and skin that can cause serious infections, especially in people who are ill or weak), and was sharing the same room as Resident 12 (from January 9, 2016, to February 3, 2016). This deficient practice placed Resident 11 at risk for MRSA infection, and Resident 12 at risk for VRE infection. Findings: 1. During the initial tour of the Neuro 2 unit with RN 24 on February 2, 2016, at 11 a.m., there was a posted sign outside the room of Residents 11 and 12 indicating Contact Isolation and Droplet Isolation. A review of the room assignment indicated Residents 11 and 12 was sharing the room from January 9, 2016, to February 3, 2016. During medication pass observation on February 3, 2016, at 8:20 a.m., LVN 5 needed to get the medication from the medication cart. The key to medication cart was with another licensed nurse in room [ROOM NUMBER]. There were posted signs out room [ROOM NUMBER] indicating the residents (Residents 11 and 12) were on contact and droplet isolation. LVN 5 without wearing a personal protective equipment (PPE) went to room [ROOM NUMBER] bed 1 and obtained the key to the medication cart and continued on with medication pass. During an interview with LVN 5 at the time of observation, LVN 5 stated he forgot to wear PPE when he went into the isolation room. A review of Resident 11's record indicated Resident 11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According Resident 11's laboratory results, Resident 11 tested positive for VRE in sputum on January 1, 2016, and was placed on droplet isolation, and on January 20, 2016, Resident 11 tested positive for VRE in urine, and was placed on contact isolation. Resident 11 was not screened for MRSA upon admission. Resident 12's record indicated Resident 12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 12 had tracheostomy (a surgical opening into the trachea, or breathing passage, for purposes of breathing and removal of lung secretions), gastrostomy tube ([DEVICE] is a tube that is inserted into a surgically created opening into the stomach for purposes of nutrition delivery and medication administration) and pressure ulcers (injury to skin) on the sacral areas and the right lateral foot. A review of the facility's record (room assignment) indicated Resident 12 (tested negative for MRSA on December 11, 2015, per laboratory report) was sharing the same room as Resident 20 (tested positive for MRSA of the nose on October 15, 2015, per laboratory report) from January 1, 2016, through January 8, 2016. According to the laboratory reports, on January 6, 2016, Resident 12 tested positive for MRSA of the sputum. Resident 12's culture of the nose tested again on January 15 and 26, 2016, and the test results were positive for MRSA. (Resident 12 tested before sharing the room with Resident 20) The facility's policy and procedures, titled, Isolation Precautions, revised October 2014, indicated the following: (For a patient on contact isolation precautions), place the patient in a private room; when a private room is unavailable, place the patient in a room with a patient(s) who has active infection with the same microorganisms, but with no other infection (cohorting). When a private room is not available, and cohorting is not achievable, consider the epidemiology of the microorganism and the patient population when determining patient placement. On February 3, 2016 at 2:15 p.m., during an interview with the Subacute Director (RN 22), RN 22 stated the unit lacked adequate space for residents who required isolation. When asked how many isolation rooms were available, RN 22 replied there were a total of five isolation rooms. On February 3, 2016 at 2:25 p.m., an interview was conducted with the Director of Infection Control (RN 23). RN 23 was questioned how he determined which residents were able to be cohorted (shared the room) together, RN 23 replied he checked resident information daily, such as whether a resident was diagnosed with [REDACTED]. RN 23 then stated it was difficult to re-locate a resident on the subacute unit who did not have a tracheostomy, or other potential sites that could become infected. RN 23 further stated many of the residents on the subacute unit were immuno-compromised (a state in which someone's immune system's ability to fight infectious disease is compromised or entirely absent). On February 3, 2016 at 3:25 p.m., an immediate jeopardy (IJ) was identified for the facility's failure to implement its policies and procedures regarding proper cohorting (room-sharing) of residents with the same micro-organisms, in order to prevent transmission of infection between residents. On February 3, 2016 at 3:50 p.m., the California Department of Public Health survey team declared an immediate jeopardy and informed the Chief Nursing Officer (RN 21) and subacute Unit Director (RN 22) of an immediate jeopardy related to the cohorting of residents who had a contagious infection, with residents who did not have an infection. On February 3, 2016 at 6:10 p.m., the facility (RN 21 and RN 22) presented an acceptable written plan of correction to the survey team, the IJ was removed after the facility transferred the residents (Resident 11, 12, and 20) with contagious infections to private rooms, and obtained cultures from a resident (Resident 11) who was cohorted with one of the contagious residents, in order to determine if the resident had become infected. 2. During a tour of Neuro 3 on February 2, 2016, at 10:30 a.m., there were 2 linen carts in the hallway with short covers. The clean linen on the bottom shelf were exposed. The front covers were partially open. During a tour of Neuro 2 North on February 2, 2016, from 2 p.m. - 2:50 p.m., in Neuro 2 North there were 6 linen carts in the hallway. The covers were short exposing the linen in the bottom shelf. The front covers were partially open. At the same time, during an interview, Certified Nursing Assistant (CNA 1) stated the linens at the bottom shelf were clean. During an interview on February 2, 2016, at 2:20 p.m., the housekeeping supervisor could not explain why the linen cart covers were short. He further stated the purchasing department was responsible for ordering the linen cart covers. In the shower room, there was a linen cart stored with a short cover exposing the clean linen at the bottom shelf. 3. During a tour of Neuro 2 South on November 3, 2016, at 7:32 a.m., in the restroom of room [ROOM NUMBER], one heel protector was stored in between the wall and the toilet pipe and one heel protector was stored between the grab bar and the wall. At the same time, during an interview, the charge nurse (RN 5) stated the heel protectors belonged to the resident in bed 2. She further stated the heel protectors should be stored in the closet. 4. During a tour of Neuro 2 South on February 3, 2016, at 7:55 a.m., in the linen closet, the clean linens were stored on shelves. The curtain provided to cover the linens was partially open exposing the clean linens approximately 2 feet on the left side and one foot on the right side from the topmost shelf to the bottom shelf. Only the middle portion from top to bottom was covered. 5. During an observation on February 3, 2016, at 10:10 a.m., at Neuro 2 North the trash bin touched one of the linen carts with clean linen in the hallway that was partially open. During an observation at Neuro 2 South on February 4, 2016, at 11:30 a.m., the housekeeping supervisor was pulling a linen cart in the hallway. The cart was partially open. At the same time, during an interview, the housekeeping supervisor stated he was distributing clean linen. A review of the facility's policy and procedure titled Storage, Collection and Transportation of Linen with a reviewed/revised date of 3/13 stipulated clean linens will be transported to patient care areas by use of covered carts by environmental services department personnel. Clean linen carts will be covered at all times, while in the linen closets of each unit and/or storage area. 6. During an observation, on February 3, 2016, at 9:22 a.m., of the morning medication pass for Resident 24, one to two sample residents, LVN 5 washed her hands but did not don gloves. LVN 5 prepared three medications for administration via a gastrostomy tube or [DEVICE], a feeding tube surgically placed directly into the stomach. LVN 5 proceeded to touch the gown, handle the [DEVICE] valves, check for proper placement of tube by aspiring gastric contents, handle the medication cups, administer medications into the feeding syringe, and perform water flushes with her bare hands. During an interview, on February 5, 2015, at 9:12 a.m., LVN 5 stated, I forgot to put my gloves on. A review of the facility's policy and procedure, Isolation Precautions, revised October 2014, under Standard Precautions, indicated, .wear gloves (clean non-sterile gloves are adequate) when touching blood, body fluids, secretions, excretions, and contaminated items; put on clean gloves just before touching mucous membranes and non-intact skin . A review of the facility's policy and procedure, Medication Administration, dated October 2015, under Procedure: Preparation of Doses-General Instructions, indicated, Sanitary techniques shall be used in the preparation of any medication .

Based on observation, interviews, and record review, the facility failed to effectively assess pain level, implement pain relief measures, and assess whether the pre-medication ordered for pain prior to pressure ulcer wound treatment was sufficient to relieve the pain during the wound care, for one of 17 sampled residents (21). During observation of wound care for a sacral (area at base of spine) pressure ulcer, and left foot pressure ulcer, Resident 21 was tearful, cried out several times, diaphoretic (sweating), and made attempts to pull her body away. The licensed vocational nurse (LVN 5), who was performing the wound care, completed the wound treatment without stopping to assess Resident 21's pain level, offering pain medication, or informing the physician of the resident's discomfort. This failure caused the resident pain and emotional distress, and had an adverse effect on the resident. Findings: On January 14, 2015 at 8:15 a.m. during the initial tour of the subacute unit, Resident 21 was observed lying on a low air loss mattress (special air-fluidized bed which relieves pressure on the skin and promotes wound healing). The resident, who was awake and alert, had a [MEDICAL CONDITION] (plastic airway tube surgically inserted into the airway for air exchange), which was connected to a ventilator (a machine that supports breathing, and breathes for people who have lost ability to breathe on their own). The resident was also receiving a tube feeding through a gastrostomy tube (G tube is a tube surgically inserted into the stomach through the abdominal wall for purposes of feeding and medication administration). A review of the clinical record indicated the resident was initially admitted to the facility on [DATE], and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident also had contractures of her lower extremities (chronic loss of joint motion due to structural changes in non-bony tissue), a chronic Stage IV (full thickness skin loss, with exposed bone/tendon/muscle) sacral (area above the crease between buttocks) pressure ulcer, and a deep tissue injury pressure ulcer (DTI- localized area of discolored intact skin or blood-filled blister, due to damage of underlying soft tissue from pressure) on her left foot. A review of the Nursing Admission Patient Assessment notes, dated December 22, 2014, indicated the resident was awake and alert, but unable to walk. The resident was incontinent of bowel, and had an indwelling urinary catheter for wound management. The resident was totally dependent on staff for all daily living activities, and communicated by nodding or shaking her head, and mouthing words. A review of the physician orders [REDACTED]. A review of the Sub Acute Weekly Wound Note, dated January 15, 2015, indicated the sacral wound measurements were 6.5 centimeters (cm) in length, 4 cm in width, and 2.2 cm in depth. The left mid lateral foot DTI pressure ulcer measurements were 1.5 cm in length, and 2.0 cm in width. The physician's orders [REDACTED]. Another order, dated December 22, 2014, indicated to administer [MEDICATION NAME] (narcotic-like pain reliever) every six hours PRN (as necessary) for severe pain. According to the online pharmaceutical website Lexi-comp), [MEDICATION NAME] is a pain reliever for the treatment of [REDACTED]. Review of a care plan titled, "Potential for Altered Comfort", dated December 22, 2014, indicated interventions such as assessing for pain every shift and as needed, provide gentle touch, massage, and repositioning, identify area and severity of discomfort, and to administer medications and monitor effects. On January 15, 2015 at 10 a.m., an observation was conducted of Resident 21's wound care treatment for [REDACTED]. LVN 5 stated he had administered [MEDICATION NAME] 650 mg via GT at 9:30 a.m. LVN 5 and RNA 1 (restorative nursing assistant) assisted the resident onto her left side, with the resident facing away from the LVN. Without informing the resident of what he was going to do, LVN 5 loosened the tape of the old dressing, then removed the soiled dressing and packing gauze (gauze which is used to fill a wound space in order to absorb puss and keep bacteria away). LVN 5 then cleaned the wound bed with normal saline solution and gauze pads in a hurried (quick) manner, again without first informing the resident. At that time, the resident jerked her body, cried out several times, had increased respiratory rate, and exhibited facial grimacing. LVN 5 asked, "Are you ok?", then stated, "We're almost done", then proceeded with the treatment without stopping to assess the resident's pain level, or ask the resident if she needed more pain medication. LVN 5 placed gauze packing and calcium alginate ointment (a treatment used in wound dressings which aids in healing of the wound) into the wound cavity, applied gauze pads on top of the packing, then applied an Island dressing pad (an absorbent pad which conforms and seals wound on all four sides). He then applied zinc oxide ointment to the reddened area below the sacral wound. LVN 5 performed each step of the treatment in a hurried manner, without informing the resident of his actions. After being repositioned onto her back following the sacral wound treatment, resident exhibited an anxious expression, she was tearful, perspiring, and breathing faster than before the treatment. The surveyor asked the resident if she was in pain, and LVN 5 repeated the question. The resident hesitated, looked from the surveyor to LVN 5 twice, then nodded her head and mouthed, "In my butt." LVN 5 repeated, "In your butt?", then immediately began treatment of [REDACTED]. After LVN 5 removed the left foot dressing, a discolored area (Area 1), with visually estimated to be two and a half cm in length, and one and a half cm in width, was observed midway on the lateral (outer) side of the foot, which LVN 5 identified as the DTI. A second discolored area (Area 2), one cm in diameter, was observed approximately five cm above Area 1. LVN 5stated he was unaware of the area, then proceeded to press on it several times. Resident 21 exhibited facial grimacing; she was crying, and her left foot was jerking. RNA 1, who was at the head of the bed, patted the resident's head and shoulder area, and stated, "It's ok, it's ok", several times. LVN 5 stated he would notify the physician of Area 2 (being new to him), then applied [MEDICATION NAME] Spray (a wound treatment) to a gauze pad, placed the pad on Area 1, and wrapped the foot with gauze wrap, again without first informing the resident of his actions. During an interview at 10:25 a.m., LVN 5 indicated Resident 21 had been receiving wound care for the sacral pressure ulcer for over six months, and that the resident was transferred back to the subacute unit from the critical care unit (CCC) the previous month. When questioned regarding what the resident received for pain, LVN 5 responded she received Tylenol 650 mg every morning, 30 minutes prior to her wound care. He then stated, "She probably needs something else. She usually does okay. Since she came back from CCC, she hasn't been tolerating the wound care as well. She was sweating." LVN 5 further indicated he would ask the resident if she wanted a dose of [MEDICATION NAME], then stated he would re-assess the resident after she received the [MEDICATION NAME], and notify the physician. LVN 5 further indicated he would update the charge nurse and the physician regarding the new skin discoloration, and would obtain an order for [REDACTED]. As the interview continued, the surveyor asked if during previous wound care, the resident had ever indicated she was having pain. LVN 5 responded, "I think so, but I think that we thought Tylenol would take care of it. She always seemed okay afterwards." LVN 5 then acknowledged the resident was grunting and making vocal sounds during the treatment, and he had hurried in order to get through the treatment. He then stated he was nervous during the treatment, and felt pressured because the surveyor was standing there. During an interview with RNA 1 immediately after the observation, she stated Resident 21 was able to communicate by nodding or shaking her head, and by mouthing words, then stated the resident sometimes mouthed that she was having pain. When RNA 1 was asked if she was able to tell when the resident was having pain, RNA 1 stated, "I can tell by her face if she has pain, like this morning. She was kind of restless." RNA 1 indicated when she performed passive range of motion (PROM- exercises during which a person's joints are being moved without their assistance) on the resident's left foot, the resident would complain of pain and tell the RNA, "Don't touch me there." During an interview at 11:20 a.m., RN 1 indicated she had notified the physician regarding the resident's pain, and the physician had ordered [MEDICATION NAME] (a combination of narcotic and Tylenol). RN 1 also stated LVN 1 had just given the resident a dose of [MEDICATION NAME]. When questioned why the resident had not received [MEDICATION NAME], as it had just been ordered, RN 1 responded that she had instructed LVN 1 to re-assess the resident's pain level following the [MEDICATION NAME] administration, and she did not want the [MEDICATION NAME] given because the resident had already received the [MEDICATION NAME]. At 11:25 a.m., during an interview with Resident 21, she nodded when asked if she experienced pain during the wound treatment that morning, and nodded again when asked if she experienced pain other then during wound treatments. At 11:40 a.m., the subacute unit director was interviewed. He stated that due to the resident having a stage IV pressure ulcer, the resident should be on a pain management program (administration of scheduled pain medication around the clock), in order to provide consistent pain control. A review of the facility's policy, titled "Assessment and Management (of) Pain", revised July 2013, indicated to assess for pain on an ongoing basis throughout the hospitalization , that interventions will be provided to alleviate pain or reduce pain to a level acceptable to the patient, and that the effects of the interventions were to be monitored. The policy's purpose included the following concepts: "-To reduce the incidence and severity of the patient's pain episodes through ongoing assessments and timely interventions. -To educate the patient on the use of a 0-10 scale for rating pain. -To ensure that the patient's pain is treated in a timely manner, and the effects of the treatments were monitored. -To reduce the negative functional and emotional effects of unrelieved pain." The section titled, "Wound Care", stipulated all patients/residents with Stage III or Stage IV pressure wounds will be pre-medicated with ordered [MEDICATION NAME] will be assessed throughout the treatment for [REDACTED].

Based on interview and record review, the facility failed to ensure that a resident (Resident 8) who have not used [MEDICAL CONDITION] medications ([MEDICATION NAME] and [MEDICATION NAME]) are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the resident's clinical record for one of 20 sampled residents (8). Resident 8 continued to receive [MEDICATION NAME] and [MEDICATION NAME] from August 2013 through October 2014 with clinically significant risks, existing adverse consequences, and drug interactions. The facility failed to act on the documented irregularities identified by the facility's consultant pharmacist. This deficient practice resulted in Resident 8 receiving; [MEDICATION NAME] and [MEDICATION NAME] from August 2013 through October 2014 without a clear indication for use to treat a specific condition as diagnosed and documented in the resident's clinical records; duplicate therapy with [MEDICATION NAME] and Dexilant; multiple drug interactions between [MEDICATION NAME], and [MEDICATION NAME] (blood pressure medication); [MEDICATION NAME] in higher than recommended dose from June 2014 through October 2014. In addition, based on interviews, and record reviews, the facility failed to ensure the medications ordered for residents have indications for its use for 10 of 20 sampled residents (1, 2, 3, 7, 10, 11, 14, 16, and 17). The facility also failed to ensure the resident does not receive medication beyond the stop date ordered for 1 of 20 sampled residents (4). Resident 4 had an order for [REDACTED]. The above violations resulted in Resident 8 received unnecessary medications and exposed Resident 8, 1, 2, 3, 4, 7, 10, 11, 14, 16, and 17 to an increased risk for adverse reactions. Findings: 1. According to the facility's patient registration form, Resident 8 was a [AGE] year-old male who was admitted on [DATE], with diagnoses that included [MEDICAL CONDITIONS] (an opening surgically created that allows air passage to help in breathing), spinal cord contusion (injuries as a result of high-impact motor vehicle accidents). Review of Resident 8's history and physical dated August 21, 2013 at 6:07 p.m., indicated, " (Resident 8) was a victim of an accident ...He was traveling in his bicycle and hit a parked car ... Multiple trauma including facial trauma ... " Review of physician's orders [REDACTED]. According to the psychiatric consultation dated September 6, 2013, at 11:44 a.m., medical physician (MD 2) indicated, "(Resident 8) with no prior psychiatric history. He was hit by a car when he was traveling on his bicycle. He suffered multiple injuries ...While going through hospitalization and so forth, he became irritated, out of control and agitated, and I believe as a result he was placed on [MEDICATION NAME] (150 mg every morning) and [MEDICATION NAME] (25 mg at bedtime). As per the staff the patient still exhibits agitation ...not able to accept the fact that how much physically disabled he is. Patient himself realizes this and tells me that he just loses control when he thinks about the admission and what it has done to him. (Resident 8) otherwise is not psychotic. Mood seems to be stable. Never been hospitalized in a psychiatric hospital. I will increase [MEDICATION NAME] to 25 mg three times a day and [MEDICATION NAME] to 300 mg every day ...No evidence of [MEDICAL CONDITION] or mania. " Plans of care for [MEDICATION NAME] and [MEDICATION NAME] dated, August 20, 2013, September 3, 2013, March 4, 2014, indicated, monitor drug levels, notify MD (physician) if abnormals noted. Evaluate need for continued use of [MEDICAL CONDITION] medications at least weekly in summary and monthly in team conference. Ensure lowest effective dose is given. Discontinue medication if not needed. Monitor resident for changes in condition. Review of physician's orders [REDACTED]. pressure that blood exerts on vessels while the heart is beating) blood pressure less than 95, [MEDICATION NAME] ([MEDICATION NAME] sodium) 250 mg three times a day for constipation, [MEDICATION NAME] 20 mg three times a day for muscle spasms (involuntary muscle movement), zinc sulfate 220 mg every day for wound healing, vitamin C 500 mg after dinner for wound healing, [MEDICATION NAME] 1 mg via [DEVICE] every 12 hours as needed for anxiety manifested by hyperventilation (is rapid or deep breathing that can occur with anxiety or panic) or shortness of breath. On October 22, 2014 at 10:30 a.m., during an interview, director of nursing (DON 1), stated, "MD 1 did not clarify on Medication Administration Record [REDACTED]. The hashmarks (the indication) on the MAR indicated [REDACTED] During an interview at 11 a.m., registered nurse (RN) 2 stated, "Resisting care is not [MEDICAL CONDITION]. The type of behavior the resident is having supposed to be added to the MAR. We do not have specific behaviors to be monitored from the physician. [MEDICATION NAME] is not an antidepressant it is an antipsychotic." On October 22, 2014 at 11:10 a.m., DON 1 in the presence of DON 2, reviewed Resident 8's clinical records and stated, "He did not see [MEDICATION NAME] labs (laboratory values used to check if medication is in therapeutic range to be effective) or an order for [REDACTED]." During an interview with the Risk Manager, on October 22, 2014 at 3:30 p.m., she reviewed the Psychiatric Consultation dated September 6, 2013, timed at 11:44 a.m. and stated, "Clearly there was no [MEDICAL CONDITION] or justification for resident to be on [MEDICATION NAME] or [MEDICATION NAME]. I didn't even know there was an interaction between [MEDICATION NAME] and [MEDICATION NAME]." On October 23, 2014 at 12:50 p.m. Resident 8 was observed in his room lying in bed talking with his nurse. When asked about the medications Resident 8 stated, "I take [MEDICATION NAME] for pain and [MEDICATION NAME] is for my anxiety." During an interview with the Consultant Pharmacist, on October 23, 2014 at 2:30 p.m., she stated, "[MEDICATION NAME] is not recommended to be given long term due to increased risk of involuntary muscle movement while on antipsychotic ([MEDICATION NAME]). Based on (Resident 8's) clinical record could not see the need for [MEDICATION NAME]. I wanted the physician to provide a better diagnosis. [MEDICATION NAME] is to be used for a well-documented, well established psychiatric issue. Physician and licensed nurses should actually define the problem and use non pharmacological interventions. Not appropriate for patient (Resident 8) to be on [MEDICATION NAME]." On October 23, 2014 at 3:35 p.m., during an interview, MD 2 stated, gradual dose reduction should be done to discontinue Patient 8's antipsychotic medication and the patient should be monitored monthly for adverse reaction. MD 2 further stated, "[MEDICATION NAME] cannot be used for non-compliance or resistant care." However, on September 6, 2013, MD 2 increased Resident 8's [MEDICATION NAME] and [MEDICATION NAME] for non-compliance and resistant care. Resident 8's [MEDICATION NAME] dose was increased again on September 26, 2013 and March 12, 2014. MD 2 stated he was unaware of the facility's consultant pharmacist's multiple recommendations to decrease and/or discontinue the [MEDICATION NAME] and [MEDICATION NAME] medications. A review of Pharmacist's Consultation Reports, dated, August 2013, October 2013, and July 2014 requesting clinical justification for the use of [MEDICATION NAME] an antipsychotic medication and for Resident 8 with no prior history of [MEDICAL CONDITION]. " ([MEDICATION NAME]) cannot be used for non-compliance or resistive to care. Please consider reducing the dose with the eventual goal of discontinuation ...please indicate the specific diagnosis/indication requiring treatment ...Evaluate for causes of behavior ...and assessment of alternative intervention." A review of Pharmacist's Consultation Reports, dated August 2013 and October 2013, indicated, "After reviewing Resident 8's chart, there appears to be no [DIAGNOSES REDACTED]." A review of Pharmacist's Consultation Report, dated, April 2014, requested discontinuation of [MEDICATION NAME] ([MEDICATION NAME]) because of the many undesirable side effects (such as drowsiness, tremor, and restlessness) and monitor Resident 8 for involuntary movements now and at least every three months. September 2014 consultant pharmacist recommended discontinuation of Resident 8's zinc sulfate which may cause GI (stomach) upset. Zinc Sulfate was not recommended to use beyond 90 days and may delay wound healing. On September 9, 2014, the sonsultant report by the pharmasist indicated resident 8 was receiving [MEDICATION NAME] for an unclear diagnosis. the report indicicated if the therapy is to contiue at the current dose, to provide rational describing a dose reduction as clinically contraindiacated. Resident 8's clinical record included a recommendation letter addressed to MD 1 signed by the facility's registered dietitian indicated: "Recommend providing Vitamin C for wound healing. Recommend D/C (discontinue) zinc sulfate, patient has been on it since 9/13 (September 2013)." October 2014 consultant pharmacist recommended Resident 8's [MEDICATION NAME] ([MEDICATION NAME] sodium, a stool softener) to be reduced from 750 milligram (mg) a day to the maximum suggested dose of [MEDICATION NAME] 300 mg once daily. A review of the facility's policy titled, "[MEDICAL CONDITION] Medication Management" dated 7/13, indicated under Sub-Acute Unit Specific: (12) The Sub-acute unit will ensure that residents who have not used anti-psychotic drugs are not given drugs unless anti-psychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record. (13) Residents on the Sub-acute Unit who use anti-psychotic drugs will receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. (14) All Residents who are on anti-psychotic medication will have their behaviors manifested clearly and specifically identified and documented in the Interdisciplinary care plan, in order to ensure objective and appropriate monitoring. 2. The review of the recapitulation of physician's orders [REDACTED]. a. An order on September 13, 2014 for potassium chloride s/f, cherry 20 mEq (milliequivalents - unit of measure) per 15 milliliters (ml) liquid - give 30 mEq via [DEVICE] (gastrostomy tube - a tube that is placed directly into the stomach for long term administration of food, fluids, and medications) every day. b. An order on September 9, 2014 for solu-[MEDICATION NAME] PF 125 mg/2 ml vial - inject 60 mg slow intravenous push every 8 hours. c. An order on September 9, 2014 for [MEDICATION NAME] SDV (UD-30) 0.5 mg/2 ml [MEDICATION NAME] - nebulizer - inhale 1 unit dose via hand held nebulizer twice daily. d. [MEDICATION NAME] BR 0.02% 0.5 mg/2.5 ml solution - inhale 2.5 ml (I unit dose) via hand held nebulizer every 6 hours. e. [MEDICATION NAME] hcl 1.25 mg/3 ml vial - nebulizer - inhale 1 unit dose (3 ml) via hand held nebulizer every 6 hours 3. The review of the recapitulation of physician's orders [REDACTED]. a. An order on April 2, 2014 for [MEDICATION NAME] 500 mg tabled via [DEVICE] at bedtime. b. An order on September 23, 2014 for [MEDICATION NAME] 10 mg, then 5 mg every day for four days. c. An order on September 23, 2014 for [MEDICATION NAME] 10 mg, then 5 mg every other day. d. An order on September 25, 2014 for [MEDICATION NAME] respule 0.5 mg/2 ml [MEDICATION NAME] - nebulize - inhale 1 unit dose via hand held nebulizer every 12 hours. 4. The review of the recapitulation of physician's orders [REDACTED]. a. An order on June 2, 2014 for folic acid 1 mg tablet via [DEVICE] every day. b. An order on February 3, 2014 for [MEDICATION NAME] 25 mg tablet via [DEVICE] every Monday, Wednesday, and Friday. 5. The review of the recapitulation of physician's orders [REDACTED]. a. An order on June 30, 2014 for aspiring orange 81 mg chewable tablet, give 1 tablet via [DEVICE] every day. b. An order on September 16, 2014 for [MEDICATION NAME] 0.5 mg tablet via [DEVICE] every day. 6. The review of the recapitulation of physician's orders [REDACTED]. a. An order on October 15, 2014 for [MEDICATION NAME] 4 mg per [DEVICE] at 5 p.m. b. An order on May 19, 2014 for [MEDICATION NAME] Diskus 50-50 mcg disk - inhale 1 puff orally twice daily. c. An order on March 1, 2014 for [MEDICATION NAME] 0.12% liquid - swish and spit 5 ml by mouth twice daily. d. An order on May 15, 2014 for [MEDICATION NAME] 5% - 700 mg patch - 1 patch to bilateral knees daily (on 12 hours and off 12 hours). e. An order on August 19, 2014 for [MEDICATION NAME] sulfate 20 mg/5 ml solution - give 6 mg via [DEVICE] every 12 hours f. An order of March 19, 2014 for multivitamin with minerals liquid - give 15 ml via [DEVICE] every day. g. An order on March 11, 2014, for potassium chloride s/f, cherry 20 mEq (milliequivalents)/15 ml liquid - give 30 ml via [DEVICE] every day. h. An order on March 1, 2014 for [MEDICATION NAME] sulfate P/F UD 2.5 mg/3 ml vial - nebulizer - inhale 1 unit dose via hand held nebulizer every 6 hours done by respiratory therapist. i. An order on March 1, 2014 for [MEDICATION NAME] 0.02% 0.5 mg/2.5 ml solution - inhale 1 unit dose via hand held nebulizer every 6 hours done by respiratory therapist. j. An order on September 29, 2014 for [MEDICATION NAME] 6 mg via [DEVICE] daily. The physician's orders [REDACTED]. a. An order on October 20, 2014 for [MEDICATION NAME] 5 mg via [DEVICE] at 5 p.m. b. An order on October 15, 2014 for [MEDICATION NAME] 220 mg every 24 hours for 10 days. c. Orders on October 13, 2014 for a one-time [MEDICATION NAME] 20 mg intravenous push, solu-[MEDICATION NAME] 40 mg intravenous push every 12 hours, [MEDICATION NAME] 1 gram intravenous piggy-back now and pharmacy to dose for seven days. d. An order on October 12, 2014 for [MEDICATION NAME] 1 gram intravenous piggy-back every 24 hours for seven days. e. An order on October 10, 2014 for [MEDICATION NAME] 500 mg intravenous piggy-back every 8 hours for 10 days. f. An order on October 9, 2014 for D5NS (5% [MEDICATION NAME] with normal saline solution), 1 liter at 100 ml per hour continuous. g. An order on October 7, 2014 for [MEDICATION NAME] 6 mg via [DEVICE] daily. 7. The review of the physician's orders [REDACTED]. a. An order on October 13, 2014 for [MEDICATION NAME] 2.5 mg/0.5 ml via hand-held nebulizer every six hours. b. An order on October 13, 2014 for Atrovent 0.5 mg via hand-held nebulizer every six hours. c. An order on October 16, 2014 for [MEDICATION NAME] 20 mg by mouth every morning for one week, then every Monday, Wednesday, and Friday. During the interview with Charge Nurse (CN) 3 on October 24, 2014, at 9:28 a.m., CN 3 stated "The physician should put the indication for use of med when ordering it." The facility policy titled "Prescribing/Ordering - General Practices" revised September 2013 indicated "XII. To be considered complete, all medication orders shall include the name of the drug, the dosage and strength, the quantity or duration (as appropriate), the route and frequency of administration, the reason the drug is ordered/indications for usage (as appropriate) and the time and date the order is written ..." 8. The review of the recapitulation of the physician's orders [REDACTED]. The document also indicated the discontinue date of the order was October 2, 2014. The "Medication Administration Record [REDACTED]. During the interview with CN 1 on October 24, 2014, at 10:58 a.m., CN 1 reviewed the physician's orders [REDACTED]. If med is ordered for 7 days, then it should stop. If patient needs it longer, they should call the doctor and ask him (to renew the order)." The facility policy titled "Medication Management Policy" revised August 2014 indicated "Medications will be administered upon the written order of a physician who has approved privileges by the medical staff." 9. The Patient Information indicated Resident 7 was admitted to the facility on [DATE], with diagnoses of anxiety, [MEDICAL CONDITION], dementia and psychiatric disease. Review of the physician's orders [REDACTED]. a. On February 9, 2014, the artificial tears ophthalmic 1.4% drops to instill 1 drop into both eyes every 4 hours. There was no documentation for artificial tears indication for use. b. On December 30, 2013, [MEDICATION NAME] with pipette 1 mg/1ml solution to give 2 mg/ml by mouth or via [DEVICE] twice daily for restlessness and climbing out of bed. The resident was receiving [MEDICATION NAME] for the behavior not because of the presence of a diagnosis. Review of the clinical record indicated the following: a. On November 19, 2013, the physician ordered [MEDICATION NAME] 20 mg daily for depression manifested by (m/b) sadness, crying and refusing care. b. On December 30, 2013, the physician ordered [MEDICATION NAME] 2mg twice daily for restlessness and climbing out of bed. c. On November 19, 2013, the physician ordered trazadone HCl 25 mg at bedtime for depression m/b sadness, crying and refusing care. d. On November 19, 2013, the physician ordered [MEDICATION NAME] 2 mg every 4 hours as needed for anxiety/agitation m/b restlessness, shortness of breath and hyperventilation. e. On April 27, 2014, the physician [MEDICATION NAME] mg at bedtime as needed for [MEDICAL CONDITION]. Review of the Interdisciplinary Chemical Restraint assessment dated [DATE] through October 2014 for the above medications indicated chemical restraint dose reduction was not applicable (N/A). 10. The Patient Information indicated Resident 10 was admitted to the facility on [DATE], with diagnoses of status [REDACTED]. Review of the physician's orders [REDACTED]. a. On December 2, 2013, aspirin chew 81 mg by mouth every day. b. On June 2, 2014, [MEDICATION NAME]/[MEDICATION NAME] 5/325 tab to take 1 tab by mouth every 12 hours. There was no documentation of indication for use for medications aspirin and [MEDICATION NAME]. c. On May 30, 2014, [MEDICATION NAME] 100 mg to take 1 tab by mouth at bedtime for psychotic behavior manifested by resisting care/suicidal ideation. On September 9, 2014, the consultant report by the pharmacist indicated the resident was receiving [MEDICATION NAME] for an unclear diagnosis. Review of the clinical record indicated the following: a. On August 27, 2014, the physician ordered [MEDICATION NAME] mg by mouth for [MEDICAL CONDITION] at bedtime. b. On October 10, 2014, the physician ordered [MEDICATION NAME] 10 mg 1 cap daily by mouth for depression. c. On December 6, 2013, the physician ordered [MEDICATION NAME] 50 mg by mouth at bedtime for psychotic behavior manifested by resisting care and suicidal ideation. On May 30, 2014, the physician ordered to increase [MEDICATION NAME] 100 mg by mouth at bedtime for psychotic behavior manifested by resisting care and suicidal ideation. d. On December 6, 2013, the physician ordered [MEDICATION NAME] 60 mg by mouth every morning for depression manifested by crying and feeling sad. On April 28, 2014, the physician ordered to increase [MEDICATION NAME] 90 mg by mouth every morning for depression manifested by crying and feeling sad. Review of the Interdisciplinary Chemical Restraint assessment dated [DATE] through October 2014 for the above medications indicated chemical restraint dose reduction was not applicable (N/A). 11. The Patient Information indicated Resident 11 was admitted to the facility on [DATE], with diagnoses of status [REDACTED]. Review of the physician's orders [REDACTED]. a. On December 7, 2012, [MEDICATION NAME] 25 mg via [DEVICE] twice a day. The order did not have indication for use. On July 31, 2013, the medication [MEDICATION NAME] was increased to 50 mg every morning and bedtime. There was no documented indication for use. On May 7, 2014, [MEDICATION NAME] 50 mg tablet to give 1 tab via [DEVICE] every morning and at bedtime. There was no documented indication for use. b. On May 7, 2014, [MEDICATION NAME] 50 mg tablet to give 1 tab via [DEVICE] every 12 hours as needed for agitation with psychotic behavior manifested by yelling and verbal abuse. The Consultant Report by the pharmacist dated June 4, 2014, indicated [MEDICATION NAME] medication use is for behavioral or psychiological symptoms related to an unclear [DIAGNOSES REDACTED]. The physician decline the recommendation and indicated patient need [MEDICATION NAME] and followed by psychiatrist signed and dated. Review of the Interdisciplinary Chemical Restraint assessment dated [DATE] through October 2014 for the above medication indicated chemical restraint dose reduction was not applicable (N/A). There was no indication the physician/pharmacist were present at the time IDT members meet monthly to discuss dose reduction/increase of resident's psychoactive medication. 12. The Patient Information indicated Resident 13 was admitted to the facility on [DATE], with diagnoses of anxiety, [MEDICAL CONDITION], depression and [MEDICAL CONDITION]. Review of the physician's orders [REDACTED]. On September 9, 2014, the consultant report by the pharmacist indicated the resident was receiving [MEDICATION NAME] for an unclear diagnosis. The following physician orders [REDACTED]. a. On June 27, 2011, [MEDICATION NAME] 5 mg via [DEVICE] every 4 hours as needed for anxiety manifested by nervousness. On August 22, 2012, [MEDICATION NAME] 10 mg via [DEVICE] every 4 hours as needed for anxiety . On December 19, 2012, [MEDICATION NAME] 15 mg via [DEVICE] every 6 hours as needed for anxiety. On January 23, 2013, [MEDICATION NAME] 15 mg via [DEVICE] every 4 hours for anxiety. b. On January 27, 2012, [MEDICATION NAME] 20 mg via [DEVICE] every morning for depression . c. On December 23, 2009, [MEDICATION NAME] 50 mg by mouth in the morning and at bedtime. On June 22, 2011, [MEDICATION NAME] 100 mg via by mouth at bedtime for psychotic behavior manifested by hearing voices. On September 9, 2014, the consultant report by the pharmacist indicated the resident was receiving [MEDICATION NAME] for an unclear diagnosis. The report indicated if the therapy is to continue at the current dose to provide rationale describing a dose reduction as clinically contraindicated. On July 2, 2014, the consultant report by the pharmacist indicated the resident was receiving [MEDICATION NAME] since January 20, 2013, and recommend to continue at the current dose to provide rationale describing a dose reduction as clinically contraindicated. On July 2, 2014, the consultant report by the pharmacist indicated the resident was receiving [MEDICATION NAME] since January 20, 2012, and recommend to continue at the current dose to provide rationale describing a dose reduction as clinically contraindicated. Review of the Interdisciplinary Chemical Restraint assessment dated [DATE] through October 2014 for the above medications indicated chemical restraint dose reduction was not applicable (N/A). During an interview on October 24, 2014, at 10:20 a.m., with LVN 11 while reviewing the residents' clinical records (Resident 7, 10, 11, and 13), she stated that she concur that there was no attempt on gradual dose reduction on the above residents, the IDT meeting to address [MEDICAL CONDITION] medications the physician is not present and the phar,macist recommendation was not acted upon. Another interview with Charge Nurse (CN) 3 was conducted on October 24, 2014, at 9:28 a.m., CN 3 stated "The physician should put the indication for use of med when ordering it." The facility policy titled "Prescribing/Ordering - General Practices" revised September 2013 indicated "XII. To be considered complete, all medication orders shall include the name of the drug, the dosage and strength, the quantity or duration (as appropriate), the route and frequency of administration, the reason the drug is ordered/indications for usage (as appropriate) and the time and date the order is written ..."

Based on observation, interviews, and record review, the facility failed to effectively assess pain level, implement pain relief measures, and assess whether the pre-medication ordered for pain prior to pressure ulcer wound treatment was sufficient to relieve the pain during the wound care, for one of 17 sampled residents (21). During observation of wound care for a sacral (area at base of spine) pressure ulcer, and left foot pressure ulcer, Resident 21 was tearful, cried out several times, diaphoretic (sweating), and made attempts to pull her body away. The licensed vocational nurse (LVN 5), who was performing the wound care, completed the wound treatment without stopping to assess Resident 21's pain level, offering pain medication, or informing the physician of the resident's discomfort. This failure caused the resident pain and emotional distress, and had an adverse effect on the resident. Findings: On January 14, 2015 at 8:15 a.m. during the initial tour of the subacute unit, Resident 21 was observed lying on a low air loss mattress (special air-fluidized bed which relieves pressure on the skin and promotes wound healing). The resident, who was awake and alert, had a [MEDICAL CONDITION] (plastic airway tube surgically inserted into the airway for air exchange), which was connected to a ventilator (a machine that supports breathing, and breathes for people who have lost ability to breathe on their own). The resident was also receiving a tube feeding through a gastrostomy tube (G tube is a tube surgically inserted into the stomach through the abdominal wall for purposes of feeding and medication administration). A review of the clinical record indicated the resident was initially admitted to the facility on [DATE], and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident also had contractures of her lower extremities (chronic loss of joint motion due to structural changes in non-bony tissue), a chronic Stage IV (full thickness skin loss, with exposed bone/tendon/muscle) sacral (area above the crease between buttocks) pressure ulcer, and a deep tissue injury pressure ulcer (DTI- localized area of discolored intact skin or blood-filled blister, due to damage of underlying soft tissue from pressure) on her left foot. A review of the Nursing Admission Patient Assessment notes, dated December 22, 2014, indicated the resident was awake and alert, but unable to walk. The resident was incontinent of bowel, and had an indwelling urinary catheter for wound management. The resident was totally dependent on staff for all daily living activities, and communicated by nodding or shaking her head, and mouthing words. A review of the physician orders [REDACTED]. A review of the Sub Acute Weekly Wound Note, dated January 15, 2015, indicated the sacral wound measurements were 6.5 centimeters (cm) in length, 4 cm in width, and 2.2 cm in depth. The left mid lateral foot DTI pressure ulcer measurements were 1.5 cm in length, and 2.0 cm in width. The physician's orders [REDACTED]. Another order, dated December 22, 2014, indicated to administer [MEDICATION NAME] (narcotic-like pain reliever) every six hours PRN (as necessary) for severe pain. According to the online pharmaceutical website Lexi-comp), [MEDICATION NAME] is a pain reliever for the treatment of [REDACTED]. Review of a care plan titled, Potential for Altered Comfort, dated December 22, 2014, indicated interventions such as assessing for pain every shift and as needed, provide gentle touch, massage, and repositioning, identify area and severity of discomfort, and to administer medications and monitor effects. On January 15, 2015 at 10 a.m., an observation was conducted of Resident 21's wound care treatment for [REDACTED]. LVN 5 stated he had administered [MEDICATION NAME] 650 mg via GT at 9:30 a.m. LVN 5 and RNA 1 (restorative nursing assistant) assisted the resident onto her left side, with the resident facing away from the LVN. Without informing the resident of what he was going to do, LVN 5 loosened the tape of the old dressing, then removed the soiled dressing and packing gauze (gauze which is used to fill a wound space in order to absorb puss and keep bacteria away). LVN 5 then cleaned the wound bed with normal saline solution and gauze pads in a hurried (quick) manner, again without first informing the resident. At that time, the resident jerked her body, cried out several times, had increased respiratory rate, and exhibited facial grimacing. LVN 5 asked, Are you ok?, then stated, We're almost done, then proceeded with the treatment without stopping to assess the resident's pain level, or ask the resident if she needed more pain medication. LVN 5 placed gauze packing and calcium alginate ointment (a treatment used in wound dressings which aids in healing of the wound) into the wound cavity, applied gauze pads on top of the packing, then applied an Island dressing pad (an absorbent pad which conforms and seals wound on all four sides). He then applied zinc oxide ointment to the reddened area below the sacral wound. LVN 5 performed each step of the treatment in a hurried manner, without informing the resident of his actions. After being repositioned onto her back following the sacral wound treatment, resident exhibited an anxious expression, she was tearful, perspiring, and breathing faster than before the treatment. The surveyor asked the resident if she was in pain, and LVN 5 repeated the question. The resident hesitated, looked from the surveyor to LVN 5 twice, then nodded her head and mouthed, In my butt. LVN 5 repeated, In your butt?, then immediately began treatment of [REDACTED]. After LVN 5 removed the left foot dressing, a discolored area (Area 1), with visually estimated to be two and a half cm in length, and one and a half cm in width, was observed midway on the lateral (outer) side of the foot, which LVN 5 identified as the DTI. A second discolored area (Area 2), one cm in diameter, was observed approximately five cm above Area 1. LVN 5stated he was unaware of the area, then proceeded to press on it several times. Resident 21 exhibited facial grimacing; she was crying, and her left foot was jerking. RNA 1, who was at the head of the bed, patted the resident's head and shoulder area, and stated, It's ok, it's ok, several times. LVN 5 stated he would notify the physician of Area 2 (being new to him), then applied [MEDICATION NAME] Spray (a wound treatment) to a gauze pad, placed the pad on Area 1, and wrapped the foot with gauze wrap, again without first informing the resident of his actions. During an interview at 10:25 a.m., LVN 5 indicated Resident 21 had been receiving wound care for the sacral pressure ulcer for over six months, and that the resident was transferred back to the subacute unit from the critical care unit (CCC) the previous month. When questioned regarding what the resident received for pain, LVN 5 responded she received Tylenol 650 mg every morning, 30 minutes prior to her wound care. He then stated, She probably needs something else. She usually does okay. Since she came back from CCC, she hasn't been tolerating the wound care as well. She was sweating. LVN 5 further indicated he would ask the resident if she wanted a dose of [MEDICATION NAME], then stated he would re-assess the resident after she received the [MEDICATION NAME], and notify the physician. LVN 5 further indicated he would update the charge nurse and the physician regarding the new skin discoloration, and would obtain an order for [REDACTED]. As the interview continued, the surveyor asked if during previous wound care, the resident had ever indicated she was having pain. LVN 5 responded, I think so, but I think that we thought Tylenol would take care of it. She always seemed okay afterwards. LVN 5 then acknowledged the resident was grunting and making vocal sounds during the treatment, and he had hurried in order to get through the treatment. He then stated he was nervous during the treatment, and felt pressured because the surveyor was standing there. During an interview with RNA 1 immediately after the observation, she stated Resident 21 was able to communicate by nodding or shaking her head, and by mouthing words, then stated the resident sometimes mouthed that she was having pain. When RNA 1 was asked if she was able to tell when the resident was having pain, RNA 1 stated, I can tell by her face if she has pain, like this morning. She was kind of restless. RNA 1 indicated when she performed passive range of motion (PROM- exercises during which a person's joints are being moved without their assistance) on the resident's left foot, the resident would complain of pain and tell the RNA, Don't touch me there. During an interview at 11:20 a.m., RN 1 indicated she had notified the physician regarding the resident's pain, and the physician had ordered [MEDICATION NAME] (a combination of narcotic and Tylenol). RN 1 also stated LVN 1 had just given the resident a dose of [MEDICATION NAME]. When questioned why the resident had not received [MEDICATION NAME], as it had just been ordered, RN 1 responded that she had instructed LVN 1 to re-assess the resident's pain level following the [MEDICATION NAME] administration, and she did not want the [MEDICATION NAME] given because the resident had already received the [MEDICATION NAME]. At 11:25 a.m., during an interview with Resident 21, she nodded when asked if she experienced pain during the wound treatment that morning, and nodded again when asked if she experienced pain other then during wound treatments. At 11:40 a.m., the subacute unit director was interviewed. He stated that due to the resident having a stage IV pressure ulcer, the resident should be on a pain management program (administration of scheduled pain medication around the clock), in order to provide consistent pain control. A review of the facility's policy, titled Assessment and Management (of) Pain, revised July 2013, indicated to assess for pain on an ongoing basis throughout the hospitalization , that interventions will be provided to alleviate pain or reduce pain to a level acceptable to the patient, and that the effects of the interventions were to be monitored. The policy's purpose included the following concepts: -To reduce the incidence and severity of the patient's pain episodes through ongoing assessments and timely interventions. -To educate the patient on the use of a 0-10 scale for rating pain. -To ensure that the patient's pain is treated in a timely manner, and the effects of the treatments were monitored. -To reduce the negative functional and emotional effects of unrelieved pain. The section titled, Wound Care, stipulated all patients/residents with Stage III or Stage IV pressure wounds will be pre-medicated with ordered [MEDICATION NAME] will be assessed throughout the treatment for [REDACTED].

Based on observations, interviews, and record reviews, the facility failed to prevent the development of new pressure for 1 of 20 sampled residents (2), and failed to prevent wound infection for 1 of 20 sampled residents (1). Resident 2 was admitted to the facility with only a Stage IV pressure ulcer on the sacral area (a type of wound with full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g. tendon, joint capsule)). After admission in July 2014, the resident developed Stage IV pressure ulcers on the right and left ischium (ischium forms the lower and back part of the hip bone). For Resident 1, who was readmitted to the Sub-Acute unit with deep tissue injuries to the right and left heel and Stage III pressure ulcer (a type of wound with full thickness skin loss involving damage to or necrosis (tissue death) of subcutaneous (lowermost layer of the skin) tissue that may extend down to, but not through, underlying fascia (a structure of connective tissue that surrounds muscles, groups of muscles, blood vessels, and nerves, binding some structures together, while permitting others to slide smoothly over each other). The ulcer presents clinically as a deep crater with or without undermining (refers to the wound being open underneath the "lip" of the boarder) of adjacent tissue) on the sacral area (triangle shaped bone at the end of the spine). During wound care observation on October 21, 2014, the sacral pressure sore was noted with the foul odor, and the pressure sore was red in the center with layer of dead tissue separating from the surrounding tissue (demonstrating signs of wound infection). Findings: 1. The clinical record for Resident 2 indicated she was admitted to the facility on [DATE] with admitting [DIAGNOSES REDACTED]. The Admission Assessment MDS dated [DATE] indicated Resident 2 was totally dependent with one - person physical assist with bed mobility totally dependent with two - person physical assist with transfers, and extensive, one - person physical assist with personal hygiene. The MDS indicated Resident 2 was admitted to the facility with one Stage IV pressure ulcer measuring 8.5 cm by 8.5 cm, 2 cm deep on the sacral area. The Quarterly Assessment MDS dated [DATE] indicated Resident 2 was totally dependent with one - person physical assist with bed mobility totally dependent with two - person physical assist with transfers, and extensive, one - person physical assist with personal hygiene. The MDS indicated Resident 2 had one Stage III pressure ulcer that was not present at the time of admission and one Stage IV pressure ulcer that was present at the time of admission. The electronic charting of the Nursing Admission assessment dated [DATE] indicated "Patient has wound(s) noted that are present", "Total number of wounds= one sacral decub (decubitus - localized injuries to the skin and/or underlying tissue that usually occur over a bony prominence as a result of pressure, or pressure in combination with shear and/or friction)". The Braden Scale dated April 2, 2014 indicated a score of 10 (a score of 12 or less represents high risk for pressure ulcer). The score on August 27, 2014 was 11. The "Wound Evaluation" forms indicated the following: a. On April 17, 2014, the Wound Consultant documented Resident 2 had a sacral Stage IV pressure ulcer measuring 6.2 cm by 7.7 cm, 2 cm deep, with bone exposure and undermining/tunneling of 2.5 cm at 10 o'clock and 1 o'clock and 3 cm at 2 to 3 o'clock. The Wound Consultant recommended the following: i. Keep area clean and dry, ii. Turn and reposition every 2 hours using the assist setting in Kin-Air bed, iii. RD (registered dietitian) consult for dietary supplements, and iv. Cleanse with normal saline, pat dry, apply Santyl, and pack loosely with calcium alginate. Cover with gauze and Island dressing daily for 21 days. b. On April 25, 2014, the Wound Consultant documented Resident 2 had a sacral Stage IV pressure ulcer measuring 6 cm by 6 cm, 2.5 cm deep, with bone exposure and undermining/tunneling of 2.5 cm, 100% granulation, and heavy drainage. The document indicated Resident 1 had developed a left and right ischium Stage I pressure ulcers (Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.). The left ischium pressure ulcer was 5.5 cm by 4.5 cm in size and the right ischium pressure ulcer was 5 cm by 7 cm in size. The Wound Consultant recommended the following: i. Keep areas clean and dry, ii. Turn and reposition every 2 hours, iii. Off - load both ischium, iv. No getting out of bed to geri-chair, v. Sacral - continue with Santyl and calcium alginate, and vi. Right and left ischium - cleanse with normal saline, pat dry, apply Allevyn gentle (a type of wound dressing) every 72 hours and as needed. c. On May 1, 2014, the Wound Consultant documented Resident 2 had a Stage IV sacral pressure ulcer measuring 6 cm by 6 cm, 2.5 cm deep, with 2.5 cm undermining/tunneling at 10 to 12 o'clock. The left and right ischium pressure ulcers had both progressed to Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous (containing or relating to both blood and the liquid part of blood) filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising). The left ischium pressure ulcer measured 4 cm by 5 cm and the right ischium measured 4.5 cm by 3.5 cm. The Wound Consultant documented the following recommendations: i. Left and right ischium - cleanse with normal saline. Pat dry. Apply [MEDICATION NAME] cream (an antibacterial ointment). Cover with gauze and Island dressing every shift and as needed for 30 days. ii. Keep all areas clean and dry. iii. Turn and reposition every 2 hours. iv. Off - load ischium. v. Sacral - cleanse with normal saline. Pat dry. Apply Medi-honey (medical dressing containing medical honey). Pack loosely with calcium alginate. Cover with gauze and Island dressing every shift for 30 days. d. On July 3, 2014, the Wound Consultant documented Resident 2 had a Stage IV sacral pressure sore, 5 cm by 6 cm, 2.2 cm deep with granulation. The undermining/tunneling was 2.2 cm at 11 to 1 o'clock, 3 cm at 2 o'clock, 4 cm at 3 o'clock, and 4.5 cm at 9 to 10 o'clock. The right ischium pressure ulcer had progressed to Stage III, 2 cm by 2 cm, 0.2 cm deep. The left ischium remained a Stage II pressure ulcer, 2.5 cm by 2 cm in size. The Wound Consultant wrote the following recommendations: i. "Ischium up stage from Stage II to Stage III due slough in wound bed. Update all documentation." ii. Keep all areas clean and dry iii. Turn and reposition every 2 hours as tolerated iv. Monitor signs and symptoms of infection and any other changes v. Supplements in place vi. Right ischium - cleanse with normal saline, apply Santyl. Cover with gauze and secure with Island dressing daily and as needed for 30 days. vii. Sacral and left ischium - continue with treatment. e. On July 8, 2014, the Wound Consultant documented Resident 2 had a Stage IV pressure ulcer in the sacral area measuring 4.5 cm by 5 cm, 2 cm deep in size with an undermining/tunneling of 2.5 cm at 12 o'clock, 4 cm at 2 -3 o'clock, and 4 cm at 9 to 11 p.m. The left ischium Stage II pressure ulcer was 1.5 cm by 1.3 cm in size and the right ischium Stage III pressure ulcer was 1.5 cm by 2 cm in size. The Wound Consultant documented the following recommendations: i. Keep areas clean and dry ii. Turn and reposition every 2 hours iii. Continue with current treatment. The Wound Consultant documented "Wounds responding well to treatment. All 3 wounds have progressed healing well." f. On July 30, 2014, the Wound Consultant documented Resident 2 had a Stage IV sacral pressure ulcer 5.5 cm by 5 cm in size, with undermining/tunneling of 2.3 cm at 12 o'clock, 2.7 cm at 2 to 3 o'clock, and 3.7 cm at 9 o'clock. The left ischium Stage II pressure ulcer measured 0.7 cm by 0.7 cm and the right ischium Stage III pressure ulcer measured 2.5 cm by 2.5 cm, 0.2 cm deep. The Wound Consultant documented the following recommendations: i. Keep areas clean and dry ii. Turn and reposition every 2 hours iii. Has been refusing treatment to be done, explained to the patient the importance and benefits and risks if not having treatment done per physician's order [REDACTED]. Supplements in place, continue with all current treatments. v. Continue with all current treatment. g. On August 19, 2014, the Wound Consultant documented Resident 2 had a Stage IV sacral pressure ulcer 5 cm by 5.5 cm, 3 cm deep with 4 cm undermining/tunneling at 2-5 o'clock, 3 cm at 9 o'clock. The Stage III right ischium pressure ulcer was 3 cm by 3 cm, 1 cm deep with 3.5 cm undermining/tunneling at 3 o'clock in size. The Stage II left ischium pressure ulcer was 0.7 cm by 0.7 cm in size. The Wound Consultant documented the following recommendations: i. Right ischium - continue with Santyl ii. Keep all areas clean and dry iii. Turn and reposition every 2 hours iv. All dietary supplements in place v. Discontinue current treatment vi. Left ischium - cleanse with normal saline. Pat dry. Apply zinc oxide. Cover with gauze and Island dressing daily for 14 days. vii. Sacral - cleanse with normal saline. Pat dry. Pack loosely with calcium alginate. Cover with gauze and Island dressing daily for 30 days. viii.The Wound Consultant documented "Wounds responding well to treatment." The sacral Stage IV pressure ulcer and right ischium Stage III pressure ulcer sizes had increase from the Wound Consultant's previous assessment. h. On August 28, 2014, the Wound Consultant documented Resident 2 had a Stage IV sacral pressure ulcer 5.5 cm by 5.5 cm, 1.5 cm deep with undermining/tunneling of 1.5 cm at 9 o'clock and 2.5 cm at 12 to 3 o'clock. The right ischium Stage III pressure ulcer was 4.5 cm by 4.5 cm, 1.8 cm deep with undermining/tunneling of 2 cm at 4 o'clock, and 3.5 cm from 9 to 12 o'clock. The left ischium Stage II pressure ulcer was 3cm by 3 cm in size. The Wound Consultant documented the following recommendations: i. Keep area clean and dry ii. Turn and re-position every 2 hours iii. Monitor right ischium for signs and symptoms of infection iv. Left ischium - cleanse with normal saline, pat dry, apply [MEDICATION NAME] cream, cover with gauze, secure with Island dressing daily for 30 days v. Right ischium - cleanse with ¼ strength Dakin's solution. Pat dry. Apply Santyl, pack loosely with calcium alginate, cover with gauze and secure with Island dressing daily for 14 days. i. On September 4, 2014, the Wound Consultant documented Resident 2 had a Stage IV sacral pressure sore, right ischium Stage III pressure sore, and the left ischium "wound now sloughed (tissue that has been shed) present up-stage from stage 2 to stage 3" with 80% granulation and 20% slough with moderate drainage. There were no documented measurements on the form. The Wound Consultant documented the following recommendations: i. Keep areas clean and dry ii. Turn and reposition every two hours iii. "Patient refuses treatment at times" iv. Supplements in place - Vitamin C, multivitamins, iron sulfate v. "pt (patient) on [MEDICATION NAME] (steroid) 10 milligrams (mg), 3 tabs (tablets) daily which causes delay in healing" vi. Continue with all current treatment vii. "Will re-evaluate left ischium next week with change [MEDICATION NAME] if needed" There was no recommendation documented to prevent the pressure ulcers from becoming worse due to the [MEDICATION NAME] use. j. On September 11, 2014, the Wound Consultant documented Resident 2 was on a support surface, on chemical restraint, with a skin risk "Braden Scale 10". The left ischium Stage III pressure ulcer was 2.5 cm by 2.5 cm, 0.3 cm deep. The right ischium Stage III pressure ulcer was 5 cm by 5 cm, 1.3 cm deep, with undermining/tunneling of 2 cm at 9 to 12 o' lock, 1.5 cm at 1 to 3 o'clock, 3 cm at 5 o'clock. The Stage IV sacral pressure ulcer was 6 cm by 5.5 cm, 1.6 cm deep with undermining/tunneling of 1.8 cm at 12 o'clock, 3.5 cm at 2 to 4 o'clock, and 1.8 cm at 9 o'clock. The Wound Consultant documented the following recommendations: i. Sacral - continue with current treatment ii. Keep area clean and dry iii. Turn and reposition every 2 hours iv. Monitor for signs and symptoms of infection v. Notify the doctor is treatment is not effective vi. "Pt on [MEDICATION NAME] 10 mg, 3 tab daily which delays healings" vii. Supplements in place viii. Right ischium - cleanse with normal saline. Pat dry. Apply Santyl. Pack loosely with calcium alginate, cover with gauze and Island dressing daily for 30 days and as needed. ix. Left ischium - cleanse with ¼ strength Dakin's solution, Pat dry. Apply Santyl; cover with gauze and Island dressing daily and as needed for 14 days. There was no recommendation documented to prevent the pressure ulcers from becoming worse due to the [MEDICATION NAME] use. k. On September 18, 2014, the Wound Consultant documented the left ischium Stage III pressure ulcer was 4 cm by 3 cm, 0.2 cm deep in size. The right ischium Stage III pressure ulcer was 4.5 cm by 5 cm, 1.2 cm deep with undermining/tunneling of 4.5 cm at 12 to 2 o'clock and 2.5 cm at 10 o'clock. The sacral Stage IV pressure ulcer was 5 cm by 5 cm, 1.2 cm deep with undermining/tunneling of 3 cm at 4 to 9 o'clock. The Wound Consultant documented the following recommendations: i. Keep areas clean and dry ii. Turn and reposition every 2 hours iii. "Pt on [MEDICATION NAME] 10 mg 3 times a day, which delays wound healing." iv. Supplements in place v. Continue with current treatment vi. The Wound Consultant documented "wounds responding well to treatment." The left ischium and sacral pressure ulcers have increased in size since the Wound Consultant's previous assessment. There was no recommendation documented to prevent the pressure ulcers from becoming worse due to the [MEDICATION NAME] use. l. On September 25, 2014, the Wound Consultant documented Resident 2 had a sacral Stage IV pressure ulcer 5 cm by 5 cm, 1.5 cm deep with undermining/tunneling of 2 cm at 3 to 9 o'clock. The right ischium Stage III pressure ulcer was 4 cm by 5 cm, 2.5 cm deep, with undermining/tunneling of 2.5 cm at 2 to 9 o'clock. The left ischium Stage III pressure ulcer was 3.5 cm by 3.5 cm. The Wound Consultant documented the following recommendations: i. Keep area clean and dry ii. Turn and reposition every 2 hours iii. Supplements in place iv. "pt on [MEDICATION NAME] - which delays wound healing" v. Continue with current treatment vi. The Wound Consultant documented "wounds responding well to treatment." The left ischium and sacral pressure ulcers' depth of the wounds have increased in size since the Wound Consultant's previous assessment. There was no recommendation documented to prevent the pressure ulcers from becoming worse due to the [MEDICATION NAME] use. No further Wound Consultant evaluation forms were provided past the September 25th assessment. The "Treatment Records" for July, August, and September 2014 were reviewed. The July 2014 Treatment Record indicated Resident 2 was not turned and repositioned every two hours on July 28, 2014 from 2 a.m. to 6 a.m. The August 2014 Treatment Record indicated Resident 2 was not turned and repositioned every two hours on August 2 from midnight to 6 a.m. The September 2014 Treatment Record indicated Resident 2 was not turned and repositioned every two hours on September 30, 2014 from 8 a.m. to 6 p.m. During the interview with CN 1 on October 24, 2014, at 1:18 p.m., CN 1 reviewed Resident 2's clinical record. CN 1 stated Resident 2 had one sacral wound on admission on April 2, 2014. CN 1 reviewed the Treatment Records and stated there were no documentation of turning and repositioning of Resident 2 on the dates and times mentioned above. During the interview with the Wound Consultant on October 24, 2014, at 2:05 p.m., the Wound Consultant stated "The first time I saw her (Resident 2) was on April 17, 2014. I sometimes don't see them when they are first admitted . The two ischium sores started here." At 2:15 p.m., the Wound Consultant stated Resident 2 was admitted with a sacral pressure ulcer. During the interview with LVN 5 on October 24, 2014, at 1:50 p.m., LVN 5 stated in order to prevent the resident from having pressure ulcers or for existing pressure ulcers to worsen, the resident "have to be repositioned every two hours, keep her dry all the time if she is incontinent, give enough fluids, and provide good skin care ..." We have to prevent it from getting bigger, prevent to place the resident on her back, just position her on the left and right side. During an interview with CN 1 on October 24, 2014, at 2:15 p.m., she stated to prevent the pressure ulcers from forming or progressing, the resident should be turned every two hours, discuss with the dietitian to either change the diet or add protein to the diet. CN 1 stated "Most important turn every two hours." CN 1 stated "yes, there were missing documentation the patient was turned. She (Resident 2) had a period when she was refusing treatment. We explained to her. For a month. Then, she was more calm and cooperative. We were able to change orders and treatment. So now, getting better. They (wound) look much better now." The "Wound Photo Records" dated July 15, 2014 and July 22, 2014 were reviewed with CN 1. CN 1 stated Resident 2 refused treatment and assessments of her wounds on those days. The Treatment Record for July 2014 indicated treatments were signed-off as performed for the sacral, left ischium, and right ischium pressure ulcers from July 13, 2014 to July 29, 2014 (the two week period documented in the Wound Photo Records that Resident 2 refused treatment and assessment). The "Interdisciplinary Team (IDT) Conference" dated July 16, 2014 indicated "continue with foley catheter (a flexible tube inserted in the bladder to drain urine) for decub (decubitus - pressure ulcer) healing." The statement was the only reference in the IDT Conference form documented. There was no IDT plan or assessment documented in the form addressing the treatment and prevention of forming and progressing of Resident 2's pressure ulcers. During the interview with Minimum Data Set Coordinator (MDS) 1 on October 29, 2014, at 1:40 p.m., MDS 1 stated the July 26, 2014 was a quarterly IDT meeting. She stated the only discussion regarding Resident 2's pressure ulcers is that she still has a Foley catheter because of it. MDS 1 stated there was no discussion regarding the pressure ulcer treatment plan or how to prevent it from progressing. MDS 1 stated they were unable to locate the other IDT meeting notes for Resident 2. The facility policy titled "Skin and Wound Care" revised October 2013 indicated to document daily the wound care provided and the dressing changes done. Weekly photo documentation of the all wounds will take place for all patients in the hospital seven days or greater. The wounds will be measured, staged, and photographed. The photographs will be documented on the wound photo record. Care plan is to be updated weekly. Upon discovery of wound or upon admission, notification of Wound Care Consultant is to be made. 2. During the tour of the facility on October 18, 2014, at 10:40 a.m., Resident 1 was observed in bed, in a supine position, asleep. Resident 1 was on an air loss mattress under a blue underpad and a bed sheet. During an observation on October 19, 2014, at 9:45 a.m., Resident 1 was on his right side. The clinical record indicated Resident 1 was admitted to the facility on [DATE] and was readmitted on [DATE] from the facility's general acute care side with admitting [DIAGNOSES REDACTED]. The Admission Assessment Minimum Data Set (MDS) dated [DATE] indicated Resident 1 is comatose and is totally dependent with two (2) person physical assist with bed mobility (how the resident moves to and from lying position, turns side to side and positions body while in bed). The MDS indicated Resident 1 is at risk for developing pressure ulcers had one (1) Stage III pressure ulcer and 2 unstageable deep tissue injuries present on admission. The electronic charting of the Nursing Admission assessment dated [DATE] indicated "Patient has wound(s) noted that are present", "Total number of wounds= 1", "Equipment - Pressure relief mattress" and "Skin intact. Has redness to left lateral foot." The Braden Scale (scale used to predict pressure sore risk) dated August 7, 2014 indicated Resident 1 scored 10 (a score of 12 or less represents high risk for pressure ulcer). There was no Braden Scale found from the prior admission. During the interview with the MDS Coordinator (MDS) 1 and Charge Nurse (CN) 3 on October 24, 2014, at 10:40 a.m., the facility was unable to locate the paper overflow chart of Resident 1 which contained the medical records from July 16, 2014 to July 28, 2014. The "Wound Evaluation" forms indicated the following: a. On August 27, 2014, the Wound Consultant documented Resident 1 had a sacral Stage III pressure ulcer that is 6.3 cm by 7 cm with a depth of 0.4 cm. The left heel DTI was 5.5 cm by 8 cm in size and the right heel DTI was 6 cm by 8.5 cm in size. The Wound Consultant recommendations included: i. To keep the area clean and dry, ii. Turn and reposition the resident every 2 hours, iii. Supplement with Prostat (liquid protein medical nutrition), vitamin C, and multivitamins with minerals. The Wound Consultant documented "wound improving responding well to TX (treatment)." b. On September 3, 2014, the Wound Consultant documented Resident 1 had a sacral Stage III pressure ulcer that is 4.7 cm by 3.5 cm, 0.4 cm deep, left heel DTI was 6 cm by 7.5 cm in size and the right heel DTI was 6 cm by 8 cm in size with a "20% open Stage III, 80% surrounding DTI". The Wound Consultant recommendations included: i. continue with [MEDICATION NAME] for the left and right heel wounds, ii. keep all areas clean and dry, iii. turn and reposition every 2 hours, iv. supplement with multivitamins and vitamin C, and v. cleanse the sacral wound with normal saline (sterile salt solution), pat dry and apply Santyl (an ointment commonly prescribed for use with skin conditions such [MEDICAL CONDITION] ulcers) to wound bed, zinc oxide to periwound (around the wound) and calcium alginate (Dressings provide antimicrobial action to prevent infection, absorb exudates and maintain a moist environment to promote rapid healing) cover with gauze and secure with Island dressing daily for 30 days. c. On September 10, 2014, the Wound Consultant documented Resident 1 had a sacral Stage III pressure ulcer that is 4 cm by 4 cm, 0.4 cm deep, a left heel DTI was 4.5 cm by 7.5 cm in size, and the right heel Stage III pressure ulcer was 6 cm by 8 cm with surrounding area DTI. The Wound Consultant recommended the following: i. Keep all areas clean and dry, ii. Turn and reposition every 2 hours, iii. Off - load heels with prevalon boots (boots that helps minimize pressure, friction and shear on the feet, heels and ankles of non-ambulatory individuals), iv. Supplement with multivitamins, vitamin C, and Prostat, and v. Continue with current treatment to sacral and bilateral heels. d. On September 17, 2014, the Wound Consultant documented Resident 1 had a sacral Stage III pressure ulcer that is 6 cm by 5.5 cm, 0.8 cm deep. The left heel DTI was 5.5 cm by 9 cm in size, and the right heel Stage III pressure ulcer was 6 cm by 6 cm in size. The Wound Consultant recommended the following: i. Keep areas clean and dry, ii. Turn and reposition every 2 hours, iii. Monitor effectiveness of treatment, iv. Left heel DTI when open stage according to tissue loss, v. Prostat, vitamin C, and multivitamins in place, and vi. Continue with all current treatment. The Wound Consultant documented "wounds responding well to treatment." The Stage IV sacral pressure ulcer and the left heel DTI had increased in size from the previous week's Wound Consultant assessment. e. On October 1, 2014, the Wound Consultant documented Resident 1 had a sacral Stage III pressure ulcer that is 5 cm by 5 cm, 1.2 cm deep with undermining/tunneling (A tunnel is an empty space that can extend in any direction from the wound; undermining is tissue destruction underlying intact skin along wound margins.) - 2.3 cm at 10 and 2 o'clock (to measure the undermining/tunneling, you measure the longest length, greatest width, and greatest depth of the wound, using the body as the face of an imaginary clock), 1 cm at 6 o'clock, and 3 cm at 8-9 o'clock. The left heel DTI was 5.2 cm by 2.7 cm, and the right heel Stage III pressure ulcer was 2 cm by 1.5 cm in size with 100% granulation. The Wound Consultant documented the following recommendations: i. Heels - continue with current treatment, ii. Keep areas clean and dry, iii. Turn and reposition every 2 hours, iv. Off - load heels, continue with prevalon boots, v. Supplements in place, vi. Sacral wound - cleanse with Dakin's (Buffered sodium hypochlorite solution, used as a bactericidal irrigation solution for open wounds) solution 1/4 strength. Pat dry. Apply Santyl. Pack loosely with calcium alginate and zinc oxide to periwound. Cover with gauze and Island dressing daily and as needed for 14 days. f. On October 8, 2014, the Wound Consultant documented Resident 1 had a sacral Stage III pressure ulcer that is 7 cm by 6 cm, 1.5 cm deep with undermining/tunneling of 3.2 cm at 9 o'clock, 3 cm at 10 and 3 o'clock, and 2.5 cm at 4 and 8 o'clock. The left heel DTI was 3 cm by 4 cm and the right heel Stage III pressure ulcer was 4 cm by 2.5 cm in size. The Wound Consultant documented the following recommendations: i. Keep area clean and dry, ii. Turn and reposition every 2 hours, iii. Continue with prevalon boots, iv. Supplements in place, v. Monitor effectiveness of treatment, and vi. Continue with all current treatment. The Wound Consultant documented heels are improving. The left heel DTI and the right heel Stage III pressure ulcer had increased in size from the previous week's assessment. g. On October 15, 2014, the Wound Consultant documented Resident 1 had a sacral Stage III pressure ulcer that is 8 cm by 7.5 cm, 1.5 cm deep with 7.5 cm undermining/tunneling at 12 o ' clock, 6 cm at 1 and 3 o'clock, 4 cm at 9 o'clock, and 9 cm at 11 o'clock. The left heel DTI was 3.5 cm by 4.5 cm and the right heel Stage III pressure ulcer was 3.5 cm by 2.5 cm and 0.1 cm deep. The Wound Consultant recommended the following: i. Keep area clean and dry, ii. Turn and reposition every 2 hours, iii. Supplements in place, iv. Monitor for effectiveness of treatment, v. Heels - continue with [MEDICATION NAME] spray, vi. Sacral - cleanse with sterile water. Pat dry. Apply Santyl. Pack loosely with calcium alginate with silver. Cover with gauze and Island dressing daily and as needed for 14 days. During the wound care observation for Resident 1 with Licensed Vocational Nurse (LVN) 18 and 19, on October 21, 2014, at 10:35 a.m., the sacral wound had a foul odor emitting from it. The sacral wound was red in the center with sloughing (A layer or mass of dead tissue separated from surrounding living tissue) of the tissue to the right side of the wound and tunneling. The right heel Stage III pressure ulcer was approximately 2.5 cm by 1.25 cm in size, dry and crusting. The left heel deep tissue injury (DTI) was on the inner part of the heel and was approximately 1 inch by 1 inch in size. The dressings covering the left and right heel pressure ulcers were Island dressings (a type of dressing with a non-adherent pad and adhesive). At the time of the observation, LVN 18 stated "Yeah, they used the wrong dressing. It's supposed to be Kerlix (a brand name of a type of gauze bandage which comes in long rolls and is made from a stretchy gauze-type material)." The review of the Physician order [REDACTED]." The same was ordered for the left heel DTI. The "Treatment Record" dated October 20, 2014 was signed - off by the licensed nurse indicating the wound treatment was carried out as ordered. The "Wound, Ostomy, and Continence Nurses Society" recognizes that "Downstaging" of granulating wounds is not appropriate since the full-thickness repair process involves replacement of the lost normal tissue with granulation tissue." (<http://www.wocn.org/>) The facility policy titled "Skin and Wound Care" revised October 2013 indicated "There is no reverse staging for Stage III or IV wound." The "#34 Infection Present" care plan dated October 12, 2014 indicated the sacral wound was infected [MEDICATION NAME](antibiotic) 1 gram intravenous every eight (8) hours for one week was started. The facility policy titled "Skin and Wound Care" revised October 2013 indicated "Weekly Charting ...2. Wounds will be measured, staged and photograph. 3. Photographs will be documented on wound photo record. 4. Care plan to be updated. " The "Wound Photo Records" were reviewed. The assessment of the right heel pressure ulcer documented on September 10, 2014 was incomplete. The form indicated the right heel was still a deep tissue injury with surrounding area as Stage III. There was a documented measurement of 6 cm long and 8 cm wide. The documentation did not indicate what part of the measurement was the open wound. There was no documentation of a Wound Photo Record of the Stage III sacral pressure ulcer on September 3 and 10, 2014. There was no documentation of a Wound Photo Record for the left heel DTI and the right heel Stage III pressure ulcers for October 8, 2014. During an interview with Charge Nurse (CN) 3 and Minimum Data Set (MDS) Coordinator 1 on October 24, 2014, at 10:40 a.m., CN 3 and MDS 1 stated they were unable to locate the "Wound Photo Record" for Resident 1 for September 3 and 10, 2014 and the left heel/right heel "Wound Photo Record" for October 8, 2014. During the interview with CN 4 on October 29, 2014, at 2:30 p.m., CN 4 reviewed the clinical record and stated she was unable to find any documentation of the Interdisciplinary Team meeting notes for Resident 1 regarding the plan of care regarding the pressure ulcer. During the interview with CN 3 on October 24, 2014, at 9:28 a.m., CN 3 stated Resident 1 is a high risk for developing pressure ulcer. When the surveyor asked CN 3 how the facility care for a resident with pressure ulcers, CN 3 stated "Because our wound nurse is a consultant, staff follows treatment recommendations. Resident is on air loss mattress (air - filled cushioned mattress). I monitor the staff on day shift; I follow and see that they are turning the patient." "I always make sure patient is turned frequently, clean and dry, always anticipate if skin starts reddened - a pressure sore is forming, follow with the dietitian with [MEDICATION NAME] (The main protein in human blood and the key to regulating the osmotic pressure (the minimum pressure which needs to be applied to a solution to prevent the inward flow of water across a semipermeable membrane) of blood.) if level is low." During the interview with CN 4 on October 29, 2014, at 2:10 p.m., CN 4 stated to prevent the pressure ulcer on the heels from progressing to a higher stage, the feet should be elevated and checked every shift.

Based on interview and record review, the facility failed to act upon the pharmacist irregularities report for 5 of 20 sampled residents (6, 7, 8, 10, and 13). Resident 8 was receiving psychotropic medications (Seroquel and Lithium) without adequate indication for use, inadequate monitoring, duplicate therapy, the pharmacist's report indicated the dose should be reduced or discontinued. From August 2013 through October 2014, Resident 8 was receiving duplicate therapy with Reglan and Dexilant; multiple drug interactions between Seroquel, Reglan, Lithium, and Lisinopril (blood pressure medication); Colace in higher than recommended dose from June 2014 through October 2014. The deficient practice resulted in Resident 8 exhibited the symptons of medication adverse reactions and the resident was treated with Lacri-lube for dry eyes, Constulose and Docusate Sodium for constipation, Reglan for stomach discomfort, Baclofen for involuntary muscle movement and Ativan for anxiety. For Resident 6, the pharmacist recommended to change the medication Flomax capsule, slow release, (medication used to treat benign prostatic hyperplasia (benign enlargement of the prostate)) to a different alpha agent due to Flomax cannot be administered via gastrostomy tube ([DEVICE], a tube that is placed directly into the stomach for long term administration of food, fluids, and medications). This failure resulted in the resident received the opened capsule and placed the resident at risk for adverse reaction due to high dose absorption (cross referred to F329). In addition, the pharmacist recommended to consider a gradual dose reduction by decreasing valproic acid to 125 mg twice daily while concurrently monitoring for re-emergence of target and/or withdrawal symptoms. For Resident 7, the pharmacist recommended increasing donezepil to 10 mg daily in the evening. There was no documentation the physician responded to the request of the pharmacist recommendation. For Resident 10, the pharmacist recommended for the initial attempt at gradual dose reduction (GDR) by decreasing Seroquel dose to 75 mg at bedtime while concurrently monitoring for re-emergence of target and/or withdrawal symptoms. There was physician signature in the form but did not indicate by a check mark the recommendation is accepted as written, accepted with modifications and declined stating the rationale. For Resident 13, the pharmacist recommended to consider gradual dose reduction for Seroquel, Buspar, Prozac and Ambien. There was no documentation the physician responded to the request. The deficient practices resuted in Resident 8 exhibiting the symptoms of medication adverse reactions, and had the potent to increased risk for adverse reactions for Resident 6, 7, 10, and 13. Findings: 1. According to the facility's patient registration form, Resident 8 was a [AGE] year-old male who was admitted on [DATE], with diagnoses that included respiratory failure, tracheostomy (an opening surgically created that allows air passage to help in breathing), spinal cord contusion (injuries as a result of high-impact motor vehicle accidents). Review of Resident 8's history and physical dated August 21, 2013 at 6:07 p.m., indicated, "(Resident 8) was a victim of an accident ...He was traveling in his bicycle and hit a parked car ... Multiple trauma including facial trauma ... " Review of physician's orders [REDACTED]. Review of physician's orders [REDACTED]. three times a day for constipation, baclofen 20 mg three times a day for muscle spasms (involuntary muscle movement), zinc sulfate 220 mg every day for wound healing, vitamin c 500 mg after dinner for wound healing, Ativan 1 mg via [DEVICE] every 12 hours as needed for anxiety manifested by hyperventilation (is rapid or deep breathing that can occur with anxiety or panic) or shortness of breath. According to the psychiatric consultation dated September 6, 2013, at 11:44 a.m., medical physician (MD 2) indicated, "(Resident 8) with no prior psychiatric history. He was hit by a car when he was traveling on his bicycle. He suffered multiple injuries ...While going through hospitalization and so forth, he became irritated, out of control and agitated, and I believe as a result he was placed on lithium (150 mg every morning) and Seroquel (25 mg at bedtime). As per the staff the patient still exhibits agitation ...not able to accept the fact that how much physically disabled he is. Patient himself realizes this and tells me that he just loses control when he thinks about the admission and what it has done to him. (Resident 8) otherwise is not psychotic. Mood seems to be stable. Never been hospitalized in a psychiatric hospital. I will increase Seroquel to 25 mg three times a day and lithium to 300 mg every day ...No evidence of psychosis or mania. " Plans of care for Seroquel and lithium dated, August 20, 2013, September 3, 2013, March 4, 2014, indicated, monitor drug levels, notify MD (physician) if abnormals noted. Evaluate need for continued use of psychotropic medications at least weekly in summary and monthly in team conference. Ensure lowest effective dose is given. Discontinue medication if not needed. Monitor resident for changes in condition. On October 22, 2014 at 10:30 a.m., during an interview, director of nursing (DON 1), stated, "MD 1 did not clarify on Medication Administration Record [REDACTED]. The hashmarks on the MAR indicated [REDACTED] During an interview at 11 a.m., registered nurse RN 2 stated, "Resisting care is not psychosis. The type of behavior the resident is having supposed to be added to the MAR. We do not have specific behaviors to be monitored from the physician. Seroquel is not an antidepressant it is an antipsychotic." According to Food and Drug Administration <http://www.fda.gov/default.htm> (FDA) label information (package inserts) for Seroquel indicated, adverse reactions include but not limited to; constipation, dry mouth, blurred vision, Tardive Dyskinesia (potentially irreversible, involuntary muscle movement), sedation, difficulty breathing, anxiety, agitation, stomach discomfort, and weight gain. http://www.accessdata.fda.gov/drugsatfda_docs/label/2013/ 9s061lbl.pdf Review of physician orders [REDACTED]. a. September 2, 2013 Lacri-Lube ophthalmic ointment for dry eyes b. September 8, 2013 Constulose daily for constipation c. October 2, 2013 Reglan for GERD. However, manufacturer cautions against the use of Reglan while taking Seroquel due to increased risk of involuntary muscle movement. d. January 1, 2014 Baclofen 20 mg three times a day for involuntary muscle movement e. March 12, 2014 Seroquel was increased to 75 mg via [DEVICE] three times a day (225 mg total daily dose). Review of Physician note dated March 21, 2014, indicated Resident 8 complained of sedation. f. June 11, 2014 Docusate Sodium 250 mg three times a day (total daily dose of 750 mg above the suggested maximum recommended of 300 mg a day) to treat constipation in addition to Constulose for the treatment of [REDACTED]. g. August 31, 2014 Ativan 1 mg12 hours as needed for anxiety manifested by hyperventilation or shortness of breath. On October 22, 2014 at 11:10 a.m., DON 1 in the presence of DON 2, reviewed Resident 8's clinical records and stated, "He did not see Lithium labs (laboratory values used to check if medication is in therapeutic range to be effective) or an order for [REDACTED]." According to DailyMed, the official provider of Food and Drug Administration <http://www.fda.gov/default.htm> (FDA) label information (package inserts), indicated, "Dosage must be individualized according to serum levels and clinical response. Regular monitoring of the patient ' s clinical state and of serum lithium levels is necessary. " http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/ 2s028, 1s027lbl.pdf During an interview with the Risk Manager, on October 22, 2014 at 3:30 p.m., she reviewed the Psychiatric Consultation dated September 6, 2013, timed at 11:44 a.m., and stated, " Clearly there was no psychosis or justification for resident to be on Seroquel or Lithium. I didn't even know there was an interaction between Seroquel and Reglan. " On October 23, 2014 at 12:50 p.m., Resident 8 was observed in his room lying in bed talking with his nurse. When asked about the medications Resident 8 stated, "I take Norco for pain and Seroquel is for my anxiety." During an interview with the Consultant Pharmacist, on October 23, 2014 at 2:30 p.m. she stated, " Do not recommend Reglan be given long term due to increased risk of involuntary muscle movement while on antipsychotic (Seroquel). Based on (Resident 8 ' s) clinical record could not see the need for Seroquel. I wanted the physician to provide a better diagnosis. Seroquel is to be used for a well-documented, well established psychiatric issue. Physician and licensed nurses should actually define the problem and use non pharmacological interventions. Not appropriate for patient (Resident 8) to be on Seroquel. " A review of Consultation Reports, dated August 2013, October 2013, and July 2014 requesting clinical justification for the use of Seroquel an antipsychotic medication and for Resident 8 with no prior history of psychosis. " (Seroquel) cannot be used for non-compliance or resistive to care. Please consider reducing the dose with the eventual goal of discontinuation ...please indicate the specific diagnosis/indication requiring treatment ...Evaluate for causes of behavior ...and assessment of alternative intervention. " A review of Consultation Reports, dated August 2013 and October 2013, indicated, "After reviewing Resident 8's chart, there appears to be no [DIAGNOSES REDACTED]. " Consultation Report, dated, April 2014 request to discontinue Reglan (metoclopramide) because of its many undesirable side effects (such as drowsiness, tremor, and restlessness) and monitor Resident 8 for involuntary movements now and at least every three months; September 2014 consultant pharmacist recommended discontinuation of Resident 8's zinc sulfate which may cause GI (stomach) upset. Zinc Sulfate was not recommended to use beyond 90 days and may delay wound healing. Resident 8's clinical record included a recommendation letter addressed to MD 1 signed by the facility's registered dietitian indicated: "Recommend providing Vitamin C for wound healing. Recommend D/C (discontinue) zinc sulfate, patient has been on it since 9/13 (September 2013)." October 2014 consultant pharmacist recommended Resident 8's Colace (docusate sodium, a stool softener) to be reduced from 750 milligram (mg) a day to the maximum suggested dose of Colace 300 mg once daily. During an interview with the Consultant Pharmacist, on October 23, 2014 at 2:30 p.m., she stated, "Do not recommend Reglan be given long term due to increased risk of involuntary muscle movement while on antipsychotic (Seroquel). Based on (Resident 8's) clinical record could not see the need for Seroquel. I wanted the physician to provide a better diagnosis. Seroquel is to be used for a well-documented, well established psychiatric issue. Physician and licensed nurses should actually define the problem and use non pharmacological interventions. Not appropriate for patient (Resident 8) to be on Seroquel. " On October 23, 2014 at 3:35 p.m., during an interview, MD 2 stated, Gradual Dose Reduction should be done to get patient off of antipsychotic and patient should be monitored monthly. He further stated, "Seroquel cannot be used for non-compliance or resistant care." However, on September 6, 2013, MD 2 increased Resident 8's Seroquel and Lithium for non-compliance and resistant care. Resident 8's Seroquel dose was increased again on September 26, 2013 and March 12, 2014. MD 2 stated he was unaware of the facility's pharmacist consultant's recommendations to decrease and/or discontinue the Seroquel and Lithium medications. A review of the facility's policy titled, "Psychotropic Medication Management " dated 7/13, indicated under Sub-Acute Unit Specific: 12. The Sub-acute unit will ensure that residents who have not used anti-psychotic drugs are not given drugs unless anti-psychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record. 13. Residents on the Sub-acute Unit who use anti-psychotic drugs will receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. 14. All Residents who are on anti-psychotic medication will have their behaviors manifested clearly and specifically identified and documented in the Interdisciplinary care plan, in order to ensure objective and appropriate monitoring. 2. The clinical record for Resident 6 indicated he was admitted to the facility on [DATE] and was readmitted on [DATE] with admitting [DIAGNOSES REDACTED]. a. The recapitulation of the physician's orders [REDACTED]. A review of the medication administration records (MAR) for Resident 6 dated August 2014, September 2014, and October 2014, the medication Flomax was administered daily at 9 p.m. The Consultant Report dated April 3, 2014 indicated "(Resident) receives tamsulosin (Flomax) per GT. This medication may NOT be crushed/opened for GT administration." "Recommendation: Please consider changing to a different alpha agent (eg: Doxazosin?) for GT administration.)" There was no documented response from the physician. The sections titled "Physician's Response" and signature were left blank. During the interview with Licensed Vocational Nurse (LVN) 3 on October 23, 2014, at 7:30 a.m., LVN 3 stated he administered Flomax to Resident 6 the evening before. LVN 3 stated he administered the medication by opening the capsule, dissolved the contents in a cup with 15 milliliters (ml) of water, and then administered the medication via the [DEVICE] by gravity. Boehringer-Ingelheim, 2012, the manufacturer of Flomax, indicated in the product insert: " FLOMAX capsules should not be crushed, chewed or opened." due to slow release. <http://bidocs.boehringer-ingelheim.com/BIWebAccess/ViewServlet.ser?docBase=renetnt&folderPath=/Prescribing+Information/PIs/Flomax+Caps/Flomax.pdf> b. The recapitulation of the physician's orders [REDACTED]. The "Consultant Report" dated April 3, 2014 from the pharmacist indicated the following recommendation: "Please consider a gradual dose reduction, perhaps decreasing to 125 mg BID (twice a day) while concurrently monitoring for re-emergence of target and/or withdrawal symptoms. If therapy is to continue at the current dose, please provide rationale describing a dose reduction as clinically contraindicated." The "Physician's Response" section of the form and physician's "Signature" section were left blank. There was no documented response from the physician regarding the pharmacist's recommendation found on the report. A review of the medication administration records (MAR) for Resident 6 dated August 2014, September 2014, and October 2014, the medication valproic acid was administered three times daily, at 9 a.m., 1 p.m., and 9 p.m. During the interview with Charge Nurse (CN) 3 on October 24, 2014, at 11:30 a.m., CN 3 stated the physician is supposed to reply to the pharmacist recommendation. The physician is supposed to agree with the recommendation or document on the report why he disagrees with the recommendation. The facility policy titled "9.1 Medication Regimen Review" dated December 1, 2007 indicated "7. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR (Medication Regimen Review) and the Director of Nursing to act upon the recommendations contained in the MRR. For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either (2) accept and act upon the recommendations contained within the MRR, or (b) reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected." 3. The Consultant Report dated February 26, 2014, from the pharmacist indicated Resident 7 has tolerated Donezepil 5 mg daily since December 6, 2013. The pharmacist recommended increasing donezepil to 10 mg daily in the evening. There was no documentation the physician responded to the request of the pharmacist recommendation. The requested response and signature sections were blank. 4. The Consultant Report dated September 9, 2014, from the pharmacist indicated Resident 10 has received Seroquel 100 mg at bedtime for an unclear [DIAGNOSES REDACTED]. The pharmacist recommended for the initial attempt at gradual dose reduction (GDR) in the facility, please consider decreasing to 75 mg at bedtime while concurrently monitoring for re-emergence of target and/or withdrawal symptoms. If theraphy continue at current dose, please provide rationale describing a dose reduction as clinically contraindicated. There was physician signature in the form but did not indicate by a check mark the recommendation is accepted as written, accepted with modifications and declined stating the rationale. 5 (a). The Consultant Report dated July 2, 2014 and September 9, 2014, from the pharmacist indicated Resident 13 has received Seroquel for an unclear diagnosis (just says psychotic behavior) since June 22, 2011. The pharmacist recommendation please consider a gradual dose reduction while monitoring for re-emergence of target and/or withdrawal symptoms. There was no documentation the physician responded to the request of the pharmacist recopmmendation. The requested response and signature sections were blank. (b) The Consultant Report dated July 2, 2014 and September 9, 2014, from the pharmacist indicated Resident 13 has received Buspar 15 mg 4 times daily for an unclear [DIAGNOSES REDACTED]. The pharmacist recommendation was to please consider a gradual dose reduction, perhaps decreasing to Buspar 10 mg 4 times daily while concurrently monitoring for re-emergence of target behavior and/or withdrawal symptoms. If therapy is to continue at the current dose, please provide rastionale describing a dose reduction as clinically contraindicated. There was no documentation the physician responded to the request of the pharmacist recopmmendation. The requested response and signature sections were blank. (c) The Consultant Report dated July 2, 2014 and September 9, 2014, from the pharmacist indicated Resident 13 has received Prozac 20 mg via [DEVICE] daily for management of depressive symptoms since January 27, 2012. The pharmacist recommended to please assess if this is still the most appropriate medication and/or dose for this resident, if possible, please consider a gradual reduction while currently monitoring for re-emergence of depressive and/or withdrawal symptoms. If therapy is to continue at the current dose, please provide rationale describing a dose reduction as clinically contraindicated. There was no documentation the physician responded to the request of the pharmacist recopmmendation. The requested response and signature sections were blank. (d) The Consultant Report dated June 5, 2014, July 2, 2014 and September 9, 2014, from the pharmacist indicated Resident 13 has an order for [REDACTED]. The pharmacist recommended to please consider reducing the dose of Zolpidem Tartrate to 5 mg at bedtime as needed, with eventual goal of discontinuation, if possible. Concurrently monitor for re-emergence of target and/or withdrawal symptoms. If therapy is to continue at the current dose, please provide rationale describing a dose reduction as clinically contraindicated. There was no documentation the physician responded to the request of the pharmacist recopmmendation. The requested response and signature sections were blank. The facility policy titled "9.1 Medication Regimen Review" dated December 1, 2007 indicated "7. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR (Medication Regimen Review) and the Director of Nursing to act upon the recommendations contained in the MRR. For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either (2) accept and act upon the recommendations contained within the MRR, or (b) reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected."