Every finding on record at Palomar Vista Healthcare Center

Based on interview and record review, the facility failed to ensure home health services were confirmed prior to discharge for three of three sampled residents (1, 2, 3).As a result, the residents were at risk of having unmet care needs, discharge summaries for Resident 1 and Resident 2 were inaccurate, and Resident 1 had to go to a General Acute Care Hospital (GACH) to have his post-discharge needs met.Findings:1. Per the facility's admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include peritoneal abscess (infection in the abdomen) and change or removal of surgical wound dressing. Resident 1 discharged to home on [DATE].Per the facility's Orders, there was an order dated 12/26/25 at 5:07 P.M., for Resident 1 to discharge from the facility on 12/26/25 with Home Health services for Registered Nurse visits, wound care, and Physical Therapy visits.Per the facility's Progress Notes, dated 12/26/25 at 6:13 P.M., At around (6 P.M.). patient is being discharged to home.Wound VAC (a sealed wound dressing that uses a vacuum pump to maintain suction on the wound to remove fluid and promote healing) present to midline abdominal incision (a surgical incision to the stomach).Per the facility's Discharge Summary and Post-Discharge Plan of Care, dated 12/26/25 at 4:48 P.M., We have arranged the following community resources to assist your transition to your new living environment.Name of Agency: [Home Health Agency (HHA) 1]Per the facility's Confirmation Report, dated 12/26/25, a referral was faxed to HHA 1 on 12/26/25 at 6:29 P.M., (about 29 minutes after Resident 1 discharged from the facility.) A handwritten note was on the fax stating that HHA 1 did not accept the referral.Per the facility's Progress Notes, dated 1/8/26, there were no progress notes regarding Resident 1's discharge planning prior to the Social Services Assistant (SSA)'s notes on 12/30/25 (four days after discharge).Per the GACH's admission History and Physical note, dated 1/1/26, Resident 1 was admitted to the GACH on 12/30/25 (four days after discharge) and Resident 1 stated that had a wound VAC placed and was told that home health was going to come to his house 3 times a week to help with he wound VAC.He went home to his family on Friday and since then no nurse has arrived, he has not known how to take care of his wound VACOn 1/14/26 at 4:05 P.M., a telephone interview was conducted with the Social Services Assistant (SSA). The SSA stated, on 12/30/25 (four days after discharge) the SSS asked her to help send referrals to HHAs.On 1/15/26 at 2:33 P.M., an interview was conducted with the Administrator and Director of Nursing In Training (DONIT). The Administrator stated, the process of sending out referrals to HHAs should have started as soon as the facility became aware of a resident's discharge date . The DONIT stated, the HHAs should have been confirmed prior to the residents' discharges.2. Per the facility's admission Record, Resident 2 was admitted to the facility on [DATE] with diagnoses to include difficulty walking and pneumocystosis (a fungal infection in the lungs). Resident 2 discharged to home on [DATE].Per the facility's Orders, there was an order on 12/29/25 at 9 A.M. for Resident 2 to discharge to home with Home Health services for Registered Nurse visits, and Physical Therapy visits.Per the facility's Discharge Progress Note, dated 12/26/25 at 10:54 A.M., Home health referral sent to [HHA 2].pending review and acceptance.Per the facility's Discharge Summary and Post-Discharge Plan of Care, dated 12/29/25 at 9:03 A.M., We have arranged the following community resources to assist your transition to your new living environment.Name of Agency: [HHA 2]Per the facility's Progress Note, dated 12/29/25 at 11:16 A.M., Resident 2 was discharged to home.Per the facility's Discharge Planning Note, dated 12/29/25 at 3:09 P.M., (more than three hours after discharge) HHA 2 did not accept the referral.Per the facility's Discharge Planning Note, dated 12/30/25 at 11:21 A.M., (more than 24 hours after discharge) the SSA documented that HHA 3 confirmed they would accept the referral for Resident 2.On 1/14/26 at 4:05 P.M., a telephone interview was conducted with the SSA. The SSA stated, the day HHA 3 confirmed that they would accept Resident 2's referral was when she documented it on 12/30/25 (the day after discharge).On 1/15/26 at 2:33 P.M., an interview was conducted with the Administrator and DONIT. The admin stated, the process of sending out referrals to HHAs should have started as soon as the facility became aware of a resident's discharge date . The DONIT stated, the HHAs should have been confirmed prior to the residents' discharges.3. Per the facility's admission record, Resident 3 was admitted to the facility on [DATE] with diagnoses to include acute cholecystitis (gallbladder inflammation causing abdominal distress), and artificial openings of digestive tract. Resident 3 was discharged to home on [DATE].Per the facility's Discharge summary, dated [DATE] at 12:07 P.M., Home Health services had been arranged with HHA 4.Per the facility's Discharge Planning Note, dated 12/24/25 at 12:12 P.M., a home health referral was made with HHA 4. Pending review and acceptance.On 1/15/26 at 2:33 P.M., an interview was conducted with the Administrator and DONIT. The admin stated, the process of sending out referrals to HHAs should have started as soon as the facility became aware of a resident's discharge date . The DONIT stated, the HHAs should have been confirmed prior to the residents' discharges.On 1/16/26 at 10:28 A.M., a telephone interview was conducted with the SSS. The SSS stated, she sent Resident 3's referral to HHA 4, but she did not hear back from HHA 4 on whether they accepted Resident 3 or not, and she did not have a chance to follow up on the referral before or after Resident 3's discharge.Per the facility's policy, titled Admission, Transfer and Discharge Rights, Subject: Discharge Planning Process, revised 5/2025, The discharge process should effectively transition them (residents) to post-discharge care.1. The Facility's discharge planning process shall.b. Ensure that the discharge needs of each resident are identified on admission, and that a discharge plan for each resident is developed and implemented in a timely manner.

Based on observations, interviews, and record review the facility failed to maintain a safe, clean, comfortable and homelike environment for seven of 21 sampled residents when it:1. Did not repair damaged phone jack boxes that were hanging from the walls and walls damaged from bed and furniture movement.2. Allowed night staff to enter and exit through an alarmed side gate and door during the night, waking residents near to that area.3. Placed a portable air conditioner in the hallway with 12 feet of 8-inch diameter (width) tubing connected to the residents' handrailing with large zip ties.This failure had the potential to increase accidents, disrupt needed sleep, and create an overall depressing atmosphere for the affected residents.Findings: 1. Review of the admission record for Resident 43 indicated she was admitted on [DATE] for diagnoses which included: Cerebral Infarction(a medical condition where blood flow to the brain is interrupted, leading to damage or death of brain tissue), Major Depressive Disorder( condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), and Functional Quadriplegia (a condition in which a person is completely unable to move due to severe disability or frailty, but without any underlying physical injury or damage to the brain or spinal cord). Review of Minimum Data Set (MDS-A standardized assessment done in nursing homes) Section C-Cognitive (thinking) Patterns for Resident 43, dated 5/15/25, indicated Brief interview for Mental Status (BIMS) score of 14 indicating intact cognition (thinking processes). Review of admission Record for Resident 85 indicated he was admitted on [DATE] for diagnoses which included: Cerebral Infarction and Major Depressive Disorder. Review of MDS Section-C Cognitive Patterns for Resident 85, dated 3/20/25, indicated a BIMS score of 5 indicating severe cognitive impairment. Review of admission Record for Resident 8 indicated she was admitted on [DATE] for diagnoses which included: Late Syphilitic Neuropathy (a complication of the sexually transmitted infection, syphilis that affects the nervous system), Human Immunodeficiency Virus Disease (is a virus that attacks the body's immune system), Schizoaffective Disorder, Bipolar Type (a mental health condition). Review of MDS Section-C, Cognitive Patterns for Resident 8, indicated a BIMS score of 12 indicating moderate cognitive impairment. On 9/9/25 at 9:54 A.M., an observation of room [ROOM NUMBER]-A's wall was conducted. 15 A's entire phone jack box was pulled out of the wall and was still connected to the 15-B's phone wire. Approximately one and a half feet of phone wire connected the phone jack box to the wall, and about a foot of phone wire for bed 15-B stretched across the floor about an inch above the floor surface to the right side of 15-B's bed.On 9/9/25 10:05 A.M., an observation of room [ROOM NUMBER]-B and interview with Resident 43 was conducted. Resident 43 stated that 15-A's phone jack had been like that for a while. 15-B's wall was observed to be scraped and scratched with plaster and paint coming off wall in a two by four-foot area on left wall of her bed. Resident 43 stated the wall was depressing and not homelike.On 9/11/25 at 8:40 A.M., an observation of room [ROOM NUMBER]-A and interview with Resident 85 was conducted. The area behind the resident's bed was observed to be damaged in an approximate two by four-foot area by the side of bed with vertical scrapes and gouges of paint and drywall. Resident 85 stated he wanted the facility to fix the wall.On 9/11/25 at 8:45 A.M., an observation of room [ROOM NUMBER] was conducted. 16-B's left wall had a one-by two-foot-long area by bedrail with large horizontal scrapes of brown paint exposing the drywall. 16-C's wall had two vertical scrapes about one inch wide by one-foot long on the right side of the bed and on left side of bed two by two-foot area with a damaged wall that had been painted over without fixing the wall.On 9/11/25 at 9:04 A.M., an interview with Resident 8 and observation of room [ROOM NUMBER]-B was conducted. Wall damage behind Resident 8's bed was observed in a two by four-feet area with the paint scraped down to drywall. Resident 8 stated the wall did not make her feel homelike and she would like it repaired.On 9/12/25 at 8:45 A.M., observation of room [ROOM NUMBER] was conducted. Broken plaster by 14-B's sliding glass door was observed to be about one foot long by one wide inch gap in the wall.On 9/12/25 8:56 A.M., an observation of room [ROOM NUMBER]-B was conducted. 11-B's phone jack box was ripped out of the wall and was resting on the floor, still connected to 11-A's phone wire. About one foot of phone wire was observed connected at one end to phone box jack, and the other end coming out of the wall.On 9/12/2025 at 8:57 A.M. an observation of room [ROOM NUMBER]-B and interview with Certified Nursing Assistant (CNA) 23 was conducted. CNA 23 confirmed that the phone jack box was pulled out of the wall and should be repaired. CNA 23 stated she would log the damage in the maintenance book and call the Environmental Service Director (ESD) to repair. CNA 23 stated that the wire could be tripping hazard and could cause accidents and, Was not homelike.On 9/12/25 at 9:05 A.M, an interview and tour of damaged rooms was conducted with the ESD. All the above observed damage of rooms 8, 11,14, 15, 16, and 25 were observed. The ESD stated that he did not have scheduled room rounds, but did random room checks. The ESD stated he did not keep any logs other than maintenance log for when he repaired reported maintenance. The ESD stated that the dislodged phone jack boxes could be a tripping hazard, the damaged walls were not homelike, and the broken wall by sliding door could let in pests. The ESD stated that the residents' environment should be safe, clean comfortable and homelike. On 9/12/2025 at 2:34 P.M., a concurrent interview with the Administrator (ADM) and observation of a slideshow of the facility damage was conducted. The ADM stated that the facility should be homelike, safe and in good repair to make residents feel at home.Review of facility policy titled Physical Environment, Environmental Conditions, dated 3/2025 indicated, The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public through monthly environmental rounds. The following environmental conditions shall be included in environmental rounds: Resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents; Facility hallways must be free of clutter.Equip corridors with firmly secured handrails on each side.2. Review of admission Record indicated Resident 69 was admitted on [DATE] for diagnoses which included: Infection of Internal Right Hip Prosthesis (an artificial body part ), Cerebral Infarction ( a medical condition where blood flow to the brain is interrupted, leading to damage or death of brain tissue), Major Depressive Disorder (condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), and Chronic Kidney Disease (a condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood). Review of Minimum Data Set (MDS-A standardized assessment done in nursing homes) Section C-Cognitive (thinking) Patterns for Resident 69, dated 8/22/25, indicated Brief interview for Mental Status (BIMS) score of 15 indicating intact cognition (thinking processes).Review of Resident Council notes from 8/21/25 indicated Resident 69, Is wondering the time frame for the side gate to be fixed. Staff are entering the building through the side door by his room and at times the door is being slammed shut. Made [Resident 69] aware that we will be speaking to staff/visitors and requesting to please be mindful of the door when entering or exiting the building. Review of Admissions Record for Resident 79 indicated resident was admitted on [DATE] for diagnoses which included: Spastic Quadriplegic Cerebral Palsy(a type of palsy (the loss of the ability to move) that affects all four limbs (arms and legs), Muscle Weakness, and Neuromuscular Dysfunction of bladder (a condition where the nerves and muscles that control bladder function are impaired, leading to abnormal urinary control). Review of MDS Section C-Cognitive Patterns, dated 8/8/25, for Resident 79 indicated a BIMS score of 12 indicating moderate cognitive impairment.On 9/9/2025 at 9:15 A.M., during initial pooling, an interview with Resident 69 was conducted. Resident 69 stated he had trouble sleeping because the employee entrance was next to his room and heard staff coming and going all night long. Resident 69 stated it was hard to sleep because the employees let door slam. In addition, Resident 69 stated the facility recently installed a gate with a coded lock. Resident 69 stated the gate sets off an alarm if the code is put in wrong. Resident 69 stated that he slept less at the facility than in the hospital. Resident 69 stated since the gate was installed, they had been using the side door as main entrance for staff entrance/exit and ambulance drop off at night.On 9/11/2025 at 9:13 A.M., a follow-up interview with Resident 69 was conducted. Resident 69 stated, The alarm goes off when code is not entered right. Had a hard time sleeping last night. Staff opening gate starts during 2nd shift at 10 PM. at 2-3 A.M., night shift staff go out gate for lunch.No peace, because every three hours the alarm goes off. The alarm went off seven times between 5:30 and 6 A.M. this morning.in the past it was the side door but now it's the gate. Employees don't know how to work the code. On 9/11/2025 at 9:21 A.M. an interview with Resident 79, Resident 69's roommate, was conducted. Resident 79 stated that the alarm from the gate woke him up from sleep often. On 09/11/2025 9:26 A.M., an observation of side door and side gate by room [ROOM NUMBER] and interview with the Environmental Service Director (ESD) was conducted. The ESD stated, The door is locked all day and should be locked at night.Nurses station has key to the door. side door was broken about 3 weeks ago. The ESD stated that if the door is labelled as for Emergency Use Only, it should be used only for emergencies. The ESD tested the door alarm, and a loud harsh tone was emitted. The ESD stated that the sound was not homelike and could wake residents from sleep. The ESD stated that a coded gate outside of room [ROOM NUMBER] window was installed recently and that he taught the staff how to enter the code. The ESD tested the gate alarm and a harsh tone was emitted. The ESD stated that the sound was not homelike and could wake a resident from sleep. On 9/12/2025 at 2:34 P.M., a concurrent interview with the Administrator (ADM) and observation of pictures depicting the side gate and side emergency door next to Resident 69 and 79's room was conducted. The ADM stated that the facility should be homelike, safe, and in good repair to make residents feel at home.Review of facility policy titled Physical Environment, Environmental Conditions, dated 3/2025 indicated .the facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public through monthly environmental rounds. The following environmental conditions shall be included in environmental rounds: Resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents, Facility hallways must be free of clutter.Equip corridors with firmly secured handrails on each side.3. On 9/11/2025 at 8:56 A.M., an observation of a portable air conditioner (AC) in hallway and interview with Environmental Service Director (ESD) was conducted. A newly installed portable AC was observed by rooms 31-32-33. The portable AC was plugged into a hallway outlet. The main AC unit was approximately two and half feet tall by two and half feet wide, by two and half feet deep, taking up approximately a quarter of the hallway. Approximately 12 feet of silver eight- inch diameter (width) tubes for portable AC were secured to patient hand railing with six large white zip ties that were over a foot long. A gap of five to six inches at the connection points on the railing were noted, where possible hand entrapment could occur. One zip tie close to the window was not cut and extended about a foot in the air. The ESD stated residents could get caught on zip ties while walking. The ESD stated the large tubes could obstruct residents who have trouble walking. The ESD stated that the whole portable AC setup did not look homelike. The ESD stated that hallways should be unobstructed to prevent accidents, and hallways should be homelike. On 9/12/2025 at 2:34 P.M., a concurrent interview with the Administrator (ADM) and observation of a slideshow of the portable hallway AC was conducted. The ADM stated that the facility should be homelike, safe and in good repair to make residents feel at home.Review of facility policy titled Physical Environment, Environmental Conditions, dated 3/2025 indicated The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public through monthly environmental rounds. The following environmental conditions shall be included in environmental rounds: Resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents, Facility hallways must be free of clutter.Equip corridors with firmly secured handrails on each side.

Based on observation, interview, and record review, the facility failed to ensure that residents receiving antipsychotic (medication for mood, behavior, or thinking) medications were monitored for side effects (SE), including postural hypotension (a drop in blood pressure from standing after lying or sitting down), for two of five residents (Resident 42 and Resident 28) sampled .These deficient practices placed both residents (Resident 42 and Resident 28) at risk for undetected adverse (serious life-threatening SE) drug reactions, which could lead to dizziness, fainting, falls, or other serious complications.Cross-Reference F658Findings: 1) A review of Resident 42's admission Record indicated Resident 42 was admitted to the facility on [DATE] with diagnoses which included history of Major Depressive Disorder (MDD- a mood disorder that causes a persistent feeling of sadness and loss of interest). On 9/10/2025 at 2:44 P.M., an interview and record review was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident 42 was on an antipsychotic (medication for mood stabilization) medication (Rexulti 2 mg [milligrams] one time a day) for depression. LN 1 stated Resident 42 was followed by a Psychiatrist (Psych) with Psych note on 9/8/25 that indicated, .This patient carries longstanding history of chronic Major Depressive Disorder [MDD] and reported that she was initiated on Rexulti approximately one year ago. She stated that Rexulti has provided effective therapeutic benefit, particularly in improving her mood stability, energy and overall functioning. She expressed a strong preference to continue this medication . On 9/11/2025 at 3:26 P.M., an interview and record review was conducted with LN 1. LN 1 stated Resident 42's antipsychotic medication monitoring for SE included, .Sedation [sleepiness], Dry mouth, constipation, slurred vision, EPS [extrapyramidal symptoms-uncontrolled movements], Weight gain, edema, Postural Hypotension . LN 1 stated there was no documentation found in Resident 42's clinical chart to support that postural hypotension was being monitored. LN 1 stated Resident 42 could have a syncope (fainting) episode, feel dizzy, experience headaches and could sustain an injury from fall accidents due to adverse SE of the antipsychotic medication. On 9/12/2025 at 11:43 A.M., an interview was conducted with Director of Nursing (DON) 1. DON 1 stated her expectations were for the LNs to be implementing the monitoring for Resident 42's side effect for postural hypotension with her antipsychotic medication use. DON 1 stated it was important that postural hypotension is monitored closely to prevent accidents such as falls. DON 1 further stated it was important for LNs to implement monitoring of SE that may be out of range findings to report to the physician and pharmacy for medication review and make recommendations that provide safety and professional standards of care for residents with antipsychotic medications. A review of the facility's policy and procedure titled, Care and Treatment Psychotropic Drug Use dated 6/2025, indicated .The Licensed Nurses shall review the classification of the drug, the appropriateness of the diagnosis, its indication/ behavior monitors and related adverse side effects prior to verification of admission orders with the Attending Physician . 2. Per the facility's admission Record, Resident 28 was admitted to the facility on [DATE] with diagnoses to include bipolar disorder (a mental illness of unstable moods). Per the facility's Medication Administration Record (MAR), dated 8/1/25 – 8/31/25 Resident 28 had an order for Lurasidone (an antipsychotic medication also used to treat bipolar disorder). The MAR included an order to monitor for side effects of Lurasidone, including postural hypotension (a drop in blood pressure when sitting up or standing up). The MAR also had an order to check his blood pressure every Sunday while lying down and while sitting. Resident 28's blood pressure while sitting was not documented for any of the Sunday's in the month. On 9/12/25 at 10:18 A.M., an interview was conducted with Licensed Nurse (LN) 11. LN 11 stated, when they documented that they were checking Resident 28's blood pressure while lying and sitting, they should have entered both blood pressure readings in the MAR. LN 11 further stated, if the second blood pressure was not documented, then there was no evidence that it happened. On 9/12/25 at 10:24 A.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated, when he took Resident 28's lying and sitting blood pressure, he should have documented both readings in the MAR. On 9/12/25 at 2:05 P.M., an interview was conducted with Director of Nursing (DON) 2. DON 2 stated, the LNs should have documented Resident 28's sitting blood pressure on the MAR to prove it was done. The facility did not have a policy on postural blood pressure monitoring.

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards for four of 21 sampled residents (30, 42, 11, 8) when;1. The facility did not accurately account and manage one of 21 sampled resident's personal medications from an outside pharmacy,2. The facility did not monitor side effects (SE) of psychotropics(medications to stabilize mood), and3. The facility did not document giving medication at the time of administration. As a result, the facility may not have been providing necessary services to residents.Cross reference F605, F755 Findings:1. Review of admission Record for Resident 30 indicated that resident was admitted on [DATE] for diagnoses which included: Joint replacement surgery, Muscle Weakness, Recurrent Dislocation (when the normal position of a joint or other part of the body is disturbed) of Left Hip, Malignant Neoplasm (an abnormal growth of cells that have the potential to invade and spread to other parts of the body) of Breast, Major Depressive Disorder(a serious mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities). Review of Minimum Data Set (MDS-standardized assessment done in nursing homes) Section C-Cognitive (thinking) Patterns, dated 7/16/25, indicated a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition (thinking processes). On 9/9/25 at 8:53 A.M., during initial pooling, an interview with Resident 30 was conducted. Resident 30 stated she was supposed to be taking an oral chemotherapy(an medication for cancer) pill, Verzenio. Resident 30 stated that she believed she had three packages of seven pills each given to her by the hospital, and she was only able to take one package of seven at the facility. Resident 30 stated that she believed the facility lost two of the three packages. Review of physician orders dated 8/28/25, indicated Verzenio Oral Tablet 100 MG (milligram-unit of measure), Give 1 tablet by mouth two times a day for Breast Cancer. A record review of the Electronic Medication Administration Record (eMAR-an electronic record of medications given for a resident) Administration Notes for Resident 30 from 8/29/25 to 9/10/25 was conducted. Review indicated Verzenio was .Not available. on the following dates 9/5/25, 9/6/25, 9/7/25, 9/8/25, & 9/9/25. Administration notes from 9/10/25 indicated .Seen by MD, was waiting for supply, md order to d/c and notify when available . On 9/11/25 at 11:20 A.M., a follow up interview was conducted with Resident 30. Resident 30 stated that she started her chemotherapy medication on 8/15/25, at the hospital. Resident 30 stated she thought the hospital had given her three packages of medication before discharge, but she had left them at the hospital by mistake along with her other medications. Resident 30 stated that on 8/30/25, the Admissions Director (AD) went to the hospital to pick up all her medications, and when she returned to the facility, she brought them to her Licensed Nurse (LN) that day, but she didn't remember who the LN was. Resident 30 stated that day, the LN sent all her other medication home with her boyfriend but kept the chemotherapy pills in the cart. Resident 30 stated that on 9/5/25 the LN stated they were out of the chemotherapy pills, but she was unsure about who the LN was. Resident 30 stated she believed two packages were missing, but she was unsure what happened. On 9/11/2025 at 11:29 A.M., an interview with the AD was conducted. The AD stated that on 8/30/25 she went to the hospital to pick up all of Resident 30's medications that were left behind when she was discharged . The AD stated that she received all of Resident 30's medication from the hospital nurse in a see-through plastic bag. The AD stated that she remembered only one packet of seven pills of Resident 30's chemotherapy medication in the bag with other medications. The AD stated that when she returned to facility, she gave the bag of medications to the nurse taking care of Resident 30 who was LN 25, to review with Resident 30. On 9/11/25 at 12:02 P.M., a phone interview was conducted with LN 25. LN 25 stated when he received Resident 30's medication from the AD, he went through all resident's medication with Resident 30. LN 25 stated he kept Resident 30's one box of chemotherapy pills containing seven individual pills. LN 25 stated he documented in the electronic medication record (EMR) the one box that was brought from the hospital, and he showed Resident 30 the one box and gave the other medications to Resident 30's boyfriend. LN 25 stated that the process for receiving personal medications from the resident was to count the medication in front of the resident and document when they gave the resident the medication. On 9/11/25 3:35 P.M. an interview with Resident 30's nurse on duty, LN 26, was conducted. LN 26 stated the process for residents with personal non-formulary medications is to: 1. Notify physician and pharmacist, 2. send medication to pharmacy to verify medication is what it is supposed to be, 3. get order by MD to approve giving said medication, 4. document medication name, dose, amount of tablets received, and consent to store medication, and 5. create a medication counting sheet. LN 26 stated the importance of properly receiving, accounting, and storing personal medication was to properly document the amount of medication that the resident brought to the facility and to prevent medicine from being lost or stolen. On 9/12/25 at 8:01 A.M., a follow up interview with LN 25 and record review of policy Pharmacy Services, Medication Administration/Med carts and Storage was conducted. LN 25 stated he did not make an account sheet to reflect the number of medications received per policy. LN 25 stated the importance of making an account sheet was to verify right medication, right dosage, right amount, and to prevent drug loss or diversion. On 9/12/25 at 11:45 A.M., a concurrent interview with LN 11 and review of the electronic Medication Administration Record (eMAR) for Resident 30 was conducted. Resident 30's eMAR indicated that LN 11 documented he gave Resident 30's chemotherapy on 9/7/25, despite the last dose in facility was given on 9/5/25. LN 11 stated he didn't remember if the chemotherapy drug was in the cart or if there had been account sheet. LN 11 stated he thought Resident 30's boyfriend had dropped off medications. LN 11 stated he thought the process for receiving resident's personal medication was . to lock the medication in the med room, administer it, and sign off. LN 27 was not aware that aware that he should verify the medication with MD or Pharmacist or that he should make an inventory sheet for personal medication brought from home. LN 27 insisted he gave the medication, despite the facility not having the chemotherapy medication since 9/5/25 as documented in Medication Administration Notes. On 9/12/25 at 1:30 P.M. a concurrent interview with Resident 30 and LN 25 was conducted. Resident 30 stated she thought she remembered three packets of medication being brought to facility, but was not completely sure. LN 25 stated he received the medication from the AD, and then reviewed each of the medications with Resident 30, and retained the one box of chemotherapy pills in the medication cart, and gave all the rest of the medications back to Resident 30's boyfriend. Resident 30 confirmed what LN 25 stated. LN 25 stated he was the one who reminded Resident 30 to call UCSD pharmacy about medication renewal when the cart was running low, and Resident 30 confirmed this as well. On 9/12/2025 at 2:38 P.M. an interview with the Director of Nursing (DON) 2 was conducted. DON 2 stated that LN 25 forgot to notify physician that Resident 30's chemotherapy medication was about to expire, and he should have. DON 2 stated the importance of notifying physicians when medication is about to expire to communicate resident's needs and prevent lapses in medication. The DON 2 stated that LN 25 should have filled out an inventory sheet for Resident 30's personal medication upon receipt to accurately account for Resident 30's medication and to prevent missing medication or diversion. DON 2 stated that LN 11 should have documented accurately in the MAR and progress note to provide clear communication that accurate medication administration occurred and to accurately account for Resident 30's personal medication. Review of facility policy titled Pharmacy Services, Medication Administration/med carts and Storage dated 3/2025, indicated It is the policy of this facility to accurately, prepare, administer, and document medications as per physician's orders. The facility to also ensure the proper and safe storage of drugs and biologicals.8. All specialty medications from outside pharmacies or brought by family must have an account sheet to reflect number of medications received. 2. A review of Resident 42's admission Record indicated Resident 42 was admitted to the facility on [DATE] with diagnoses which included history of Major Depressive Disorder (MDD- a mood disorder that causes a persistent feeling of sadness and loss of interest). On 9/11/2025 at 3:26 P.M., an interview and record review was conducted with LN 1. LN 1 stated Resident 42's antipsychotic medication monitoring for SE included, .Sedation [sleepiness], Dry mouth, constipation, slurred vision, EPS [extrapyramidal symptoms-uncontrolled movements], Weight gain, edema, Postural Hypotension . LN 1 stated there was no documentation found in Resident 42's clinical chart to support that postural hypotension ( a drop in blood pressure from standing after lying or sitting down) was being monitored. LN 1 stated Resident 42 could have a syncope (fainting) episode, feel dizzy, experience headaches and could sustain an injury from fall accidents due to adverse SE of the antipsychotic medication. On 9/11/25 a review of Resident 42's psychotropic (medications that affects behavior, mood, thoughts, or perception) care plan initiated 7/4/25 was conducted. Resident 42's care plan goals indicated, .Will be/remain free of drug related complications, including.discomfort.hypotension. and interventions that indicated, .Monitor/record/report to MD prn [as needed] side effects and adverse reactions of psychoactive Medications. On 9/12/2025 at 11:43 A.M., an interview was conducted with Director of Nursing (DON) 1. DON 1 stated her expectations were for the LNs to be implementing the monitoring of Resident 42's SE for postural hypotension with her antipsychotic medication use. DON 1 stated it was important that postural hypotension was monitored closely to prevent accidents such as falls. DON 1 further stated it was important for LNs to implement monitoring of SE that may be out of range findings to report to the MD and pharmacy for medication review and make recommendations that provide safety and professional standards of care for residents with antipsychotic (medication for mood, behavior, or thinking) medications. 3. Per the facility's admission Record, Resident 11 was admitted to the facility on [DATE] with diagnoses to include diabetes (unstable blood sugar levels). On 9/11/25 a review was conducted of Resident 11's medical record. Per the facility's Medication Administration Record (MAR) dated 9/1/25 – 9/30/25, Resident 11 had an order for Humulin insulin (a medication to treat high blood sugar) with meals. There was no documentation to show the facility administered her 7 A.M. dose on 9/8/25 or her 12 P.M. dose on 9/4/25, 9/8, or 9/10. On 9/11/25 a review was conducted of Resident 11's progress notes. There were no progress notes on 9/4/25, 9/8, or 9/10 to explain the missing doses of Humulin insulin. On 9/11/25 at 3:24 P.M., an interview and record review was conducted with Licensed Nurse (LN) 2. LN 2 stated, she forgot to sign on the MAR that she administered the Humulin insulin on 9/4/25 and 9/10. On 9/12/25 at 9:07 A.M., an interview was conducted with LN 13. LN 13 stated, she gave Resident 11 both doses of Humulin insulin on 9/8/25, but she did not sign them on the MAR at the time of administration. On 9/12/25 at 11:20 A.M., an interview was conducted with Director of Nursing (DON) 2. DON 2 stated, the LNs should have documented giving Resident 11's Humulin insulin at the time of administration. The facility's policy titled, Medication Administration/ med carts and Storage, revised 3/2025, did not have specific guidance to staff on when they should have documented their medication administration. 4. Per the facility's admission Record, Resident 8 was admitted to the facility on [DATE], with a diagnosis of Late Syphilitic Neuropathy (a neurological complication that occurs as a result of untreated or inadequately treated syphilis [A bacterial infection usually spread by sexual contact] infection). During an interview on 9/12/2025 at 9:10 A.M. with Licensed Nurse 13 (LN13), LN13 stated I had not documented the medications I had given. I have them all written down and plan to get them in today. I should document as they are given to prevent errors. During an interview on 9/12/2025 at 9:25 A.M. with Director of Nursing 2 (DON2), DON2 stated The expectation is that documentation occurs at the time it is given. If it isn't, the resident may get too much medication or not enough. LN13 should have documented. During a review of Resident 8's Medication Administration Record (MAR) for the month of September 2025, the MAR printed at 6:21 P.M. on 9/11/25 indicated that on 9/8/2025: The 12:00 P.M. dose of Buspirone HCL (medication to treat depression) 10 milligrams (mg) was not given. The 8:00 A.M. and 12:00 P.M. doses of Gabapentin (medication to treat pain) 600mg were not given. During a review of the facility's policy and procedure titled Policy/Procedure-Nursing Clinical: Pharmacy Services: Medication Administration/ med carts and Storage reviewed March 2025, the policy indicated, It is the policy of this facility to accurately prepare, administer and document medications as per physician's orders. The facility was unable to provide a policy and procedure on Nursing role with documentation and monitoring.

Based on observation, interview, and record review, the facility failed to follow standardized recipes during meal preparation on the tray line.This deficient practice placed 69 residents at risk for receiving meals that were not consistent, nutritionally adequate, or in line with physician orders and resident preferences.Findings:A review of the facility recipe on 9/11/25 was conducted. The recipe for Zesty Lasagna was used for a serving size of 72 was as followed:- Ground Turkey 6 lbs [pounds]Onion, Chopped 1 1/2 lbsOregano, dried 3/8 cupThyme, ground 1 TBSP [tablespoon]Cayenne pepper 3/4 tsp [teaspoon]Garlic Powder 1 1/2 TbspBasil, dried 1 Tbsp+3/4 tspTomato Sauce 5 Qts [Quarts]+1 CupTomato Paste 2 1/4 cupsLarge, pasteurized eggs, slightly beaten 15Cottage Cheese 4 1/2 lbsMozzarella cheese, shredded 3 lbs 12 oz [ounce]Parmesan cheese, grated, garnish As DesiredLasagna noodles, wheat or white 3 lbs 12 ozBoiling water 3 Gal [gallon]On 9/11/2025 at 9:26 A.M., an observation and interview was conducted with the Cook, in the kitchen during meal preparation for lunch. The [NAME] had already measured the turkey that was on the stove then measured onions on a scale as per recipe. The [NAME] used a green scoop (equivalent to 1/3 cup) to scoop dried oregano. The oregano recipe was for 3/8 cup, but the cook stated he was unable to find the ivory scoop (equivalent to 3/8 cup). The [NAME] continued to proceed with the recipe and used the same tablespoon and teaspoon without washing in between for thyme, cayenne, garlic powder then mixed all the dried ingredients together (including the 1/3 cup of oregano). The [NAME] then proceeded with the pasteurized eggs, cottage cheese, and mozzarella cheese per recipe. The [NAME] then mixed cottage cheese, mozzarella cheese and sprinkled an unmeasured amount of parmesan cheese with pasteurized eggs. The cook stated he mixed the parmesan cheese as desired unless a resident stated they did not want parmesan cheese. The [NAME] stated they did not have individual packets of parmesan cheese to give residents as to why he mixed the parmesan cheese. The [NAME] had already prepared the tomato sauce, tomato paste, and ground beef that was on the stove then combined them together along with the dried ingredients then mixed them together with the onions in the pot.On 9/11/2025 at 12:15 P.M., an interview was conducted with the Dietary Supervisor (DS). The DS stated it was important that the [NAME] used appropriate portions and followed the recipe. The DS stated not using the right amount of measurements such as the wrong scoop (green scoop versus ivory scoop) could affect the taste, and nutritional value of the meal.A review of the facility's policy and procedure titled, Meal Service dated 2023, indicated .Meals that meet nutritional needs of the resident will be served in an accurate and efficient manner .

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the facility kitchen for 69 residents when:1. The chlorine (common chemical cleaner that kills germs, bacteria, and algae) level with the low-temperature dishwasher was below the required sanitation (reduces harmful bacteria on surfaces) level to fully sanitize and clean dishware and cookware.2. The scoop drawer was unorganized, creating a risk for kitchen staff to touch multiple utensils with unclean hands.These deficient practices placed all 69 residents at risk for foodborne illness, cross-contamination, and unsafe meal service.Findings:1. On 9/9/2025 at 8:46 A.M., an initial kitchen tour observation was conducted with the Cook. The [NAME] tested the chlorine levels for the low-temperature dishwasher with a test strip and placed the test strip on a cookware surface. The chlorine test strip turned light purple that indicated 10 parts per million (PPM- a unit used to describe very small concentrations of a substance in a larger solution) according to the chlorine test strip tube. The [NAME] stated he did not know the chlorine levels ranges for sanitizing dishware and cookware with the low-temperature dishwasher. The [NAME] stated it was important for the chlorine levels to be within range to sanitize dishware and cookware to kill bacteria, and prevent food borne illness that can cause infection.On 9/9/25 at 8:57 A.M., a document titled Dish Machine Temperature Log was reviewed. The document section for Litmus [piece of paper used to figure out if a liquid is an acid or a base] Strips indicated a range of 50-100.On 9/10/2025 at 8:48 A.M., an interview was conducted with the Dietary Supervisor (DS). The DS stated that the chlorine test on litmus paper should be within the range of 50-100 PPM to properly sanitize dishware and cookware. The DS stated that it was important that the chlorine levels be within range to prevent food-borne illnesses for residents that are served food from the kitchen.A review of the facility's policy and procedure titled, Sanitation dated 2003, did not provide sanitation testing and monitoring on low-temperature dishwashing machines.2. On 9/11/2025 at 9:26 A.M., an observation and interview was conducted with the Cook, during meal preparation in the kitchen. The [NAME] looked for scoops in a drawer while trying to prepare measurements for dried ingredients for a recipe. Another kitchen employee (cook resource) and the Dietary Supervisor (DS) helped to look for appropriate scoops in the same drawer with their hands touching and moving around the scattered scoops in the drawer.On 9/11/2025 at 12:15 P.M., an interview was conducted with the Dietary Supervisor (DS). The DS stated they (the cook resource, [NAME] and DS) were all trying to find the right scoop that the [NAME] needed. The DS acknowledged that different hands were touching the scattered scoops in the drawer (the cook resource, [NAME] and DS). The DS stated the scoop drawer was, messy and should be organized to easily get the scoops needed without having to touch everything else that was in the drawer to prevent cross contamination. A review of the facility's policy and procedure titled, Sanitation dated 2003, indicated .All utensils, counters, shelves, and equipment shall be kept clean .

Based on interview and record review, the facility failed to accurately screen newly admitted residents for a mental disorder for two of three sampled residents (9, 11).As a result, the facility may not have been providing necessary services to Resident 9 and Resident 11.Findings:1. Per the facility's admission Record, Resident 9 was admitted to the facility on [DATE] with diagnoses to include Huntington's disease (a disorder that effects movement, thinking, and behavior), post-traumatic stress disorder (PTSD - a mental illness caused by a traumatic event), and major depressive disorder (depression - a mental illness).Per the facility's Preadmission Screening and Resident Review (PASRR) Level 1 Screening, dated 10/17/24, Resident 9 did not have a diagnosed mental disorder such as depressive disorder or mood disturbance, and did not require a level 2 mental health evaluation.On 9/12/25 at 8:18 A.M., an interview and record review was conducted with the Admissions Director (AD). The AD stated, the latest PASRR completed for Resident 9 was dated 10/17/24. The AD further stated, the MDS nurse checked the PASSR of newly admitted residents for accuracy.On 9/12/25 at 11:22 A.M., an interview was conducted with Director of Nursing (DON) 2. DON 2 stated, the facility should have reviewed Resident 9's admission PASSR for accuracy and updated it if it was inaccurate.2. Per the facility's admission Record, Resident 11 was admitted to the facility on [DATE] with diagnoses to include schizophrenia (a serious mental illness of disconnection from reality).Per the facility's Notice of Exempted Hospital Discharge, dated 8/21/24, If the individual remains in the NF (Nursing Facility) longer than 30 days, the facility must resubmit a new level 1 Screening as a Resident Review on the 31st day.Per the facility's Preadmission Screening and Resident Review (PASRR) Level 1 Screening, dated 2/13/25, Resident 11 was positive for the serious mental illness of schizophrenia.Per the facility's Notice of PASRR Level 1 Screening Results, dated 2/13/25, a level 2 mental health evaluation was required.Per the facility's Notice of Attempted Evaluation, dated 2/13/25, Unable to complete level II evaluation for serious mental illness.Facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I Screening. The case is now closed. To reopen, the facility must resubmit a new Level I Screening.On 9/11/25 at 3:36 P.M., an interview and record review was conducted with the AD. The AD stated, Resident 11 had PASSR screenings conducted on 8/21/24 and 2/13/25.On 9/11/25 at 3:53 P.M., an interview and record review was conducted with the MDS Coordinator (MDSC). The MDSC stated, the facility should have completed Resident 11's PASSR reevaluation on the 31st day of her admitting to the facility. The MDSC further stated, Resident 11's positive PASSR 1 on 2/13/25 should have triggered a PASSR level 2 review, and the facility should have followed up to see why the evaluation was not completed.On 9/12/25 at 11:22 A.M., an interview was conducted with DON 2. DON 2 stated, the facility should have reevaluated Resident 11's PASSR.Per the facility's undated policy, titled, Resident assessment Subject: PASRR, It is the policy of this facility to ensure that each resident is properly screened using the PASRR specified by the State.

Based on observation, interview, and record review, the facility failed to ensure a resident's right to make choices for two of three residents (Resident 42, Resident 24) sampled when a shower was not provided as requested, and vitamins were taken from a resident's room.This deficient practice placed Resident 42 and Resident 24 at risk for not having their dignity, comfort, and personal preferences respected, which could negatively impact quality of life.Findings: 1. A review of Resident 42's admission Record indicated Resident 42 was admitted to the facility on [DATE] with diagnoses which included history of Major Depressive Disorder (MDD- a mood disorder that causes a persistent feeling of sadness and loss of interest). A record review of Resident 42's minimum data set (MDS - a federally mandated resident assessment tool) dated 6/10/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15 possible points which indicated Resident 42 had no cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 9/9/2025 at 10:13 A.M., an observation and interview was conducted with Resident 42, in Resident 42's room. Resident 42 was lying in bed in an upright position wearing a facility gown. Resident 42 stated she was really mad that she did not get a shower yesterday (9/8/25) when she requested for one. Resident 42 stated she was told she was not allowed to have one because she had an intravenous line (IV-flexible plastic tubing to deliver medications or fluids) on her left arm. Resident 42 stated she was ready to get a shower but had not received one. On 9/9/2025 at 2:34 P.M., an observation, and interview was conducted with Resident 42, in Resident 42's room. Resident 42 stated that she still did not get a shower and was still wearing the same facility gown from the morning. Resident 42 stated she did not feel clean. On 9/10/2025 at 3:13 P.M., an interview and record review was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident 1 was given a sponge bath on 9/8/25 as documented by a registry certified nursing assistant (CNA). LN 1 stated Resident 42's shower schedule was given on Mondays and Thursdays. LN 1 stated a sponge bath was not the same as a shower. On 9/12/2025 at 7:49 A.M., an observation and interview was conducted with CNA 1, in Resident 42's room. Resident 42 had a shower/bathing calendar on her dresser cabinet wall by the bathroom. CNA 1 stated Resident 42 was scheduled every Monday and Thursday to receive a shower if Resident 42 wanted one. CNA 1 stated Resident 42 was on a B bed which meant she received showers during the P.M. (late afternoon-evening) shift. CNA 1 stated bed baths are not considered showers and stated she preferred to give her assigned residents showers because the benefits include skin checks and was preferred to get the whole body cleaned from head to toe. CNA 1 stated Resident 42 should have received a shower if she requested a shower and not a bed bath because that was her preference and her right to receive one. CNA 1 stated Resident 42 would not feel good and may feel bad that her request was not honored. CNA 1 stated showering would make Resident 42 feel stimulated, happy and feel good about herself. On 9/12/2025 at 8:05 A.M., an interview was conducted with LN 2. LN 2 stated that all facility residents can request showers at anytime and not limited to their shower/bathing schedule. LN 2 stated Resident 42 should have received a shower and not a bed bath because they were not the same. LN 2 stated Resident 42's preference for a shower should have been honored to preserve her rights and dignity to make decisions about her care. LN 2 stated Resident 42 is alert and knows what she likes and would feel bad if that preference was not honored because this would make her feel bad like nobody cares. On 9/12/2025 at 11:02 A.M., an interview was conducted with Director of Nursing (DON) 1. DON 1 stated her expectations were that nursing staff honor Resident 42's preference for a shower. DON 1 stated a bed bath was not the same as a shower and if Resident 42 wanted a shower, then her preference had to be honored because it was Resident 42's right to have her preferences respected. A review of the facility's policy and procedure titled, Resident Rights Accommodation of needs dated 5/2025, indicated .Examples of Accommodation of needs but is not limited to the following .Showers 2. Per the facility's admission Record, Resident 24 was admitted to the facility on [DATE] with diagnoses to include generalized anxiety (worry) disorder. On 9/9/25 at 2:44 P.M., an interview was conducted with Resident 24. Resident 24 stated, she had vitamins in her room which went missing. Resident 24 further stated, she told the administrator and other facility staff about her missing vitamins but they told her they couldn't find them and didn't do anything to help her. On 9/10/25 at 4:18 P.M., an interview was conducted with the Administrator (ADM). The ADM stated, the facility searched resident rooms throughout the facility and took Resident 24's vitamins from her room. On 9/12/25 at 9:16 A.M., an interview was conducted with the Social Worker (SW). The SW stated, they took Resident 24's vitamins because she was not allowed to store them in her room. The SW further stated, she did not remember if anyone from nursing was involved in the process of taking Resident 24's vitamins. On 9/12/25 at 9:20 A.M., an interview was conducted with Director of Nursing (DON) 1. DON 1 stated, when Resident 24's vitamins were taken, no one notified the doctor. DON 1 further stated, when they first took her vitamins, someone should have explained to Resident 24 why they had to take her vitamins, and they should have notified her doctor at that time to obtain an order to give her the vitamins she wanted. DON 1 further stated, they should have evaluated Resident 24 for the ability to self-administer her vitamins. On 9/12/25 at 9:23 A.M., an observation was conducted of Resident 24's vitamins with DON 1. The bag of vitamins was labeled 9/6/25 with Resident 24's name. The bag included a vision defense dietary supplement, hair skin and nails dietary supplement, eye health supplement, and Vitamin E (supplement for skin health). There was no documentation from the time of the incident. Per the facility's policy titled, Resident's Rights Subject: Accommodation of Needs, revised May 2025, Staff will Review resident's preferences and accommodate their needs.

Based on observation, interview, and record review, the facility failed to help formulate (assist) an advance directive (AD-a legal document indicating resident preference on end-of-life treatment decisions) for one of three residents (Resident 42) sampled.This deficient practice placed Resident 42 at risk for not having their medical treatment wishes known or respected during an emergency or serious illness.Findings:A review of Resident 42's admission Record indicated Resident 42 was admitted to the facility on [DATE] with diagnoses which included a history of Major Depressive Disorder (MDD- a mood disorder that causes a persistent feeling of sadness and loss of interest).A record review of Resident 42's minimum data set (MDS - a federally mandated resident assessment tool) dated 6/10/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15 possible points which indicated Resident 42 had no cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 9/9/2025 at 4:05 P.M., a record review was conducted on Resident 42's electronic health record (EHR) and live chart. Resident 42's Physician Ordered Life Sustaining Treatment (POLST) document was marked .No Advance DirectiveOn 9/10/2025 at 1:57 P.M., an interview was conducted with Resident 42, in Resident 42's room. Resident 42 stated prior to transferring to the facility the acute Hospital had given her information about an AD but was not completed. Resident 42 stated she was not asked if she had an advanced directive. Resident 42 stated she would have wanted assistance to formulate an advanced directive if it was offered at the facility but was not offered.On 9/10/2025 at 3:17 P.M., an interview and record review was conducted with the Social Service Director (SSD). The SSD stated she completed Resident 42's Social Service Assessment/Evaluation (SSAE) on 6/9/25. The SSD stated Resident 42's SSAE was not checked off that she asked Resident 42 if she required assistance to formulate an AD or had an AD. The SSD stated she only checked off that Resident 42 would be using the POLST. The SSD stated that it was important to know Resident 42's health care decisions should an emergency or life-threatening illness happen to Resident 42 to respect Resident 42's health care decisions and for staff to know what to do during an emergency and/or life threatening illness to care for her in a dignified manner. The SSD stated that a POLST was not an AD and therefore cannot be treated as an AD.On 9/12/2025 at 10:59 A.M., an interview was conducted with Director of Nursing (DON) 1. DON 1 stated her expectations was for the SSD to help Resident 42 to help formulate an AD because a POLST was not an AD. DON 1 stated it was important for facility staff to know what Resident 42's AD should an emergency arise so that Resident 42's health care decisions were respected and dignified when Resident 42 can no longer make health care decisions for herself.A review of the facility's policy and procedure titled, Residents Rights Advanced Directive/POLST revised 6/20/2025, indicated .to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.

Based on observation, interview, and record review, the facility failed to ensure two of 21 residents (Resident 85 and Resident 25) minimum data set (MDS - a federally mandated resident assessment tool) was coded accurately when:1. Resident 85's Hospice status was not coded.2. Resident 28's unstageable pressure ulcer was not coded as present on admission.As a result Resident 85 and Resident 28's MDS were sent to the federal database with inaccurate information. Findings: 1. A review of Resident 85's admission Record indicated Resident 85 was admitted to the facility on [DATE] with diagnoses which included history of Cerebral Infarction (stroke- disrupted blood flow to the brain). A record review of Resident 85's MDS dated [DATE] indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of six points out of 15 possible points which indicated Resident 85 had severe cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 9/9/2025 at 9:56 A.M., an observation, and interview was conducted with Resident 85, in Resident 85's room. Resident 85 would smile and say a-ha but was unable to carry on a full conversation. Resident 85 had oxygen being administered through his nose by an oxygen concentrator placed on the floor with a humidifier attached to the oxygen tubing. On 9/9/2025 at 4:14 P.M., a record review was conducted on Resident 85's clinical chart. Resident 85 had hospice active orders since 3/13/25 that indicated, .patient admitted to hospice. [Name of Hospice].with dx [diagnosis] of cerebrovascular disease [conditions that affect blood flow to your brain]. On 9/10/2025 at 3:45 P.M., an interview and record review was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident 85 has been with (Name of Hospice) since 3/13/25. LN 1 stated Resident 85's hospice status was never discontinued. On 9/11/2025 at 11:27 A.M., a record review was conducted on Resident 85's MDS assessment reference date (ARD) 6/20/25 quarterly assessment. Resident 85's MDS Section O was not coded for Hospice care while at the facility. On 9/12/2025 at 9:47 A.M., an interview and record review was conducted with the MDS Coordinator (MDSC), in the MDS office. The MDSC stated Resident 85's quarterly MDS ARD 6/20/25 was coded inaccurately in Section O. The MDSC stated he was unable to find documentation that Resident 85's hospice orders were discontinued during the MDS look-back period (within the last 14 days of the ARD). The MDSC stated that Resident 85's MDS was coded incorrectly and was sent to Centers for Medicare and Medicaid Services (CMS-federal database) for reimbursement, and quality measures of the facility. The MDS stated he needed to do a modification to Resident 85's MDS and re-send the correct data to CMS. On 9/12/2025 at 11:21 A.M., an interview was conducted with Director of Nursing (DON) 1. DON 1 stated that her expectations was for the MDS to be coded accurately to reflect Resident 85's health status. DON 1 stated the MDSC had to modify the MDS and re-send to CMS. A review of the facility's policy and procedure titled, Resident Assessment Instrument [RAI] dated 10/1/2023, indicated .Each person completing the MDS attests to the accuracy by affixing his/her electronic signature to that section of the MDS . 2. Per the facility's admission Record, Resident 28 was admitted to the facility on [DATE] with diagnoses to include pressure ulcers (wounds caused by sitting or lying in one position for too long). On 9/9/25 at 12:04 P.M., an interview was conducted with Resident 28. Resident 28 stated he had pressure ulcers, but already had all of them prior to admitting to the facility. On 9/11/25 a review was conducted of Resident 28's medical record. Per the facility's LN (Licensed Nurse)- Skin Pressure UIcer Weekly, dated 3/21/25, Resident 28 had four stage four (a deep wound exposing bone or muscle) pressure ulcers, and one unstageable (a wound of uncertain depth) pressure ulcer, all present on admission. Per the facility's MDS, dated [DATE], Resident 28 had four stage four pressure ulcers and zero unstageable pressure ulcers on admission to the facility. On 9/11/25 at 3:30 P.M., an interview and record review was conducted with the MDS Coordinator (MDSC). The MDSC stated, Resident 28 had four stage four pressure ulcers and one unstageable pressure ulcer on admission, but the unstageable pressure ulcer was not documented on Resident 28's 3/19/25 MDS. The MDSC further stated, the facility's usual MDSC should have documented the unstageable pressure ulcer on the MDS. On 9/12/25 at 11:17 A.M., an interview was conducted with Director of Nursing (DON) 2. DON 2 stated, the MDSC should have documented the unstageable pressure ulcer on the 3/19/25 MDS. Per the facility's policy, titled Policy/Procedure – Resident assessment Instrument, updated 10/1/23, 6) Each person completing a section of the MDS attests to its accuracy by affixing his/her electronic signature to that section of the MDS.

Based on interview and record review, the facility failed to refer a resident with a new mental disorder to the state designated authority for evaluation for one of three sampled residents (10).As a result, the facility may not have been providing necessary services to Resident 10.Findings:Per the facility's admission Record, Resident 10 was admitted to the facility on [DATE], and had a diagnosis of major depressive disorder (depression - a serious mental illness) dated 7/31/24.Per the facility's Preadmission Screening and Resident Review (PASRR) Level 1 Screening, dated 6/6/24, Resident 10 was negative for serious mental illness, and the case was closed.On 9/11/25 at 11:26 A.M., an interview and record review was conducted with the MDS Coordinator (MDSC). The MDSC stated, if a resident had a new diagnosis of a serious mental illness such as major depressive disorder, then the facility should have done a new resident review and updated the PASRR.On 9/11/25 at 3:36 P.M., an interview and record review was conducted with the Admissions Director (AD). The AD stated, the latest PASRR completed for Resident 10 was dated 6/6/24.On 9/12/25 at 8:06 A.M., an interview was conducted with Director of Nursing (DON) 1. DON 1 stated, the PASSR should have been updated when Resident 10 had a new diagnosis of major depressive disorder.Per the facility's undated policy, titled, Resident assessment Subject: PASRR, It is the policy of this facility to ensure that each resident is properly screened using the PASRR specified by the State.

Based on observations, interviews, and record review the facility failed to keep one out of 21 sampled residents' (79) call bell within reach.This failure had the potential to prevent Resident 79 from summoning help when needed and preventing him from meeting his care needs.Findings:Review of the Admissions Record for Resident 79 indicated he was admitted on [DATE] for diagnoses which included: Spastic Quadriplegic Cerebral Palsy(a type of palsy [the loss of the ability to move) that affects all four limbs (arms and legs), Muscle Weakness, and Neuromuscular Dysfunction of bladder (a condition where the nerves and muscles that control bladder function are impaired, leading to abnormal urinary control).Review of Minimum Data Set (MDS-mandated clinical assessment of all residents in Medicare and Medicaid-certified nursing homes) Section C-Cognitive Patterns, dated 8/8/25, for Resident 79 indicated a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive (thinking processes) impairment.On 9/9/25 at 3:40 P.M., Resident 79 was observed verbally asking for a urinal. Resident 79's call light was observed on the floor. On 9/9/25 at 3:42 P.M., an observation of Resident 79's call bell and interview with Certified Nursing Assistant (CNA) 21 was conducted. CNA 21 stated that Resident 79's call light should be within reach, so he could make his needs known. On 9/9/25 at 3:46 P.M., an observation of Resident 79's call bell and interview with Licensed Nurse (LN ) 22 was conducted. LN 22 stated Resident 79's call light should be within reach, so he could make his needs known.On 9/12/2025 at 2:47 P.M., an interview with the Director of Nursing (DON) 2 was conducted. DON 2 stated that all residents' call lights should be within reach of the residents to provide the residents the care that they need.Record review of facility policy titled Resident's Rights, Accommodation of Needs, dated 3/2023, indicated that It is the policy of this facility to provide accommodation of reasonable needs to the residents while in the facility.Examples of Accommodation of needs is not limited to the following.Call lights

Based on observation, interview and record review the facility failed to develop a person-centered comprehensive care plan that identified a language preference for one of seven residents (Resident 61) sampled. This deficient practice placed Resident 61at risk for having care provided that did not reflect their individual goals, needs, and choices, that could negatively impact communication, dignity, and quality of care.Findings:A review of Resident 61's admission Record indicated Resident 61 was admitted to the facility on [DATE] with diagnoses which included history of Respiratory Failure (inability of the respiratory system to maintain an adequate blood oxygen level).A record review of Resident 61's minimum data set (MDS - a federally mandated resident assessment tool) dated 8/26/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 11 points out of 15 possible points which indicated Resident 61 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 9/9/2025 at 12:25 PM a record review was conducted on Resident 61's clinical chart included:- Resident 61's MDS comprehensive assessment dated [DATE] indicated, Resident 61's preferred language was Vietnamese.- Resident 61's Social Services Assessment/Evaluation dated 8/27/25 indicated, .Language. Resident has verbalized the need of an interpreter to communicate with doctor or health care staff . Answered yes and indicated .Primary Language .Vietnamese.On 9/10/2025 at 7:42 A.M., an observation and interview was conducted with Resident 61's son, in Resident 61's room. Resident 61 was lying in bed asleep. Resident 61's son stated Resident 61 was not fluent in English and spoke Vietnamese. Resident 61's son stated Resident 61 does not eat the food at the facility and brought Resident 61 food from home. On 9/11/2025 at 8:52 A.M., an interview that was translated in Vietnamese by translator services was conducted with Resident 61, in Resident 61's room. Resident 61 stated she did not know how to speak English. Resident 61 stated she spoke Vietnamese and that her son spoke for her when he visited her. Resident 61 stated she cooked from home and her preference was Vietnamese food from home because she did not like American food that was being served at the facility. Resident 61 stated the facility did not offer her alternatives or mention that there was alternatives if she did not like the food. Resident 61 stated there was a language barrier with the staff to communicate her needs when her son was not with her at the facility. Resident 61 stated she was able to understand a little English but not fluently.On 9/11/2025 at 11:28 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 3, outside of Resident 61's room. CNA 3 stated she was Resident 61's CNA. CNA 3 stated Resident 61 did understand a little bit of English if asked simple questions. CNA 3 stated alternative food choices were not offered because Resident 61 never asked for alternative options. CNA 3 stated she was unsure what language Resident 61 spoke and did not know of any co-workers that spoke Resident 61's language (Vietnamese). CNA 3 stated Resident 61 preferred food from home that her son would bring to the facility. CNA 3 stated Resident 61 did eat some food at the facility but would prefer to eat familiar food brought from home. On 9/11/2025 at 11:46 A.M., an observation and interview was conducted with Licensed Nurse (LN) 3, in Resident 61's room. LN 3 stated he was Resident 61's nurse. LN 3 stated usually residents who need assistance with translation have signs to use or a communication board in their rooms to better assist with translation. LN 3 stated Resident 61 did not have any written or visual translation and/or communication methods accessible in Resident 61's room.On 9/11/2025 at 11:49 A.M., an interview was conducted with CNA 3. CNA 3 stated she did not know if the facility offered translation services and further stated it was important to honor Resident 61's language preferences to better understand and communicate Resident 61's needs. CNA 3 stated Resident 61 had no written or visual translation and/or communication methods she had used to communicate with Resident 61.On 9/11/2025 at 11:53 A.M., an interview and record review was conducted with LN 3. LN 3 stated Resident 61's care plan did not include Resident 61's language preference. LN 3 stated it was important that language preference be included in Resident 61's care plan to better communicate with Resident 61's health care needs. LN 3 stated Resident 61 preferred Vietnamese food and had lost weight as compared to her initial weight taken on 8/27/25 at 108.2 lbs (pounds) and on 9/2/25 at 103.8 lbs possibly due to meal intake and food preference.On 9/12/2025 at 11:05 A.M., an interview was conducted with Director of Nursing (DON) 1. DON 1 stated Resident 61's care plan should include Resident 61's language preference as captured in Resident 61's comprehensive assessment to provide person-centered care. DON 1 stated her expectations was for facility staff to provide a person-centered plan of care that is needed to improve communication, dignity and quality of life for Resident 61.A review of the facility's policy and procedure titled, Comprehensive Person-Centered Care Planning revised 10/2023, .It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment .

Based on observation, interview, and record review, the facility failed to provide an activities program that met the interests and needs for one of seven sampled residents (Resident 42).As a result, Resident 42 was not invited to group social activities (movie social, manicures, social coffee, arts and crafts and any social games such as BINGO) that did not support Resident 42's right to participate in activities of choice and placed Resident 42 at risk for social isolation, boredom, and decreased quality of life.Findings:A review of Resident 42's admission Record indicated Resident 42 was admitted to the facility on [DATE] with diagnoses which included history of Major Depressive Disorder (MDD- a mood disorder that causes a persistent feeling of sadness and loss of interest).A record review of Resident 42's minimum data set (MDS - a federally mandated resident assessment tool) dated 6/10/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15 possible points which indicated Resident 42 had no cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 9/9/25 at 2:41 P.M., an observation and interview was conducted with Resident 42, in Resident 42's room. Resident 42 was lying in bed wearing a facility gown with sunny weather outside appearing from the window. Resident 42 stated she wanted to get out of bed so much and could not stand being in her bed. Resident 42 stated she was not given an activities calendar and further stated, They don't ask anymore because they assume I don't want to go. Resident 42 stated she liked social activities such as painting and drawing, manicures, BINGO (starts at 2PM every day except Wednesday and Friday), and social coffee. Resident 42 stated she did not do anything all week but lay in her bed. On 9/10/2025 at 2:02 P.M., an observation and interview was conducted with Resident 42, in Resident 42's room. Resident 42 was lying in bed wearing a facility gown with sunny weather outside appearing from the window. Resident 42 stated, They didn't give me an activity schedule today or get me out of bed. Resident 42 stated she would have wanted to join social activities today but was not asked.On 9/10/2025 at 2:03 P.M., an observation and interview was conducted with Activities Assistant (AA) 1, in Resident 42's room. AA 1 passed out an activities calendar to Resident 42 and dropped of the facility's newsletter called The Daily Chronicle. AA 1 stated Resident 42 liked to do social activities such as BINGO, and any social activities that were available. Resident 42 was lying down in bed and agreed with AA 1. AA 1 stated Resident 42 did not participate with social activities on Monday (9/8/25), yesterday (9/9/25) and today (9/10/25). AA 1 stated BINGO was offered on Monday (9/8/25) and yesterday (9/9/25) but Resident 42 did not go because she was not invited and assisted to go to the dining room for activities. AA 1 stated Resident 42 should have been invited and that this was important for Resident 42 because this activity made her happy and kept Resident 42 busy from feeling depressed (unhappy). On 9/10/25 a record review was conducted on Resident 42's clinical chart. - MDS dated [DATE] indicated, Resident 42's social activities were .somewhat important. favorite activities was .very important. going outside to get fresh air when the weather was good was .very important. and religious services .very important.- Resident 42's activity care plan initiated 6/16/25 indicated, . (Resident 42's first name) is dependent on staff for activities, cognitive stimulation, social interaction. and interventions (plans) to include .Invite to scheduled activities.- Resident 42's social activities from June 2025-September 2025 showed Resident 42 participated with social activities on:* July: 7/4/25, 7/9/25, 7/10/25, 7/11/25, 7/12/25, 7/13/25, 7/16/25, 7/17/25, 7/18/25, 7/20/25, 7/21/25, 7/25/25, 7/26/15, 7/27/25, 7/29/25, 7/31/25* August: 8/1/25, 8/2/25, 8/3/25, 8/4/25, 8/5/25, 8/6/25, 8/7/25, 8/8/25, 8/11/25, 8/12/25, 8/13/25, 8/14/25, 8/17/25, 8/18/25, 8/19/25, 8/20/25, 8/21/25, 8/23/25, 8/28/25, 8/29/25 * September: 9/3/25, 9/6/25, 9/7/25, 9/8/25On 9/12/2025 at 8:14 A.M., an interview was conducted with the Activities Director (AD). The AD stated it was her expectation that Resident 42 attend social activities of her choice and if Resident 42 liked BINGO, then Resident 42 should have been invited to join the activity when BINGO was scheduled. The AD stated it was important for Resident 42 to attend social activities because this kept Resident 42 stimulated, happy, and engaged thereby improving the quality of life at the facility.On 9/12/2025 at 10:51 A.M., an interview was conducted with Director of Nursing (DON) 1. DON 1 stated it was important for Resident 42 to participate in activities of her choice because doing so kept Resident 42 active with social events to increase positive mood, happiness, and engaged with other residents that promotes a better quality of life. A review of the facility's policy and procedure titled, Quality of Life Activities Program revised 4/2025, indicated .Residents who wish to meet with or participate in social or religious activities, or other community activities, at or away from the facility, is encouraged to do so.

Based on observation, interview, and record review, the facility failed to follow physician's (MD) orders for tube feeding for one of one resident (Resident 100) reviewed with enteral (refers to any method of feeding that uses the stomach to deliver nutrition and calories) nutrition.As a result Resident 100 did not receive enteral feeding at scheduled time as per MD order and potential risk for malnutrition. Findings:A review of Resident 100's admission Record indicated Resident 100 was re-admitted to the facility on [DATE] with diagnoses which included history of Malignant Neoplasm of Prostate (prostate cancer- an abnormal tumor located below the bladder in males).A record review of Resident 100's minimum data set (MDS - a federally mandated resident assessment tool) dated 5/31/24 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15 possible points which indicated Resident 100 had no cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 9/9/2025 at 12:25 P.M., a record review was conducted on Resident 100's clinical chart. Resident 100's care plans and physician (MD) active orders included:- Care plan initiated 9/9/25 indicated, .Requires Tube feeding (TF-soft, flexible plastic tubes through which liquid nutrition travel through the stomach) . Is dependent with tube feeding and water flushes. See MD orders for current feeding orders.- MD orders dated 9/9/25 indicated, .Enteral Feed Order Two times a day Continuous Water Flush of 60 ml [milliter] /[per]hr[hour] x 18 hours to provide 1080 ml of H20 [water] in 24 hrs [hours] via enteral feed.- MD orders dated 9/10/25 indicated, . Enteral Feed Order two times a day Initiate [Brand of Nutrition] 1.5 via G-tube [gastrointestinal-through the stomach] start @ [at] 30ml/h and advance to 10 ml per shift to goal @ 70mL/h x18h with FW [sic] flushes 60mL q [every] 1h [one hour] On at 1400 [2PM], off at 0800 [8AM] next day.On 9/9/2025 at 12:09 P.M., an observation and interview was conducted with Resident 100, in Resident 100's room. Resident 100 stated that he was not sure if he ate or had TF running that day. Resident 100's TF machine was turned off with no water flushes or nutritional feedings hung on Resident 100's TF pole.On 9/11/2025 at 8:29 A.M., an observation and interview was conducted with Resident 100, in Resident 100's room. Resident 100's TF machine was turned off with no water flushes or nutritional feeding hung on Resident 100's TF pole. Resident 100 stated I think it's my final encounter. On 9/11/2025 at 3:36 P.M., an interview and record review was conducted with licensed nurse (LN) 1, at the nursing station. LN 1 stated Resident 100 had an ordered ultrasound on 9/11/25 at midnight due to abdominal swelling and pain. LN 1 stated that the ultrasound technician came to see Resident 100 as per nursing notes ultrasound completed at 12 P.M. on 9/11/25.On 9/11/2025 at 3:43 P.M., an observation and interview was conducted with LN 1, in Resident 100's room. Resident 100's TF machine was turned off with no water flushes or nutritional feeding hung on Resident 100's TF pole. LN 1 stated she was unsure what happened and why Resident 100's enteral feeding orders were not initiated at 2 P.M. LN 1 stated if Resident 100's TF was off all day Resident 100 could have complications to include dehydration (not enough water intake), hypoglycemia (low sugar levels), loss of consciousness (e.g. confusion, dizziness, weakness) and further health decline.On 9/11/2025 at 3:47 P.M., an observation and interview was conducted with Resident 100, in Resident 100's room. Resident 100 stated his TF was not given to him and had been off all day.On 9/11/2025 at 4:00 P.M., an interview and record review was conducted with LN 1, at the nursing station. LN 1 stated Resident 100 did not eat anything for breakfast but ate 45% of his lunch. LN 1 stated there was no baseline weight taken for Resident 100 upon admission but was taken on 9/10/25 at 135.4 lbs (pounds) without weight monitoring recommendations by the Registered Dietician (RD).On 9/12/2025 at 8:27 A.M., an interview and record review was conducted with the RD. The RD stated that the Dietary Supervisor (DS) opened his Nutrition Evaluation on 9/8/25 but did not complete Resident 100's assessment until 9/9/25 to get Resident 100's weight. The RD stated weights are taken on Monday and Thursday. The RD stated he did not know his policy and procedure for when weights were supposed to be taken for new admissions. The RD stated Resident 100 was not within his ideal body weight (IBW) 180-184 lbs. The RD stated he had not observed Resident 100 eat but used data available to him via Resident 100's clinical chart. The RD stated if the MD placed an order at 2 P.M. for an enteral TF then the TF should be started according to the MD orders. The RD stated Resident 100 would not receive the full nutritional values from the TF and is at risk for malnutrition (poor nutrition that contributes to weight loss). On 9/12/2025 at 11:38 A.M., an interview was conducted with Director of Nursing (DON) 1. DON 1 stated Resident 100's TF was not connected after 4 P.M., even though physician's orders required it to be started at 2 P.M. DON 1 explained that because of the delay, Resident 100 may not have received nutrition as ordered, which could prevent meeting Resident 100's caloric (units of energy that fuel essential body functions) and hydration (the body's ability to absorb water) needs. DON 1 stated her expectations were that TF orders be followed exactly as prescribed by the MD and carried out in a timely manner to ensure Resident 100 received adequate nutrition and hydration.A review of the facility's policy and procedure titled, Physician Orders dated 5/2025, indicated .It is the policy of this facility to accurately transcribe and implement orders in addition to medication orders (treatment, procedures) only upon the written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care .

Based on observation, interview, and record review, the facility failed to assess residents for the risk of bedrail entrapment (getting caught between the bed and the bedrail), review the risks and benefits of bedrails, and obtain informed consent prior to installing bedrails for two of three sampled residents (11, 98).As a result, Resident 11 and Resident 98 were placed at an increased risk of entrapment related injury.Findings:1. Per the facility's admission Record, Resident 11 was admitted to the facility on [DATE] with diagnoses to include muscle weakness.On 9/10/25 a review was conducted of Resident 11's medical record.The facility's LN(Licensed Nurse)-Restraint/Enabling Device/Safety Device Evaluation - V2, dated 1/28/25 was not filled out, and had all sections blank including the sections on consent and risks and benefits.The facility's LN-Restraint/Enabling Device/Safety Device Evaluation - V2, dated 2/24/25 was not filled out, and had all sections blank including the sections on consent and risks and benefits.On 9/10/25 at 3:16 P.M., an interview and observation was conducted with Resident 11. Resident 11's bed was observed to have bedrails attached. Resident 11 stated that she did not use her bedrails and wanted them to be removed.On 9/11/25 at 11:51 A.M., an interview and record review was conducted with the Medical Records Director (MRD). The MRD was unable to a bedrail consent, or a completed bedrail entrapment risk assessment in Resident 11's medical record. The MRD stated, the admissions nurse should have completed the 1/28/25 safety device evaluation, and the MDS (Minimum Data Set-resident assessment tool) nurse should have completed the 2/24/25 safety device evaluation.On 9/11/25 at 12:04 P.M., an interview was conducted with Director of Nursing (DON) 1. DON 1 stated, the admissions nurse should have completed the 1/28/25 safety device evaluation, and the MDS nurse should have completed the 2/24/25 safety device evaluation. The DON further stated, that the bedrail entrapment risk assessment, reviewing the risks and benefits of bedrails, and obtaining informed consent should have been completed prior to installing bedrails.2. Per the facility's admission Record, Resident 98 was admitted to the facility on [DATE] with diagnoses to include age-related physical debility.On 9/11/25 at 4:07 P.M., an observation was conducted of Resident 98's bed. There were bedrails attached.On 9/12/25 at 8:28 A.M., an interview and record review was conducted with the MRD. The MRD stated, she was unable to find documentation of a bedrail entrapment risk assessment for Resident 98.On 9/12/25 at 11:04 A.M., an interview was conducted with DON 2. DON 2 stated, the bedrail entrapment risk assessment should have been completed for Resident 98.The facility did not have a policy on bedrails.

Based on observation, interview and record review the facility failed to accurately acquire, receive, and account for one of 21 sampled residents (30) personal chemotherapy medication.This failure had the potential for harm to Resident 30 related to missing ordered chemotherapy medications.Cross reference F658Findings:Review of admission Record for Resident 30 indicated that resident was admitted on [DATE] for diagnoses which included: Joint replacement surgery, Muscle Weakness, Recurrent Dislocation (when the normal position of a joint or other part of the body is disturbed) of Left Hip, Malignant Neoplasm (an abnormal growth of cells that have the potential to invade and spread to other parts of the body) of Breast, Major Depressive Disorder(a serious mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities).Review of Minimum Data Set (MDS-standardized assessment done in nursing homes) Section C-Cognitive (thinking) Patterns, dated 7/16/25, indicated a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition (thinking processes). On 9/9/25 at 8:53 A.M., during initial pooling, an interview with Resident 30 was conducted. Resident 30 stated she was supposed to be taking an oral chemotherapy (a medication for cancer) pill, Verzenio. Resident 30 stated that she believed she had three packages of seven pills each given to her by the hospital, and she was only able to take one package of seven at the facility. Resident 30 stated that she believed the facility lost two of the three packages.Review of physician orders dated 8/28/25, indicated Verzenio Oral Tablet 100 MG (milligram-unit of measure), Give 1 tablet by mouth two times a day for Breast Cancer. A record review of the Electronic Medication Administration Record (eMAR-an electronic record of medications given for a resident) Administration Notes for Resident 30 from 8/29/25 to 9/10/25 was conducted. Review indicated Verzenio was .Not available. on the following dates 9/5/25, 9/6/25, 9/7/25, 9/8/25, & 9/9/25. Administration notes from 9/10/25 indicated .Seen by MD, was waiting for supply, md order to d/c and notify when available .On 9/11/25 at 11:20 A.M., a follow up interview was conducted with Resident 30. Resident 30 stated that she started her chemotherapy medication on 8/15/25, at the hospital. Resident 30 stated she thought the hospital had given her three packages of medication before discharge, but she had left them at the hospital by mistake along with her other medications. Resident 30 stated that on 8/30/25, the Admissions Director (AD) went to the hospital to pick up all her medications, and when she returned to the facility, she brought them to her Licensed Nurse (LN) that day, but she didn't remember who the LN was. Resident 30 stated that day, the LN sent all her other medication home with her boyfriend but kept the chemotherapy pills in the cart. Resident 30 stated that on 9/5/25 that the LN stated that they were out of the chemotherapy pills, but she was unsure about who the LN was. Resident 30 stated that she believed two packages were missing, but she was unsure what happened.On 9/11/2025 at 11:29 A.M., an interview with the AD was conducted. The AD stated that on 8/30/25 she went to the hospital to pick up all of Resident 30's medications that were left behind when she was discharged . The AD stated that she received all of Resident 30's medication from the hospital nurse in a see-through plastic bag. The AD stated that she remembered only one packet of seven pills of Resident 30's chemotherapy medication in the bag with other medications. The AD stated that when she returned to facility, she gave the bag of medications to the nurse taking care of Resident 30, LN 25, to review with Resident 30. On 9/11/25 at 12:02 P.M., a phone interview was conducted with LN 25. LN 25 stated when he received Resident 30's medication from the AD, he went through all resident's medication with Resident 30. LN 25 stated he kept Resident 30's one box of chemotherapy pills containing seven individual pills. LN 25 stated he documented in the electronic medication record (EMR) the one box that was brought from the hospital, and he showed Resident 30 the one box and gave the other medications to Resident 30's boyfriend. LN 25 stated that the process for receiving personal medications from the resident was to count the medication in front of the resident with resident and document when they give the resident the medication.On 9/11/25 3:35 P.M. an interview with Resident 30's nurse on duty, LN 26, was conducted. LN 26 stated the process for residents with personal non-formulary medications is to :1. Notify physician and pharmacist, 2. send medication to pharmacy to verify medication is what it is supposed to be, 3. get order by MD to approve giving said medication, 4. document medication name, dose, amount of tablets received, and consent to store medication, and 5. create a medication counting sheet. LN 26 stated the importance of properly receiving, accounting, and storing personal medication was to properly document the amount of medication that the resident brought to the facility and to prevent medicine from being lost or stolen.On 9/12/25 at 8:01 A.M., a follow up interview with LN 25 and record review of policy Pharmacy Services, Medication Administration/Med carts and Storage was conducted. LN 25 stated he did not make an account sheet to reflect the number of medications received per policy. LN 25 stated the importance of making an account sheet was to verify right medication, right dosage, right amount, and to prevent drug loss or diversion. On 9/12/25 at 11:45 A.M., a concurrent interview with LN 11 and review of the electronic Medication Administration Record (eMAR) for Resident 30 was conducted. Resident 30's eMAR indicated that LN 11 documented he gave Resident 30's chemotherapy on 9/7/25, despite the last dose in facility was given on 9/5/25. LN 11 stated he didn't remember if the chemotherapy drug was in the cart or if there had been account sheet. LN 11 stated he thought Resident 30's boyfriend had dropped off medications. LN 11 stated he thought the process for receiving resident's personal medication was . to lock the medication in the med room, administer it, and sign off. LN 27 was not aware that aware that he should verify the medication with MD or Pharmacist or that he should make an inventory sheet for personal medication brought from home. LN 27 insisted he gave the medication, despite the facility not having the chemotherapy medication since 9/5/25 as documented in Medication Administration Notes. On 9/12/25 at 1:30 P.M. a concurrent interview with Resident 30 and LN 25 was conducted. Resident 30 stated she thought she remembered three packets of medication being brought to facility, but was not completely sure. LN 25 stated he received the medication from the AD, and then reviewed each of the medications with Resident 30, and retained the one box of chemotherapy pills in the medication cart, and gave all the rest of the medications back to Resident 30's boyfriend. Resident 30 confirmed what LN 25 stated. LN 25 stated he was the one who reminded Resident 30 to call UCSD pharmacy about medication renewal when the cart was running low, and Resident 30 confirmed this as well. On 9/12/2025 at 2:38 P.M. an interview with the Director of Nursing (DON) 2 was conducted. DON 2 stated that LN 25 forgot to notify physician that Resident 30's chemotherapy medication was about to expire, and he should have. DON 2 stated the importance of notifying physicians when medication is about to expire to communicate resident's needs and prevent lapses in medication. The DON 2 stated that LN 25 should have filled out an inventory sheet for Resident 30's personal medication upon receipt to accurately account for Resident 30's medication and to prevent missing medication or diversion. DON 2 stated that LN 11 should have documented accurately in the MAR and progress note to provide clear communication that accurate medication administration occurred and to accurately account for Resident 30's personal medication. Review of facility policy titled Pharmacy Services, Medication Administration/med carts and Storage dated 3/2025, indicated It is the policy of this facility to accurately, prepare, administer, and document medications as per physician's orders. The facility to also ensure the proper and safe storage of drugs and biologicals.8. All specialty medications from outside pharmacies or brought by family must have an account sheet to reflect number of medications received.

Based on interviews, and record review, the facility failed to ensure consents were signed by the appropriate person for one of four residents (Resident 8). This failure had the potential for Resident 8 to receive medications for which they did not know the risks and benefits. Findings:Per the facility's admission Record, Resident 8 was admitted to the facility on [DATE], with a diagnosis of Late Syphilitic Neuropathy (a neurological complication that occurs as a result of untreated or inadequately treated syphilis [A bacterial infection usually spread by sexual contact] infection).During an interview on 9/11/2025 at 8:38 A.M. with Certified Nursing Assistant 31 (CNA31), CNA31 stated capacity was when a resident is alert and oriented and can make decisions for themselves. If they do not have the capacity, they cannot sign a consent form. The responsible party will need to sign the consent.During an interview on 9/11/2025 at 8:44 A.M. with Licensed Nurse 3 (LN3), LN3 stated capacity means they can make decisions for themselves. If they do not have capacity, they cannot make decisions or sign consents. LN3 further stated A person without capacity should not be asked to sign a consent. It would not be valid.During an interview on 9/11/2025 at 9:00 A.M. with the Director of Staff Development (DSD), the DSD stated the resident was not alert and oriented. The DSD further stated that They (the resident) cannot make decisions on their own. They should not be asked to sign a consent form. The consent would not be valid.During an interview on 9/12/2025 at 9:25 A.M. with the Director of Nursing 2 (DON2), DON2 stated Mental capacity is the ability to understand what is being said, what are the risks and benefits. If they (the Resident) don't (have capacity), we still involve them but also contact the Resident Representative. If the resident does not have capacity the consent would not be valid. If it is an invalid consent, then the resident might get medication they shouldn't be getting. During a record review of Resident 8's Electronic Medical Record (EMR), the Nurse Practitioner note dated January 24, 2025, the note indicated that for Decision Making: Patient does not have capacity to make medical decisions.During a record review of Resident 8's Electronic Medical Record (EMR), the document titled Consent for Treatment: Use of Sedative-Hypnotic[sleep] Medication dated 2/12/2025, was signed by Resident 8 only. Medication: Zolpidem Tartrate 5 milligrams.During a record review of Resident 8's Electronic Medical Record (EMR), the document titled Consent for Treatment: Use of Anti-Anxiety[restlessness] Medication dated 2/12/2025, was signed by Resident 8 only. Medication: Buspirone HCL 100 milligrams.During a record review of Resident 8's Electronic Medical Record (EMR), the document titled Consent for Treatment: Use of Other medication used as Psychotropic [medication for mood regulation] dated 05/07/2025, was signed by Resident 8 only. Medication: Valproic Acid 250 milligrams per 5 milliliters.During a record review of Resident 8's Electronic Medical Record (EMR), the document titled Consent for Treatment: Use of Other medication used as Psychotropic dated 06/12/2025, was signed by Resident 8 only. Medication: Gabapentin (pain medication) 600 milligrams.The facility did not provide a policy and procedure document regarding informed consent.

Based on observation, interview, and record review, the facility failed to properly store and dispose of refuse (trash, garbage or rubbish) in a sanitary manner when the outside dumpster lids were opened and accessible to pests.This deficient practice placed all 69 residents at risk for pest infestation, foul odors, and the spread of infection.Findings:On 9/10/2025 at 8:48 A.M., an observation and interview was conducted with the Dietary Supervisor (DS), outside of the kitchen back exit. There was two dumpsters outside with one dumpster's lid open. The opened dumpster contained garbage in clear plastic bags and cardboard boxes scattered in the dumpster with a foul odor coming out from the dumpster. The DS stated the dumpster lids needed to be closed to contain the garbage that was inside the dumpster and to prevent pests such as rats, and flies from entering the dumpster and potentially spreading infection.A review of the facility's policy and procedure titled, Miscellaneous Areas dated 2023, indicated .Garbage and trashcans must be inspected daily that no debris is on the ground or surrounding area, and that the lids are closed .

Based on observation, interview, and record review, the facility failed to properly store intravenous (IV-a plastic tubing inserted through the vein) supplies for one of 21 residents (Resident 42) when an opened IV flush syringe (device used to inject fluids a water solution through an IV that prevents clogs) and a green IV cap cover was left unattended and stored improperly.This deficient practice placed Resident 42 at risk for contamination, infection and unsafe administration of IV medications and supplies.Findings:A review of Resident 42's admission Record indicated Resident 42 was admitted to the facility on [DATE] with diagnoses which included history of Irritable Bowel Syndrome (IBS-uncomfortable or painful abdominal symptoms).A record review of Resident 42's minimum data set (MDS - a federally mandated resident assessment tool) dated 6/10/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15 possible points which indicated Resident 42 had no cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 9/9/2025 at 10:13 A.M., an observation and interview was conducted with Resident 42, in Resident 42's room. Resident 42 was lying in bed in an upright position with an IV medication flowing to her left (L) lower arm. Resident 42's dresser had her gray purse with an opened IV flush and a green IV cap cover left unattended.On 9/9/2025 at 10:53 A.M., an observation and interview with Director of Nursing (DON) 1 was conducted, in Resident 42's room. DON 1 stated she was the only Registered Nurse (RN) on the floor at that time and was the IV nurse responsible for administration of IV medications. DON 1 observed Resident 42's dresser and on top of the dresser was an unattended opened IV flush with a green IV cap cover. DON 1 stated this should not be here and picked up the unattended IV supplies. DON 1 stated this was a safety issue because Resident 42's line if used could get contaminated causing an infection and/or inappropriately used by someone else to cause a safety issue if used incorrectly. DON 1 stated the IV supplies need to be stored properly in the IV cart and locked when unattended.A review of the facility's policy and procedure titled, Medication Administration/Med cart and Storage Revised 3/2025, indicated .Drugs and/or biologicals should not be left unsecured/unattended. Drug deliveries should be stored immediately after delivery and should not be left unattended/unsecured.

Based on observation, interview and record review, the facility did not ensure that 1 of 3 residents (Resident 1) was protected from the potential for sexual abuse when: 1. Resident 2 who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . 2.After accepting Resident 2 as a new admission, there was no documented evidence related to the following: Accurate admission and ongoing safety assessment, development of interdisciplinary and core staff communication for the planning, monitoring and evaluating of Resident 2's plan of care to ensure Resident 2 did not interfere with other residents' safety. As a result, Resident 2 was found by staff in Resident 1's room laying in bed with Resident 1. Resident 1's gown was above her hips and her intact brief was exposed. In addition, staff reported when Resident 2 was found laying in bed with Resident 1, Resident 2 stated he was bored and was having fun with (Resident 1's last name). The lack of identification, assessment, development and planning for Resident 2's admission did not ensure staff were ensuring the safety of all residents and had the potential for Residents to not be free from sexual abuse from Resident 2. Findings: A review of Resident 1's undated Facesheet indicated, Resident 1 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS - a clinical assessment tool) and Brief Interview for Mental Status (BIMS - test used for cognitive function) dated 6/21/2021 indicated Resident 1 scored 3 which indicated severe impairment. A review of Resident 2's undated Facesheet indicated that Resident 2 was admitted to the facility on [DATE]. A review of Resident 2's registry from the agency that tracks and monitors prisoners, previously incarcerated offenders, indicated Resident 2's Risk Assessment Score: Tool Level of Service/Case Management Inventory (LS/CMI - Risk assessment instrument used in California to predict risk of violent re-offense by sex offenders) Year: 2021 score 30. LS/CMI Score Categories indicated 30+ = Very High. A record review of Resident 1's Change of Condition Note dated 1/26/2022 at 12:10 A.M., completed by Licensed Nurse (LN) 1 indicated, At approximately 12 midnight, resident (Resident 1) was seen laying down in her bed with a male resident (Resident 2). Residents (Resident 1 and Resident 2) were separated immediately. With Resident's (Resident 1) current level of consciousness, Pt (Resident 1) not oriented to current situation, to name, place or time, LN (Licensed Nurse - LN 1) and staff (Certified Nursing Aid - CNA 1) were unable to get accurate statement of the incident. LN (LN 1) and CNA (CNA 1) performed a head-to-toe assessment, no injury of skin alteration noted at this time. Peri-area appears normal and without signs of trauma. Pt (Resident 1) appears to not be in pain or discomfort. Pt (Resident 1) appears content and calm without signs of emotional distress. Notified MD (Doctor of Medicine) and RP (Responsible Party). A record review of Resident 1's Change of Condition Note dated 1/26/2022 at 12:15 A.M., completed by LN 1 indicated, Addendum: At the time of the incident, Pt's (Resident 1) clothes and diaper were on and intact. No signs of Pt (Resident 2) removing clothing. Head to toe skin assessment performed, no skin alterations or bodily fluids found. No foreign objects found. Pt's diaper was dry, clean, and intact. Pt's (Resident 1) psychological status at the time of incident was normal, no s/s [signs or symptoms] of emotional distress, Pt (Resident 1) was content and calm. No crying, whimpering, or moaning noted. Reported to Dr. (Name) and received order to report incident to management and to the police. Also ordered to send Pt out to (Name of Hospital) ER [Emergency Department] for further eval and tx [Evaluation and Treatment] for possible sexual abuse if the Pt's sister (Name of Sister) is agreeable d/t [related to] Pt being under hospice care [comfort care during terminal illness]. A record review of Resident 2's Change of Condition Note dated 1/26/2022 at 12:10 A.M., completed by LN 1 indicated, At approximately 12 midnight, resident (Resident 2) was walking around the hallways of station (station number) , not long after staff (CNA 1) went to check where he (Resident 2) was at and he (Resident 2) was found in room (Resident 1's room number) laying down next to the female patient (Resident 1) in room (Resident 1's room number). Resident (Resident 2) was asked to leave the room immediately by staff (CNA 1) member. Pt (Resident 2) obliged and left the room right away. Resident (Resident 2) was very apologetic when LN (LN 1) asked what he (Resident 2) was doing in that room. Resident (Resident 2) stated ' I did not know that I wasn't allowed in there.' Residet [sic] (Resident 2) was informed that per company policy males and females cannot be in the same room. Pt (Resident 2) replied ' nobody told me that when I first got here.' Pt (Resident 2) denied performing inappropriate acts with the female resident (Resident 1) and claimed all he (Resident 2) did was lay down next to her (Resident 1) on the right side of bed. Notified MD and RP. Pt will be put on 72 hour visual checks. On 2/9/2022 at 8:48 A.M., a telephone interview was conducted with the Responsible Party (RP). The RP stated that Resident 1 mumbled off when communicating but had clear outburst at times. The RP stated that during her hospital visit with Resident 1 on 1/26/2022 at 3 P.M., Resident 1 had a clear outburst and stated The guy from other house last night put his hand down there - pointing at her groin area. The RP stated Resident 1 was restless and stated Where is he? I am scared. He kissed me. He touched me. He pushed me. On 2/10/2022 at 7:30 A.M., a telephone interview was conducted with LN 1. LN 1 stated that around 12 A.M. of 1/26/2022, CNA 1 informed him that Resident 2 was found in Resident 1's room and was lying in bed with Resident 1. LN 1 stated that he conducted a full body assessment of Resident 1 with CNA 1. LN 1 stated Resident 1 was non-verbal and just mumbled, the diaper was intact, there were no injuries or marks noted during the skin assessment. On 2/11/2022 at 7:26 A.M., a telephone interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated around 12 AM of 1/26/2022 Resident 2 was observed in the hallway. CNA 1 stated that after 5 minutes, Resident 2 was found lying in bed next to Resident 1. CNA 1 stated Resident 2 was kind of smiling and embarrassed that I found him lying in the bed next to Resident 1. CNA 1 stated Resident 1 was in bed laying on her back while Resident 2 was side lying facing Resident 1. CNA 1 stated Resident 1 was wearing her gown and the lower end of the gown was over the hips area. CNA 1 stated Resident 1's diaper was visible, and that the diaper was fastened. CNA 1 stated that Resident 2 apologized, made ' excuses, and told her Me and her were adults, we are doing adult things by an adult to adult, he was a man, was bored, and was having fun with (Resident 1's last name). On 3/30/2022 at 3:35 P.M., an observation and interview were conducted with Resident 1. Resident 1 was observed seated on the wheelchair in the dining area and was wheeled by a staff to her room. Resident 1 had no recall of the event during the interview. Additionally, the Social Services Director (SSD)was interviewed on 3/30/2022 at 4:40 P.M., and during the interview, the SSD did not have supporting documentation that Resident 1 was interviewed and did not recall the alleged event of Resident 2 lying in her bed. A review of Resident 2's Admission Referral, dated 12/29/2021 indicated Resident 2 was previously incarcerated and was on parole. A review of Resident 2's facility undated Face sheet entered by admission staff indicated Resident 2 was previously incarcerated and was on parole. A review of Resident 2's Skin Wound Note dated 1/1/2022 at 7:27 P.M., indicated Skin assessment completed . Left ankle bracelet[monitoring device for Resident 2 as part of his parole] noted . On 2/9/2022 at 11:26 A.M., an interview was conducted with the Administrator (ADM) 1. The ADM 1 stated that he was aware that Resident 2 was a parolee but was not aware of Resident 2's criminal history. The ADM stated that the facility did not have a procedure on the requirements and process of a parolee. The ADM stated that he had a conversation with a Parole Officer, the Parole officer stated that they were just checking on Resident 2, and that Resident 2 did nothing and was not in any trouble. On 2/9/2022 at 12:40 P.M., an interview was conducted with LN 3. LN 3 stated he was informed that Resident 2 had an ankle brace monitor and had a parole officer that came to the facility to check on Resident 2. On 2/18/2022 at 12:29 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD admitted that she was the admission nurse of Resident 2. The DSD stated it was not communicated to her during the hand off from the General Acute Care Hospital (GACH) that Resident 2 had an ankle bracelet and was followed up by a parole officer. On 4/20/2022 at 3:44 P.M., an interview was conducted with The Director of Nursing (DON) 2 and Corporate Acting Director of Nursing (CADN). During the interview, the DON indicated the DSD did Resident 2's admission paperwork from home via teleworking and this was not in accordance with the facility's admission process. Furthermore, the DON indicated the facility's expectation was for admissions to be conducted in person to prevent inaccurate assessments. On 2/9/2022 at 1:57 P.M., an interview and record review were conducted with the Director of Marketing and Admissions (DMA). The DMA stated that the process of admission was that the information provided by the transferring facility was compared to the facility's admission criteria. The DMA stated that if he was aware of Resident 2's criminal history the admission team would not have accepted Resident 2, and Resident 2's criminal history would be investigated prior to admission. On 2/9/2022 at 2:35 P.M., an interview was conducted with the Administrator (ADM) 1. The ADM 1 stated that the facility should have been aware of the criminal history of Resident 2. The ADM stated that indicators such as Resident 2's Parole Officer visiting the facility and the ankle bracelet worn by Resident 2, should have triggered further investigation of Resident 2's criminal history. On 2/9/2022 at 3:15 P.M., an interview was conducted with the ADM 1. The ADM 1 stated that he was not aware of any investigation by the Social Services Director (SSD) about Resident 2 being a parolee and Resident 2's criminal records. The Administrator stated it would be good to know the legal history of the resident as this could help the Interdisciplinary Team (IDT- a team of different types of staff that work together to share expertise, knowledge, and skills to impact on patient care) determine additional safeguards for the residents. On 2/18/2022 at 12:02 P.M., a joint interview and record review were conducted with Director of Staff Development (DSD). The DSD stated there was no investigation or inquiries documented in Resident 2's Progress Notes except the note on 1/3/2022 at 7:44 P.M. completed by Social Services Director (SSD) that indicated Resident has a Parole Officer that per resident will be checking in on him . The DSD stated the progress note dated on 1/1/2022 at 7:27 P.M., completed by LN 2 indicated .Left ankle bracelet noted . The DSD stated there were no other documentations in Resident 2's medical record about resident's background, social history related to Resident 2 being a parolee. On 4/20/2022 at 3:30 P.M., a joint record review and interview with Director of Nursing (DON) 2 was conducted. The DON 2 stated Resident 2's Admission Notes was dated 12/31/2021 at 21:37 P.M. and completed by Director of Staff Development and indicated admitted .at approximately 2039 via (name of transport company) . Resident 2's LN-Initial Admission Record was completed by DSD and had Effective Date: 12/31/2021 at 20:39 In addition on 4/21/2022 an interview and record review were conducted with DON 2 and Administrator (ADM) 2. The DON 2 stated DSD's timecard indicated she worked on 12/30/2021 from 6:30 PM until 12/31/2021 at 7:00 AM and on 12/31/2021 from 10 AM to 9 PM. In addition, on 4/21/2021 at 5 P.M., the DON 2 and the ADM stated based on timecard, they would not know which hours were worked from home and hours worked in the facility. Per DON 2, during the investigation and inquiry about the multiple hours, the DSD stated I do admission assessment from home. A review of Admission Note by DSD indicated. Effective Date: 12/31/2021 21:37:00 The DON 2 stated, effective date was the date and time the content of the document happened. Created date: 1/2/2022 16:38:53 refers to date and time the note was created or completed. In addition, a review of LN-Initial Admission Record indicated Effective Date: 12/31/2021 20:39 . Signed by (DSD) Licensed Vocational Nurse - Hourly [e-SIGNED] . Signed Date 1/26/2022. The DON 2 stated the signed date and time meant the time it was signed and completed. The DON 2 reviewed the file of Resident 2 and stated the signed date of 1/26/2022 was the day of discharge of the resident from the facility. On 2/18/2022 at 1:18 P.M., an interview was conducted with the Activities Director (AD). The AD stated on 1/1/2022, she noticed the left ankle bracelet during Resident 2's activity assessment. The AD stated that she informed the SSD, the Director of Nursing (DON) and the staff that attended the daily stand-up meeting. On 2/18/2022 at 2:51 P.M., an interview was conducted with the Corporate Acting Director of Nursing (CADN). The CADN stated the SSD made a progress note about the parole officer and that there was no other documentation that the legal history of Resident 2 was thoroughly investigated. The CADN stated that the SSD should have pursued the investigation to develop the appropriate plan of care for Resident 2. The CADN stated a lot of people knew about the ankle bracelet and the parole officer, but no one looked into it and thoroughly investigated Resident 2's legal history. On 4/20/2021 at 11:36 A.M., an interview was conducted with the Admission Coordinator (AC). The AC stated she was not aware of Resident 2's legal history and background. The AC stated that if she had known about Resident 2's legal history, she would not have accepted or admitted him for the safety of the resident's and staff. The AC stated because the facility was not aware of Resident 2's legal background, it posed the risk to resident's safety. On 4/20/2022 at 12:07 P.M., an interview was conducted with the Operations Manager (OM)/ Administrator (ADM) 2. The OP/ADM 2 stated Resident 2's legal history should have been investigated. The OP/ADM 2 stated appropriate interventions could have been implemented to keep Resident 2 away from other residents and to keep everyone safe. OP/ADM 2 stated Resident 2 could have been placed on 1:1 monitoring or every certain minute's monitoring. On 4/20/2022 at 1:01 P.M., an interview was conducted with Director of Nursing (DON) and OP/ADM 2. The DON stated, if she was aware of Resident 2's legal history, she would really think hard to admit him in the facility. The DON 2 stated, it should have been investigated why the resident had an ankle bracelet and was followed up by a parole officer. The DON 2 stated we needed to know the information to take care of the safety of residents and staff. The DON 2 stated, with Resident 2's legal history, she would implement close observation and monitoring of Resident 2 and transfer the Resident 2 to another facility that could take care of him better. The DON 2 stated Resident 2's unknown legal history to facility posed safety risk to residents and staff. On 4/14/2022 at 3:17 P.M., a telephone interview was conducted with the CADN. The CADN stated it was important to know the purpose that Resident 2 was wearing an ankle bracelet, and the purpose that Resident 2 was monitored by the parole officer. The CADN stated the result of the inquiry could help identify the plan of care that would be provided to Resident 2. The CADN stated the facility did not protect Resident 1 from potential sexual abuse by Resident 2. A review of the Facility's Policy and Procedure titled Abuse: Prevention of and Prohibition Against last revised 4/2019 indicated It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.

Based on interview, and record review, the facility failed to ensure Resident 1's pain medication was not excessive. The facility failed to question an order for [REDACTED]. As a result, Resident 1 was transferred to the Emergency Department (ED), and subsequently admitted to the hospital for the treatment of [REDACTED]. Findings: Resident 1 was admitted to the facility on [DATE], from the hospital, with [DIAGNOSES REDACTED]. According to the same document, Resident 1's wife was listed as his primary contact. The discharge instructions from the hospital included the medication [MEDICATION NAME] ER 200 mg, give 1 tablet every 12 hours for pain management for 60 administrations (to be administered 60 times). The total daily dose was 400 mg. Resident 1 ' s clinical record was reviewed on 11/9/16 starting at 2:20 P.M. with the ADON and DSD. According to the nurse's notes, [MEDICATION NAME] not available. The skilled nursing facility physician (Physician 1) authorized one dose of [MEDICATION NAME] 5/325 mg (a strong pain medication), which was administered at 10:59 P.M. on 8/26/16. Physician 1 also instructed the nurse to administer [MEDICATION NAME] mg when the medication arrived from the pharmacy, and administer the second dose of this medication 10 hours later. Resident 1 received the first dose of [MEDICATION NAME] 00:55 AM on 8/27/16, the second dose of [MEDICATION NAME] mg at 11:09 AM on 8/27/16 and a third dose of [MEDICATION NAME] 7:30 PM on 8/27/16. On 8/28/16 at 8:35 A.M., Resident 1 was sent to the Emergency Department (ED) at Hospital A via ambulance for, shortness of breath. On 8/28/16, Resident 1 arrived at Hospital A's ED at 9:34 A.M., with the chief complaint of shortness of breath, altered mental status. At 10:52 A.M., Resident 1 was administered [MEDICATION NAME] ([MEDICATION NAME], a medication to treat opiate overdose). According to the ED Notes on 8/28/16 at 11:19 A.M., After giving [MEDICATION NAME] 0.4 mg IV pt (patient) . began speaking, continued with slurred speech and states, what did you give me. Informed him it was [MEDICATION NAME] he received . (Patient) states, I can open my eyes much easier. sitting up in bed speaking with wife On 8/28/16, at 2:08 P.M., Resident 1 was administered [MEDICATION NAME] continuous infusion at 0.1 mg per hour. On 8/28/16, at 5 P.M., Resident 1 was administered [MEDICATION NAME] continuous infusion at 0.5 mg per hour. On 8/28/16, at 5:12 P.M., Resident 1 was admitted to the Intensive Care Unit (ICU). According to the records received from Hospital A, Resident 1 was admitted from 8/28/16 to 9/10/16. According to the Discharge Summaries, dated 9/10/16, the list of Active Hospital Problems included the [DIAGNOSES REDACTED]. An interview was conducted on 11/9/16 at 2:50 P.M. with LN 1, who administered one dose of [MEDICATION NAME] 8/27/16 at 7:30 P.M. LN 1 stated she had been an LN since 2007, and from her experience, the usual dose for [MEDICATION NAME] 100 mg. LN 1 acknowledged it was the first time she administered a 200 mg dose. LN 1 said, I know it's high and she would normally verify with the physician. However, in this case, she would assume it was already verified with the physician by someone else. LN 1 added, when the medication dose was high, she would clarify with the supervisor, then the supervisor would clarify with the physician. LN 1 acknowledged she was not aware if Resident 1 was previously on such high dose, and she did not remember clarifying it with the supervisor. On 11/9/16 at 3:35 PM, Resident 1's clinical record, including the history of pain medication administration from the hospital, which was available to LNs and physicians, was reviewed with the DON. Per the clinical record, when Resident 1 was in the hospital, he received [MEDICATION NAME] and [MEDICATION NAME] for pain. The maximum total amount of pain medication Resident 1 could have received daily was an equivalent of 120 mg of [MEDICATION NAME]. Resident 1 had no prior history of receiving 400 mg of [MEDICATION NAME] daily. The DON acknowledged this information did not justify why the LN at the skilled nursing facility administered 400 mg of [MEDICATION NAME] day. The DON stated LNs had access to Resident 1 ' s clinical record from the hospital, and should have reviewed the medication history, and questioned the appropriateness of the high dose of MS Contin. Furthermore, the LNs should have brought this to Physician 1 ' s attention. On 11/10/16 at 10:30 AM, Physician 1 was interviewed via telephone. Physician 1 stated when a resident came with medication orders from another physician, she would continue the same medications. She explained, since she would not see the resident for another 48 to 72 hours, and would not have access to the whole medical record that came with the resident, she would continue the same medications unless they were questionable. Physician 1 acknowledged she did not have access to Resident 1's medical record when she prescribed MS Contin. She came in on 8/27/16 to see Resident 1. Even though she had access to the medical record on 8/27/16, Resident 1 was comfortable, therefore she did not question the dose of MS Contin. Physician 1 acknowledged 400 mg of [MEDICATION NAME] day was high, Agreed it's kind of too high. According to the facility's policy, Medication Orders, revised 5/07, Any dose or order that appears inappropriate considering the resident's age, condition, or [DIAGNOSES REDACTED]. According to the facility's policy, Medication Administration - Oral, revised 5/07, If there is any question in regard to the dosage, the person in doubt should not give the drug until she has obtained information which clarifies drug dosage. The facility ' s failure to follow its existing medication administration policy and procedures has resulted in a significant medication error for Resident 1, requiring an avoidable hospital admission.

Based on observation, interview, and record review the facility failed to: 1. Provide the necessary care, based on the residents plan of care, and within recognized standards of practice, for 17 total residents which included 5 sampled residents (14, 37, 42, 45, and 51) and 11 unsampled residents (9, 10, 13, 19, 22, 29, 34, 47, 48, 56, and 64) with a [DIAGNOSES REDACTED]. 2. Clarify and implement physician's orders [REDACTED]. As a result, residents requiring routine glucometer testing were at risk of inaccurate monitoring of their blood sugar levels, uncontrolled blood sugar levels, over and under dosing of insulin, insulin shock ([DIAGNOSES REDACTED]), and diabetic coma ([MEDICAL CONDITION]). In addition, Resident 22 did not receive her pain medication as ordered, experienced continued severe pain, loss of sleep, and there was potential for Resident 22 to experience opiate withdrawal symptoms. Findings: 1. On 5/13/15, at 10:30 A.M., during an observation and interview, LN 10 conducted a Q. C. test on the Cart #3 Glucometer. LN 10 proceeded to turn the glucometer ON, place a test strip into the glucometer, and apply high control solution to the top of the test strip. After several seconds, the glucometer displayed a result of 362 mg/dl. LN 10 acknowledged the result was outside the parameters printed on the test strip container and indicated there may be something wrong with the glucometer. LN 10 stated she would repeat the test for a result within the control parameters. LN 10 could not state the facility procedure for glucometer Q.C. test failure and could not provide a copy of the glucometer operator's manual. An online copy of the operator's manual (dated; rev 05/2014) was reviewed with LN 10. LN 10 acknowledged the manufacturer's instructions for operation included; putting the glucometer into the control solution mode, placing the control solution at the tip of the test strip, and to not use the system if the control result was out of range. LN 10 stated, I have not seen the instructions; this is how everyone does it, and Night shift usually does it. LN 10 further stated, I haven't had any training, they just showed me how to do it. On 5/13/15, at 10:40 A.M., during an observation, interview, and record review, DSD 1 acknowledged that the Cart #3 Glucometer required it be in the control solution mode and the solution sample be placed at the tip of the test strip for the Q.C. test to be both valid and accurate. DSD 1 acknowledged that the glucometer had a memory which kept a record of the last 500 tests conducted, and that the Q.C. tests would have a special indicator display on the screen to separate them from the tests done on residents. A joint review of the operator's manual confirmed this. DSD 1 acknowledged the night shift LN's were responsible for the daily Q.C. testing, as per facility policy for Glucometer Calibration, dated 5/2007. DSD 1 stated, Don't bother looking in the staff files for training records, there are none. DSD 1 acknowledged that there were no records related to staff training on the glucometers, and stated, They just learn from the other nurses. A joint review of the glucometer memory indicated 40 results between the dates of 5/10/15 and 5/13/15, and correlating them to resident tests indicated that no Q.C. tests were present. They also indicated that four paired test results (Normal/High), done within a minute of each other, and on the night shift, displayed abnormally high results outside the acceptable limits on the test strip bottle. DSD 1 acknowledged that those results were likely the incorrectly done daily Q.C. tests resulting in the out of range high results. A joint review of the facility Quality Control Record (Q.C. testing record) for the Cart #3 Glucometer, correlated with the glucometer memory, indicated: On 5/10/15, the Q.C. Record high control result was documented within range as 279 mg/dl. The glucometer memory indicated the actual reading displayed as 439 mg/dl. Outside of the acceptable range. On 5/11/15, the Q.C. Record high control result was documented within range as 294 mg/dl. The glucometer memory indicated the actual number displayed as 456 mg/dl. Outside of the acceptable range. On 5/12/15, the Q.C. Record high control result was documented within range as 241 mg/dl. The glucometer memory indicated the actual number displayed as 436 mg/dl. Outside the acceptable range. On 5/13/15, the Q.C. Record high control result was documented within range as 301 mg/dl. The glucometer memory indicated the actual number displayed as 439 mg/dl. Outside the acceptable range. DSD 1 acknowledged the documented results did not match what was recorded on the glucometer memory and that any of the actual out of range high results should have led to the removal of the glucometer from service, as it may not have been functioning properly. DSD 1 acknowledged an inaccurate glucometer reading could result in the resident being given an overdose of insulin resulting in insulin shock or denied insulin resulting in diabetic coma. DSD 1 identified the LN's responsible for documenting the Q.C. test results for Glucometer #3 as; LN 11 and LN 12. On 5/13/15, at 12 P.M., the Q.C. Record for the Cart #2 Glucometer was reviewed with DSD 1 and compared with it's internal memory. According to the Q.C. Record, the LNs documented the high control result was within range from 5/1/15-5/13/15 and there was no corrective action taken. The internal memory of the glucometer was reviewed with DSD 1. DSD 1 stated there were no Q.C. tests done according to the glucometer's memory. DSD 1 stated the glucometer memory was 500 tests. A joint review of the facility Q.C. Record for the Cart #2 Glucometer, correlated with the glucometer memory, indicated: On 5/10/15, the Q.C. Record high control result was documented within range as 288 mg/dl. The glucometer memory indicated the actual reading displayed as 448 mg/dl. Outside of the acceptable range. On 5/11/15, the Q.C. Record high control result was documented within range as 296 mg/dl. The glucometer memory indicated the actual reading displayed as 406 mg/dl. Outside of the acceptable range. On 5/12/15, the Q.C. Record high control result was documented within range as 287 mg/dl. The glucometer memory indicated the actual reading displayed as 429 mg/dl. Outside of the acceptable range. On 5/13/15, the Q.C. Record high control result was documented within range as 273 mg/dl. The glucometer memory indicated the actual reading displayed as 403 mg/dl. Outside of the acceptable range. DSD 1 confirmed the entries on the Q.C. Record did not match the memory of the glucometer stating, Those numbers aren't even in the meter. DSD 1 identified the LN's responsible for documenting the Q.C. Test results for Glucometer #2 as; LN 11, LN 12 and LN 20. On 5/13/15, at 2:51 P.M., the Q.C. Log for Cart #1's Glucometer was reviewed with DSD 1 and compared with its internal memory. DSD 1 was unable to locate the glucometer's daily Q.C. tests. DSD 1 stated, I'm not finding any controls. I don't think they were clicking the control button. On 5/13/15, at 3:03 P.M., DSD 1 identified the LNs responsible for performing the Q.C. Test results for Cart #1's Glucometer as LN 11 and LN 12. On 5/13/15, at 3:15 P.M., during an interview and record review, LN 11 stated she had been a nurse for, about 3 years and at the facility for, six months. LN 11 stated, I oriented for about 4 or 5 shifts, I didn't get any diabetic training, and the nurse just showed me how to use the glucometer. LN 11 stated, I was never told you have to put the glucometer in Q.C. mode. LN 11 acknowledged she was responsible on the night shift to do the daily Q.C. testing and that she did it the same way she did the resident testing (omitting putting the glucometer into Q.C. mode as required by the manufacturer). LN 11 stated, I did the Q.C. test (Incorrectly) on May 1st, 2nd, 7th, 9th, and 11th for Cart #3; May 1st, 2nd, and 10th for Cart #2, and May 10th for cart #1. I wrote down the wrong numbers so that they would be in range. I should've told the DSD that the glucometer wasn't working, but I didn't. LN 11 acknowledged that she did not document accurate results in the facility Q.C. Record for 3 of 3 glucometers because, That's what everyone else does. LN 11 further acknowledged that incorrect glucometer results could lead to residents receiving the incorrect does of insulin, no insulin at all, could result in unstable blood sugar and adverse consequences for the residents. On 5/13/15, at 4:10 P.M., during an interview and record review, LN 12 stated, I've been a nurse for less than a year, I oriented to the facility over 3 or 4 shifts and I was shown how to use the glucometer by my preceptor. I didn't get any other glucometer training. LN 12 stated, For the Q.C. test I turn on the glucometer, insert the test strip and put the control solution on it. If it's too high, I try twice more and if still high I disregard the test. LN 12 stated his preceptor (LN 11) told him not to worry about the high (out of range) test result. LN 12 stated, 75% of the time I get high test results out of range. It's very unlikely the test result is accurate; I just document a number on the record that is within range. I was following what my preceptor said, just put in a number that is within range. LN 12 then stated, When I do the testing on my patients I know the numbers are inaccurate so I just watch them (residents) closely. LN 12 reviewed the facility Q.C. Record for May 2015 and indicated that he had documented the following Q.C. Test results for the Cart #3 Glucometer: On 5/10/15, the Q.C. Record high control result was documented within range as 279 mg/dl. The glucometer memory indicated the actual reading displayed as 439 mg/dl. Outside of the acceptable range. For Cart #2 glucometer: On 5/09/15, the Q.C. Record high control result was documented within range as 271 mg/dl. The glucometer memory indicated the actual reading displayed as 431 mg/dl. Outside of the acceptable range. On 5/11/15, the Q.C. Record high control result was documented within range as 296 mg/dl. The glucometer memory indicated the actual reading displayed as 406 mg/dl. Outside of the acceptable range. On 5/12/15, the Q.C. Record high control result was documented within range as 287 mg/dl. The glucometer memory indicated the actual reading displayed as 429 mg/dl. Outside of the acceptable range. On 5/13/15, the Q.C. Record high control result was documented within range as 273 mg/dl. The glucometer memory indicated the actual reading displayed as 403 mg/dl. Outside of the acceptable range. LN 12 confirmed he purposely documented inaccurate information in the Q.C. Record. On 5/13/15 at 5 P.M., during a joint interview and record review, LN 20 stated she had been a LN for less than 1 year, received 2 days of training at the facility, and LN 11 trained her to perform glucometer Q.C. testing. LN 20 was unaware the glucometer must be in Q.C. mode in order to perform the Q.C. testing according to the manufacture's guidelines. LN 20 stated she followed what others were doing and just put the right number down in the Q.C. Record. LN 20 confirmed all of the documented high control results on the May 2015 Q.C. Record were not the acutual results she obtained . LN 20 reviewed the facility Quality Control Record for May 2015 and indicated that she had documented the following Q.C. Test results for the Cart #3 Glucometer: On 5/12/15, the Q.C. Record high control result was documented within range as 241 mg/dl. The glucometer memory indicated the actual number displayed as 436 mg/dl. Outside the acceptable range. On 5/13/15, the Q.C. Record high control result was documented within range as 301 mg/dl. The glucometer memory indicated the actual number displayed as 439 mg/dl. Outside the acceptable range. On 5/13/15, at 5:26 P.M., during a joint interview and record review of the facility's policy on Glucometer Calibration (dated; revised 05/2007) with the NHA and DON. The DON stated he expected the LNs to document accurately. Both the NHA and DON acknowledged it was facility policy to ensure the glucometers were calibrated correctly and Q.C. test results were to be recorded accurately. A review of the American Diabetic Association website (http://www.diabetes.org/) indicates, Keeping your blood glucose levels as close to normal as possible can be a lifesaver. Tight control can prevent or slow the progress of many complications and harmful effects of diabetes such as damage to the eyes, heart, blood vessels, nervous system, teeth and gums, feet and skin, or kidneys. Studies show that keeping blood glucose, blood pressure and low-density lipoprotein cholesterol levels close to normal can help prevent or delay these problems of diabetes, giving you extra years of healthy, active life. Keeping a log of your results is vital. A review of the U.S. Food and Drug Administration website (http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/TipsandArticlesonDeviceSafety/ucm 9.htm) pertaining to glucometer operations indicates, All operators, from patients to non-lab health care workers to medical technologists and physicians, should be thoroughly familiar with any device prior to using it. The best way to do this is to read the package insert and user manual carefully before using a device for the first time. If you have any questions, ask someone who is familiar with the device. Another option is calling the customer service telephone number located on most package inserts. The people on the other end are there to help. Another good tip is to reread the package insert every few months. It is a good practice and there may be changes. 2. Resident 22 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 5/18/15 at 7:20 A.M., LN 1 was observed during Resident 22's medication pass. LN 1 asked Resident 22, what is your pain level? and Resident 22 responded, 9/10. LN 1 prepared Resident 22's scheduled 8 A.M., medications. LN 1 also prepared 30 mg of [MEDICATION NAME]. LN 1 stated, She has a prn pain medication I can give her. LN 1 stated, One pill is missing, I need to call the pharmacy. LN 1 stated, Resident 22 should have received [MEDICATION NAME] 4 mg (fast acting muscle relaxant) but the medication had not been delivered by the pharmacy. LN 1 administered Resident 22's medication with the exception of the [MEDICATION NAME]. During an interview on 5/18/15 at 8:10 A.M., the ADON stated the pharmacy requested the order for the [MEDICATION NAME] be faxed so that they could fill the medication. During a joint interview and review of Resident 22's MAR on 5/18/15 at 8:45 A.M., the ADON stated the LNs documented they administered Resident 22's [MEDICATION NAME] on 5/15/15, 5/16/15, and 5/17/15 at 8 A.M. The ADON stated, The pharmacy said they have no record of the medication being requested. The ADON stated, the facility did not have the medication and it could not have been administered. During a joint interview and review of Resident 22's MAR on 5/18/15 at 9:30 A.M., LN 1 confirmed she documented she administered Resident 22's [MEDICATION NAME] at 8 A.M. on 5/15/15. LN 1 confirmed she did not actually administer the [MEDICATION NAME]. LN 1 stated, she intentionally inaccuratley documented on the MAR. LN 1 stated, I didn't have the medication; I thought it would come from pharmacy on my shift, so I charted I gave it. LN 1 stated she did not notify the physician Resident 22 did not receive the medication and did not notify a supervisor the medication was not available to administer. During a joint interview and review of Resident 22's MAR on 5/18/15 at 9:45 A.M., LN 2 confirmed she documented she administered Resident 22's [MEDICATION NAME] at 8 A.M., on 5/16/15 and 5/17/15. LN 2 confirmed she did not actually administer the medication either day. LN 2 stated, I documented I gave it, but it wasn't available to give. LN 2 further stated, When I charted I gave it but I didn't, I falsified the MAR. LN 2 stated, she did not notify the DON or follow up on the status of the [MEDICATION NAME] when the medication was still unavailable when she returned the next day (5/17/15). LN 2 stated she did not notify the physician Resident 22 had not received her [MEDICATION NAME] as ordered. On 5/18/15, at 10:10 A.M., during a joint interview and record review the DON stated he spoke with the dispensing pharmacy and the pharmacy had no record of the [MEDICATION NAME] order and never dispensed the medication to the facility. During an interview on 5/18/15 at 11 A.M., Resident 22 stated, she had an appointment with her pain management physician on 5/14/15. Resident 22 stated she brought her pain management orders back to the facility. The Resident stated, the orders were for scheduled pain medication, So that I don't have to wait and ask for it and a different muscle relaxant (also to be scheduled) because the previous muscle relaxant was not working. Resident 22 stated she had not received a muscle relaxant since she returned from her pain management appointment and she had not received her scheduled pain medication as ordered by her pain management physician. Resident 22 stated, she asked the LN (she did not remember which LN) when she would receive her muscle relaxant and the LN told her she'd check on it, but never came back. Resident 22 stated, she experienced constant pain in her lower back and left hip at a level of 7-9 out of 10 (on a scale of 1 being the least and 10 being the worst pain). Resident 22 stated, I'm having more spasms, that's for sure. Resident 22 reported spasms in her lower back were at a level of 9 out of 10. The resident stated she had trouble sleeping because the spasms woke her at night. Resident 22 stated, It would help if I got my pain med for the spasms, I haven't gotten it for 3 days. Resident 22 stated, she had been followed by her pain management physician for years and he was familiar with her past medical history and her pain management needs. Resident 22 stated, The nurses don't believe me (regarding her pain) and they think they know better. On 5/18/15 at 11:15 A.M., Resident 22's clinical record was reviewed: According to the Physician's Progress Notes dated 5/7/15 at 3:50 P.M., Resident 22's primary physician wrote . I'm not able to reverse pain management orders and she (Resident 22) needs to go through her pain management physician . Please direct pain management questions to (Resident 22's pain management physician) . According to the pain management physician's orders [REDACTED].M., . [MEDICATION NAME] 4 mg- 1 tab Q day. [MEDICATION NAME] 30 mg- 1 tab po every four hours. [MEDICATION NAME] 15 mg- 1 tab five times per day . According to the pain management physician's orders [REDACTED]. According to Resident 22's MAR, the resident received a total of: 60 mg of [MEDICATION NAME] in 24 hours on 5/15/15, 60 mg of [MEDICATION NAME] in 24 hours on 5/16/15, and 30 mg of [MEDICATION NAME] in 24 hours on 5/17/15 According to Resident 22's MAR, between the dates of 5/1/15- 5/18/15, the LNs documented Resident 22's daily pain level was 6-9/10 on each date. According to Resident 22's MAR, the LNs documented Resident 22 slept 2 hours on 5/14/15, 3 hours on 5/15/15, 7 hours on 5/16/15, and 6 hours on 5/17/15 for evening and night shifts combined. According to Resident 22's Controlled Drug Record, between the dates of 5/1/15- 5/18/15, the LNs documented 133 tablets of [MEDICATION NAME] 15 mg tablets were removed from the narcotic count. According to Resident 22's MAR, between the dates of 5/1/15- 5/18/15, the LNs documented 91 tablets of [MEDICATION NAME] 15 mg were administered to Resident 22. 42 tablets of [MEDICATION NAME] were unaccounted for within 18 days. During a joint interview with the ADON and LN 3 on 5/18/15 at 2:15 P.M., the ADON stated, the pain management physician's orders [REDACTED]. The ADON stated there was no documentation in the clinical record Resident 22's primary physician had been notified. The ADON stated, LN 2 sent a fax to the primary physician notifying him of the new pain medication orders on 5/15/15 at 2:20 P.M. (over 24 hours after the new pain medication orders were written), but, there was no follow up. LN 3 stated, he spoke with Resident 22's primary physician at 2 P.M. on 5/18/15 to clarify the orders and implemented them (4 days after the orders were received). LN 3 and the ADON were both unaware of the orders from the pain management physician until 5/18/15. The ADON confirmed, It should not take 4 days to clarify orders with the primary physician and implement the orders. LN 3 stated Resident 22 could experience increased pain with the delay in implementing the new pain medication orders. On 5/18/15 at 2:20 P.M., Resident 22's primary physician clarified the pain medications orders, . [MEDICATION NAME] 30 mg every 4 hours routine and [MEDICATION NAME] 15 mg every 4 hours as needed for moderate to severe pain . (4 days after the orders were written by the pain management physician) During a follow up telephone interview on 5/18/15 at 2:40 P.M., LN 1 stated, she worked PM shift on 5/17/15 and did not follow up to assure Resident 22's pain medication orders had been implemented. LN 1 further stated, Resident 22 routinely requests pain medication every 4-5 hours. LN 1 stated, Resident 22 often described her pain as lower back aching and complained of cramps and spasms. LN 1 confirmed the [MEDICATION NAME] ordered by the pain management specialist was to treat Resident 22's back spasms. During an interview on 5/18/15 at 4 P.M., LN 4 stated, Resident 22 complained of back pain every 3-4 hours and requested pain medication. LN 4 stated he was responsible to complete an audit of Resident 22's clinical record which included looking for new orders to assure they had been carried out and implemented on 5/15/15 and 5/16/15. LN 4 stated, he was unaware that Resident 22 went to the pain management clinic and received new orders and was unaware the new orders had not been implemented. On 5/19/15 at 8:20 A.M., Resident 22's MAR and Controlled Drug Record were reviewed with the DON. The DON stated, the MAR and Controlled Drug Record should match and the LNs should have documented on the MAR when they administered the [MEDICATION NAME] tablets removed from the narcotic count or documented the medication was wasted, per facility policy. During an interview on 5/19/15 at 8:30 A.M., LN 5 stated Resident 22 frequently complains of pain in her legs and he noticed Resident 22 grimacing. LN 5 stated, Resident 22 reported her pain as 7-8 out of 10 and requested [MEDICATION NAME] every 4 hours. LN 5 stated he received orders from the pain management physician on 5/14/15. LN 5 stated he endorsed to the oncoming nurse that Resident 22 ' s new pain medication orders needed to be clarified and approved by the primary physician. LN 5 stated he was surprised when he returned to work on 5/18/15 the orders had not been implemented. LN 5 stated pain medication orders should have been clarified immediately so that the resident did not experience unnecessary pain. During an interview on 5/19/15 at 9 A.M., CP 1 stated she expected the LNs documentation on the MAR to be accurate since the MAR is a crucial part of her medication review. CP 1 stated if the information documented on the MAR was not accurate, she could make a medication recommendation based on false information which could adversely affect the resident. CP 1 stated, when the pain management physician ordered 255 mg of [MEDICATION NAME] in 24 hours based on Resident 22's history of opiate usage, and the resident only received 30-60 mg of [MEDICATION NAME] per day, the resident could not only experience increased pain, but could also experience withdrawal symptoms. CP 1 stated, the pain management physician's [MEDICATION NAME] order was appropriate for the resident and there is no maximum dose of opiate. CP 1 stated, she reviewed Resident 22's clinical record on 4/20/15 and made a recommendation to consider ordering scheduled pain medication in lieu of as needed dosage. During a telephone interview on 5/19/15 at 10:10 A.M., the Medical Director stated he expected resident's MARs to be accurate. The Medical Director stated, he reviews the MAR for frequency of pain medications and inaccuracy of the MAR could adversely affect resident care. The Medical Director stated the LNs should clarify consulting physician's orders [REDACTED]. During an interview on 5/19/15 at 11:45 A.M., the DON confirmed the IDT did not meet to discuss Resident 22's pain management needs. The DON stated, he instructed the LNs to verify orders received by the consulting physician with the primary physician prior to implementing the order. The DON stated the facility did not have a written policy and procedure detailing this practice. The DON stated 72 hours was an acceptable timeframe for the primary physician to verify consulting physician's orders [REDACTED]. The DON stated he did not consider the pain medication order clarification an emergency. The DON stated he was still looking for documentation related to the 42 unaccounted for [MEDICATION NAME] tablets. During an follow up interview on 5/19/15 at 1 P.M., the DON stated he misunderstood and wanted to clarify his previous statement. The DON stated four days was not an acceptable time frame to clarify Resident 22's pain medication orders with the primary physician. The DON stated, the LNs should have clarified the orders the same day. Resident 22's primary physician was unavailable for interview during the survey. Resident 22's pain management physician was unavailable for interview during the survey. The facility was unable to provide documentation on the disposition of the 42 unaccounted for [MEDICATION NAME] 15 mg tablets by the end of the survey. The facility was unable to provide progress notes from Resident 22's pain management physician's appointments by the end of the survey. According to the facility's policy and Procedure entitled, Medication Administration Documentation and Charting, revised 5/2007, . Document on the MAR as the medications are administered . According to the facility's policy and procedure entitled, Pain Management, revised 06/2013, . consult physician for additional interventions if pain is not relieved by currently ordered treatment modalities . According to the facility's policy and procedure entitled, Documentation and Charting, revised 05/2007, . documentation should also include . any time the physician is called about the resident as well as their response .