Every finding on record at Peninsula Post-Acute

Based on record review and interview, the facility failed to ensure nursing staff assessed and reported significant changes in condition for 1 of 1 resident (Resident 1) who experienced two documented episodes of tachycardia (fast heart rate). This failure had the potential to place the resident at risk for delayed recognition and treatment of an acute medical condition.Findings:Review of Resident 1's medical record titled admission Records, dated 11/21/25, indicated he had multiple active diagnoses including: metabolic encephalopathy (brain malfunction caused by imbalance in internal chemicals), pneumonia (lung infection), post kidney transplant (surgery to replace diseased kidney with donor kidney), end stage kidney disease (kidney failure and operating at around 15% capacity to filter body waste) and diabetes (body's inability to use and/or produce adequate insulin. Insulin= a hormone that regulates your blood sugar). During a concurrent interview and record review on 6/1/26 at 1:40 AM, the Social Service Director (SSD) was asked to search Resident 1's records for abnormal vital signs. The SSD found documentation Resident 1 had an abnormal heart rate of 128 beats per minute on 12/8/25 and an abnormal heart rate of 130 beats per minute 12/9/25. The SSD was asked to search for:Documented evidence nurses assess Resident 1 to rule out any clinical causes for these abnormal heart rates.Documented evidence staff informed Resident 1's physician regarding these abnormal heart rates.The SSD searched Resident 1's records and stated she was unable to find documented evidence staff had informed the physician or assessed Resident 1 after these episodes. During an interview on 06/01/2026 at 3:10 PM, the tachycardia episodes were discussed with the Director of Nursing (DON). The DON stated she was aware of Resident 1's clinical conditions and agreed Resident 1 had serious admitting diagnoses. The DON stated her expectations were: staff should have assessed Resident 1 after each tachycardiac episode; staff should have informed Resident 1's physician regarding these tachycardiac episodes and their assessed findings; staff should have documented their assessments and reporting to Resident 1's physician. The DON was asked to provide the facility's policy regarding what nurses should do when a resident have abnormal vital signs such as tachycardia. Review of the facility's policy titled Change in a Resident's Condition or Status, dated 2001, indicated .Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status . The nurse will notify the resident's attending physician or physician on call when there has been a(an):.significant change in the resident's physical/emotional/mental condition. Review of the policy found no language directing nurses to assess residents with abnormal vital signs before reporting to the resident's physician.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were met for food storage in the kitchen when the kitchen did not document the initial temperatures for 3 food items on the cool down log. These failures were likely to result in putting residents at risk for foodborne illness (diseases caused by consuming contaminated food or drink).Cooling is the specific method and guideline used to rapidly lower the temperature of cooked food to a safe storage level, preventing bacterial growth. Improper cooling is a major factor in causing foodborne illness. Taking too long to chill potentially hazardous food, which means food that requires time/temperature control for safety to limit the growth of pathogens, has been consistently identified as one factor contributing to foodborne illness. Foods that have been cooked and held at improper temperatures promote the growth of disease-causing microorganisms that may have survived the cooking process (e.g., spore-formers). Cooked potentially hazardous foods that are subject to time and temperature control for safety are best cooled rapidly within 2 hours, from 135 F (Fahrenheit, a temperature system) to 70 F, and within 4 more hours to the temperature of approximately 41 F. The total time for cooling from 135 F to 41 F should not exceed 6 hours. 2022 Food Code from U.S. Food and Drug Administration (FDA) indicated, . Improper cooling remains a major contributor to bacterial foodborne illness . Cooked hot food should be discarded immediately if the food is: Above 70 F and more than two hours into the cooling process; or Above 41 F and more than six hours into the cooling process . During a concurrent interview and record review on 3/25/26 at 10:25 AM with Director of Dietary (DoD), the facility's cool down logs titled, SPECIAL COOL DOWN LOG was reviewed. DoD stated the log was documented from 2025 to 2026 when asked why no years were documented on it. DoD verified each date and each item recorded in the log, one by one. The log indicated, as of 10 AM on 12/24/25, pudding's initial temperature was not documented, then it reached 35 F at 11:30 AM. The log further indicated, as of 10 AM on 12/31/25, cream square's initial temperature was not documented, then it reached 38 F at 11:30 AM. The log also indicated, as of 9 AM on 1/3/26, salad's initial temperature was not documented, then it reached 39 F at 11:30 AM. DoD stated that these 3 items' initial temperatures were room temperature. DoD acknowledged that there was no evidence that the initial temperatures of these 3 items were at room temperature when asked. DoD acknowledged that they should have checked the initial temperatures and recorded them in the log to track temperature changes when asked. During a concurrent interview and record review on 3/25/26 at 2:55 PM with DoD, the facility's policy and procedure (P&P) titled, COOLING AND REHEATING OF POTENTIALLY HAZARDOUS OR TIME/ TEMPERATURE CONTROL FOR SAFETY FOOD dated 2023 was reviewed. The P&P indicated, . MONITORING TEMPERATURES AND COOL DOWN LOG During the cooling process . Note menu item, date, time, temperature, and cook's initials on the cool down log used . DoD acknowledged that the initial temperatures for 3 items listed on the log were missing, and that they had failed to follow the cooling procedures specified in the P&P when asked. During a review of the facility's P&P titled, STORAGE OF FOOD AND SUPPLIES dated 2023, the P&P indicated, . Food and supplies will be stored properly and in a safe manner . During a review of the facility's P&P titled, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices dated 2001, the P&P indicated, . 1. All employees who handle, prepare or serve food are trained in the practices of safe food handling and preventing foodborne illness . During a review of the facility's P&P titled, Policies and Procedures - Infection Prevention and Control dated 2001, the P&P indicated, . The facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary . environment and to help prevent and manage transmission of diseases and infections .

Based on observation, interview, and record review the facility failed to ensure a food storage area was pest free when rodent droppings were seen in a dry good storage area. This failure may expose residents to contaminated food items and/or expose residents to food borne illnesses.Findings:During a concurrent observation and interview with the Director of Dietary (DOD) on 3/23/26 at 9:35 AM, four spring loaded snap type rodent traps were seen on the floor of the dry goods storage room. The DOD was asked if the facility had a rodent problem. The DOD stated she was unaware of any rodent problems in the kitchen and/or kitchen storage area. The DOD explained the rat traps may have been placed there by the pest management company as a preventative measure versus actual management of a rodent problem. Further inspection of a corner of the dry goods storage room revealed little round pellet like substances on the floor. There were approximately 12 of these black pellets. The DOD was interviewed about these pellets, and she agreed they looked like rodent droppings. Review of the facility policy titled Pest Control, not dated, indicated . facility shall maintain an effective pest control program.This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on observation, interview, and record review, the facility failed to ensure medications (drug or medicine, used to diagnose, cure, treat, or prevent disease) and biologicals were properly stored when one of one sampled medication storage room refrigerators contained an opened and undated multi dose vial (a small bottle of medication that contains more than one dose) for Resident 41.This failure had the potential to result in the use of unsafe and expired medication for Resident 41. During a concurrent observation and interview on [DATE] at 11:20 AM with the Assistant Director of Nursing (ADON), an opened and undated multi dose vial for Novolin N (an intermediate-acting insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication] used to treat diabetes) for Resident 41 was found in the medication storage room [ROOM NUMBER]'s medication refrigerator. The ADON stated the multi dose vial should have been dated when the medication was opened to make sure the medication is still good. During an interview on [DATE] at 3:35 PM, the Director of Nursing (DON) acknowledged she was aware of an opened and undated Novolin N multi dose vial found in the medication storage room [ROOM NUMBER]'s medication refrigerator. The DON stated when licensed nurse opens the multi dose vial, it should be labeled with date. If the opened multi dose vial came from home either it will be discarded or sent back to the family.Review of the Drug Label Information (detailed description of a medication that is available to clinicians) for Novolin N, updated on [DATE], retrieved from DailyMed (internet database operated by the U.S. National Library of Medicine providing labeling for prescription and nonprescription drugs) indicated, .Opened Novolin N vials can be stored at room temperature up to 77 (degrees) F (Fahrenheit, a temperature scale). Do not refrigerate. Throw away all opened Novolin N vials after 42 days, even if they still have insulin left in them.Review of facility's policy and procedure (P&P), titled, Medication Labeling and Storage, dated 2001, indicated, . Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial .

Based on interview and record review, the facility failed to investigate an unusual occurrence for Resident 69, 1 out of 15 sample residents. Resident 69 had a fall and had neurosurgery (surgery to the brain) ten days later. Failure to investigate an unusual occurrence for Resident 69 did not ensure the facility had ruled out neglect and/or potential failures within their system for provision of nursing care. Findings:Review of Resident 69's medical records titled Progress Notes admission Summary, printed on 3/26/26, indicated upon admission on [DATE], she had multiple diagnoses including: dementia ( progressive loss of memory, language, reasoning, and other thinking skills), glaucoma (buildup of pressure within the eye, leading to vision loss), repeated falls, abnormal gait and mobility (walking and getting around) and subdural hematoma (blood collecting between the surface of the brain and its outer covering usually caused by torn veins from a head injury).Review of Resident 69's medical records titled Change in Condition Evaluation, dated 1/21/26, indicated, around .(5:00 AM), . (Resident 69) was found sitting on the floor towards the foot of. her bed. (Resident 69) was not able to state what and why she fell. (Resident 69) denies hitting head, no new skin tear, PERRLA (a quick, noninvasive eye exam to check for head injuries, brain damage etc.), was able to grip with her upper .(arms), able to move her (legs), refused vital sign (measurable indicators of your body's essential function=temperature, heart rate, breathing rate, and blood pressure) at the moment. Denies pain.During an interview on 3/24/26 at 4:00 PM, Resident 69's family member stated she saw Resident 69 on 1/31/26 and noticed right away that Resident 69 was very different from the last time she visited. Resident 69's family member stated Resident 69 was lethargic and less responsive. Resident 69's family member stated she had to beg staff to transfer Resident 69 out to a hospital for evaluation. During an interview on 3/25/26 at 3:30 PM, this case was discussed with the Director of Nursing (DON). The DON stated she was aware of Resident 69's fall on 1/21/16, her transfer to the hospital for evaluation on 1/31/26, and her surgery at the hospital on 1/31/26. The DON was asked if she identified this case as an unusual occurrence and formally investigated this case. The DON stated she did not formally investigate this case. The DON added, looking back, she should have formally investigated this case. During an interview on 03/26/26 at 10:28 AM, the outline of this case was discussed with the facility's Medical Director. The Medical Director was made aware if a resident had a subdural hematoma prior to admission due to a fall; resident had a fall on 1/21/26, was deemed stable; resident had neurosurgery due to a worsening subdural hematoma on 1/31/26. The Medical Director was asked if the facility should have formally investigated this case to see if nursing practices needed to be improved and the Medical Director answered Yes. Review of Resident 69's hospital records titled ED to Hospital Admission, dated 1/31/26 indicated .On 1/21 daughter was notified .(Resident 69) experienced a fall at the facility. Over the last several days daughter has noticed .(Resident 69) becoming more unsteady on her feet, lethargic, not eating well.(Resident 69) presents with altered mental status (a change in how alert, aware, or mentally sharp a person is compared to their normal baseline) and less mobility (reduced movement control) over past weeks but especially acute last couple days. She now has a left holohemispheric chronic SDH (SDH= Subdural hematoma; holohemispheric chronic SDH=a large, slow-forming collection of old, liquid blood that covers the entire surface of one side of the brain) which is likely contributing to her condition.She is still full code (if a patient's heart stops beating or they stop breathing, the medical team will do everything possible to save their life) and daughter understands surgery is to prevent death but won't actually improve her overall baseline state. She still wished everything to be done. I have recommended a left .([NAME] hole drainage) of (the) subdural hematoma ([NAME] hole drainage: a hole is surgically made in the skull to remove blood that has collected under the outer layer of the brain to help alleviate symptoms and prevent further complications.)During an interview on 3/26/26 at 8:57 AM, the Administrator was asked to provide their policy on unusual occurrences and investigations of these unusual occurrences. Review of a facility policy titled Unusual Occurrence Reporting, not dated, indicated .As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors. occurrences that .affect the welfare, safety, or health of residents . The policy provided does not address if these unusual occurrences will be formally investigated to identify deficiencies and formulation of interventions to address identified deficiencies.

Based on interviews and record reviews, the facility failed to update a comprehensive, person-centered care plan for one of 15 sampled residents (Resident 18) when facility staff continued to maintain Resident 18's urinary catheter care plan after the urinary catheter had been discontinued. This failure had the potential to result in care that did not reflect Resident 18's current needs and failed to support his highest practicable well-being.Review of Resident 18's admission Record, indicated Resident 18 was admitted to the facility on [DATE] with diagnoses including obstructive and reflux uropathy (a condition when urine flows backward from the bladder up to the kidneys) and benign prostatic hyperplasia (BPH, a noncancerous enlargement of the prostate gland) with lower urinary tract symptoms.Review of Resident 18's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 3/6/26, indicated Resident 18 had a Brief Interview for Mental Status (BIMS, MDS tool that measures resident cognition) score of 13, indicating intact cognitive function. During an interview on 3/23/26 at 10:17 AM, Resident 18 stated, I no longer have a catheter (pertaining to urinary catheter, a hollow tube inserted into the bladder to drain or collect urine). Resident 18 further stated, I used to have one, but it was removed. During a concurrent interview and record review on 3/26/26 at 2:00 PM with Licensed Vocational Nurse (LVN) 3, Resident 18's electronic health record was reviewed. The record indicated an active care plan addressing a urinary catheter, which included goals and interventions related to catheter use. LVN 3 confirmed Resident 18 did not currently have a urinary catheter, and the urinary catheter care plan had not been discontinued to reflect the resident's current status. When asked if the care plan was person-centered, LVN 3 stated, No, and acknowledged its importance, explaining the facility staff rely on the care plan to understand a resident's needs, goals, and appropriate interventions.During a concurrent interview and record review on 3/26/26 at 3:32 PM with the Director of Nursing (DON), Resident 18's electronic health record was reviewed. The record indicated Resident 18 had an active care plan addressing catheter use, despite the urinary catheter having been discontinued. The DON stated, Resident 18's urinary catheter care plan remained active and should have been resolved once the catheter was removed. When asked whether it is important to update the care plan based on Resident 18's current condition, the DON stated, Yes.Review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person -Centered, dated 2001, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, mental, psychosocial and functional needs is developed and implemented for each resident . The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . Assessments of residents are ongoing, and care plans are revised as information about the residents and the resident's conditions change .

Based on observations, interviews, and record reviews, the facility failed to meet professional standards of quality when one of two sampled resident (Resident 18) received oxygen therapy outside the prescriber's order. This failure could potentially result in unnecessary treatment, and care that was not clinically indicated for Resident 18.Review of Resident 18's admission Record, indicated Resident 18 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a lung disease that makes breathing hard), acute and chronic respiratory failure with hypoxia (low oxygen in the body), and syncope (passing out) and collapse.Review of Resident 18's oxygen care plan, initiated on 3/4/26, indicated interventions to change humidification and oxygen tubing.During an observation on 3/23/26 at 10:22 AM, Resident 18 was receiving oxygen at 2 liters per minute (lpm, unit that express flow rate) via nasal cannula (a medical device that provides supplemental oxygen to a resident through the nose) connected to an unlabeled humidifier and oxygen concentrator (medical device that gives oxygen). During an observation on 3/23/26 at 10:26 AM, Resident 18 was receiving oxygen at 2 lpm via nasal cannula connected to an unlabeled humidifier and oxygen concentrator. During a concurrent observation and interview on 3/23/26 at 10:27 AM with Licensed Vocational Nurse (LVN) 1 in Resident 18's room. LVN 1 was observed tracing the oxygen tubing from the resident to the oxygen concentrator. LVN 1 stated Resident 18 has a humidifier. It was unlabeled with date and initials. LVN 1 further stated, another resident can use it, if unlabeled. During a concurrent interview and record review on 3/26/26 at 3:27 PM with the Director of Nursing (DON), Resident 18's electronic health record was reviewed. The physician's order in the record, dated 3/3/26, indicated oxygen at 2-3 lpm for shortness of breath, chest pain, oxygen saturation level (a measurement of how much oxygen the blood is carrying as a percentage) less than 90%. When asked whether the order included the use of a humidifier, the DON stated, No. When asked about the importance of following the physician's order, particularly regarding the use of humidifier during oxygen administration, the DON stated, It is very important, and explained it must be specifically indicated. Review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 2001, indicated .The comprehensive, person-centered care plan: .reflects currently recognized standards of practice for problem areas and conditions.Review of the facility's P&P titled, Oxygen Administration last updated in January 2021, indicated, .Review the physician's orders or facility protocol for oxygen administration .

Based on observation, interview, and record review, the facility failed to ensure accurate administration of medication when nursing staff did not follow the prescribed medication order for one of three sampled residents (Resident 52). This failure resulted in prescribed dose not being administered and may not manage Resident 52's pain.Review of Resident 52's Physician Order, dated 3/3/26, indicated lidocaine (used for pain relief) 4% patch was to be applied to the lower back for pain. The order specified applying two patches to clean, dry skin at 9:00 AM, to be worn for 12 hours and removed at 9:00 PM.During a concurrent medication pass observation and interview on 3/25/26 at 9:41 AM, an unlabeled patch was observed on Resident 52's back. Licensed Vocational Nurse (LVN) 2 was then observed removing the old patch and applying a new lidocaine 4% patch, labeled with date, to the same area on Resident 52's back. When asked how many patches were applied, LVN 2 stated, one. During a concurrent interview and record review on 3/25/26 at 1:59 PM with LVN 2, Resident 52's electronic health record was reviewed. The record indicated a physician's order for two lidocaine 4% patches were to be applied to clean, dry skin at 9:00 AM, to be worn for 12 hours and removed at 9:00 PM. LVN 2 stated one patch was applied. LVN 2 added she did not read the order in its entirety. When asked about the presence of an old patch prior to applying the new one, LVN 2 further stated the patch was expected to have been removed the night before and was not supposed to be there. During a concurrent interview and record review on 3/26/26 at 3:25 PM with the Director of Nursing (DON), Resident 52's electronic health record was reviewed. The record indicated a physician's order for two lidocaine 4% patches were to be applied to clean, dry skin at 9:00 AM, to be worn for 12 hours and removed at 9:00 PM. The DON acknowledged the physician's order required two lidocaine 4% patches and stated that not following the order means the prescribed dose was not administered and may not manage the resident's pain. The DON further acknowledged she was aware the previous lidocaine 4% patch was present in Resident 52's back prior to the administration of the new one. The DON further added, the expectation was to follow the order.Review of the facility's policy and procedure titled, Administering Medications dated 2001, indicated, . Medications are administered in accordance with prescriber orders .

Based on observation, interview, and facility document review, the facility failed to ensure food was stored, prepared, and served in a safe and sanitary environment when: 1. The fish served was not cooked to the appropriate temperature; 2. The fish was not thawed properly; 3. The resident's refrigerator contained unlabeled, undated and expired items; 4. Proper hand hygiene and glove use was not followed; 5. The microwave was not clean; 6. The plate warmer was not clean; and 7. The food carts were not cleaned appropriately; These failures had the potential to result in contamination of food, food preparation equipment, and utensils used for food, leading to food borne illness (any illness resulting from eating contaminated/spoiled foods) for 56 residents who received food from the kitchen. 1. During a kitchen observation on [DATE] at 12:02 PM, the Dietary Supervisor (DS) removed a pan of fish from the oven and placed a piece of fish on a plate for a resident's lunch. The tray holding the resident's plate was placed in the cart to serve to the resident. DS stated the fish temperature was not measured before it was placed on the resident's plate. DS measured the temperature of a piece of fish on pan. The initial temperature of the fish was 126.6 degrees Fahrenheit (F, a temperature scale). The surveyor also measured the temperature of two pieces of fish on the pan with a calibrated thermometer and the temperatures were 109.1 degrees F and 117.9 degrees F. DS removed the resident's tray with the fish from the serving cart and placed all pieces of fish back in the oven. When DS removed the fish from the oven she rechecked the temperature of one piece of fish, which was 137.1 degrees F. DS placed the piece of fish on the resident's plate which was placed on the food cart to serve to the resident. During an interview on [DATE] at 1:17 PM, DS stated the recommended cooking temperature for fish was 145 degrees F and confirmed the fish was cooked to 137 degrees F. Review of facility's policy and procedure (P&P) titled Meal Service, dated 2023, showed meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner, and served at the appropriate temperatures. The food will be served on trayline at the recommended temperatures to cook potentially hazardous foods (PHF, food capable of supporting bacterial growth associated with foodborne illness) to specific time and temperature standards. For fish, the standard is 145 degrees F for 15 seconds. 2. During a concurrent kitchen observation and interview on [DATE] at 9:24 AM with [NAME] 2, raw fish fillets were laid out on four large metal pans sitting on the countertop. The fish appeared frozen but slightly thawed with clear fluid surrounding the fish in the pan. [NAME] 2 stated the fish was frozen and was thawing. A concurrent observation and interview with [NAME] 2 on [DATE] at 10:30 AM, showed the pans of raw fish remained on the countertop. [NAME] 2 stated he planned to place the fish in the oven about 11:15 AM. During an interview on [DATE] at 1:17 PM, DS confirmed thawing fish on the countertop was not acceptable. DS stated, proper ways of thawing fish are using running water and the use of microwave. Review of facility's P&P titled Thawing of Meats, dated 2023, showed thawing meat properly can be done in four ways: 1. In a refrigerator at 41 F or colder 2. In a microwave if foods are to be cooked immediately following the thawing process 3. Submerge under running, potable water at a temperature of 70 F or lower, with a pressure sufficient to flush away loose particles 4. Foods can be thawed as part of the cooking process. 3. A concurrent observation and facility document review on [DATE] at 11:40 AM, showed a residents' refrigerator located in the hallway across from the therapy room. A document posted on the outside of the refrigerator read To all residents and families . Please make sure ALL items are labeled clearly with RESIDENT'S NAME (not room numbers) and CURRENT DATE. Any items not properly labeled will be thrown away or any items older than 3 days will be thrown out . The following items were noted in the residents' refrigerator: a. Four individual containers of yogurt, two with a manufacturer's expiration date of [DATE], and two with a manufacturer's expiration date of [DATE]. The yogurts were inside a Ziploc bag labeled with one discharged resident's name; b. An individual sized carton of a protein drink with no resident's name and a manufacturer's expiration date of [DATE]. c. An opened 48 fluid ounce container of almond milk with no resident's name, no open date or use by date label; d. Two individual serving size nutrition shakes with no resident's name; and e. An opened 64 fluid ounce carton of oat milk with no resident's name and a manufacturer's expiration date of [DATE]. During an interview on [DATE] at 11:40 AM, DS stated the items observed in the refrigerator including expired yogurt, expired protein drink, opened almond milk, opened and expired oat milk, and the individual nutrition shakes were all items belonging to residents. DS stated all resident items stored in the refrigerator should have a label indicating the resident name and an open date if opened. DS further stated, she was responsible for monitoring the refrigerator for expired items and expired items should be discarded. DS stated she monitored the refrigerator every Friday. DS confirmed the refrigerator should be monitored daily to ensure no expired items were stored in the refrigerator. Review of the facility's P&P titled Foods Brought in by Family/Visitors, revised [DATE], showed perishable food containers are labeled with the resident's name and the use-by date. The nursing staff will discard perishable foods on or before the use-by date. Review of facility's P&P titled Labeling and Dating of Foods, dated 2023, showed newly opened food items will need to be labeled with an open date and used by the date that follows the various storage guidelines. 4. According to the 2022 Federal Food Code, Food employees shall clean their hands immediately when changing tasks and after engaging in other activities that contaminate the hands. Review of facility's P&P titled Glove Use Policy, dated 2023, showed the appropriate use of gloves is essential on preventing food borne illness. Gloved hands are considered a food contact surface that can get contaminated or soiled. The P&P also showed the glove use procedure: 1. Wash hands and forearms 2. Using clean, dry hands, place glove on each hand. 3. Wash hands when changing to a fresh pair. Gloves must never be used in place of hand washing. During a kitchen observation on [DATE] at 9:34 AM, DS picked up a thermometer that fell from the freezer to the floor and placed it back in the freezer without cleaning the thermometer and washing her hands, before putting on gloves. During a kitchen observation on [DATE] at 9:57 AM, DS picked up a plastic bag from the floor while wearing gloves but did not remove the gloves after touching the bag from the floor, or wash her hands before opening a drawer where the food scoops were stored. During an interview on [DATE] at 2:21 PM, DS acknowledged it was not appropriate to not remove gloves and wash hands after picking up items dropped on the floor. DS added, it could cause cross contamination (physical transfer of harmful bacteria from one person, object or place to another) when you do that. 5. During a concurrent kitchen observation and interview with DS on [DATE] at 9:38 AM, the microwave had noticeable orange and black residue on the internal top surface. DS stated, the cook is responsible for cleaning (the microwave) after the preparation of food. During a concurrent kitchen observation and interview on [DATE] at 11:21 AM, DS stated the microwave was just cleaned by [NAME] 1. [NAME] 1 confirmed she just cleaned the microwave. The inside top surface was wiped with a clean paper towel and noticeable orange and black residue transferred to the paper towel. Then DS confirmed the microwave was not clean. Review of the facility provided document titled Job Description: Cook, dated ,d+[DATE], showed one of the cook's essential duties is to maintain the kitchen and cooking area in a safe, orderly, clean, and sanitary manner. During a concurrent interview and record review on [DATE] at 9:43 AM with DS, the facility provided undated document titled Food Safety & Cleaning Schedule for Aides was reviewed. DS stated the cleaning schedule did not include the microwave. Then DS provided another document titled Food & Nutrition Services Department Cleaning Schedule and Check List, dated 2023, which showed to clean the microwave weekly. According to the 2022 Federal Food Code, equipment food-contact surfaces are to be clean to sight and touch. Nonfood-contact surfaces of equipment are to be kept free of an accumulation of food residue and other debris. In addition, the cavities and door seals of microwave ovens shall be cleaned at least every 24 hours by using the manufacturer's recommended cleaning procedure. 6. During a concurrent kitchen observation and interview on [DATE] at 9:48 AM with DS, the plate warmer had orange and brown residue on the inside surface. DS confirmed the inside surface of the plate warmer was not clean and it should be cleaned after each trayline food service. During a concurrent interview and record review on [DATE] at 9:43 AM with DS, the facility provided undated document titled Food Safety & Cleaning Schedule for Aides was reviewed. DS stated the plate warmer was not on the cleaning schedule. According to the 2022 Federal Food Code, food-contact surfaces of equipment are to be clean to sight and touch. Nonfood-contact surfaces are to be kept free of an accumulation of food residue and other debris. 7. Review of the facility's P&P titled Food Carts, dated 2023, showed the food cart cleaning procedure included 1. Brush or wipe off all loose soil. Clean out corners. 2.Prepare a hot solution of detergent following manufacturer's instructions. Clean cart inside and outside with a clean cloth. Be sure to get into corners, under shelves and brackets, and into seams or joints. Then rinse with clean warm water. 3.Prepare quaternary sanitizing solution (commonly used in water dilution to create a highly effective sanitizing solution) following manufacturer's-instructions and spray or wipe down cart .For heavily soiled carts, take cart outside and clean with a pressure washer and detergent following manufacturer's instructions. During a concurrent observation and interview on [DATE] at 10:02 AM with [NAME] 3, food carts were outside near the trash dumpster area. The carts were wet. [NAME] 3 stated she cleaned the food carts outside. [NAME] 3 stated she hosed them down, sprayed and wipe them with bleach, then hosed them down again. [NAME] 3 further stated the sanitizer bleach solution used was half bleach and half water. During a concurrent interview and facility document review on [DATE] at 11:32 AM with DS, the facility provided undated document titled Food Safety & Cleaning Schedule for Aides was reviewed. DS confirmed the cleaning schedule showed to wipe and sanitize food carts every meal and daily. In addition, the facility provided document titled Food & Nutrition Services Department Cleaning Schedule and Check List, dated 2023 was reviewed. DS confirmed on this cleaning schedule, it showed weekly cleaning of food carts. DS stated the weekly cleaning was deep cleaning. During an interview and document review on [DATE] at 10:22 AM, DS stated the concentration of the bleach solution used to sanitize the food carts should have been one tablespoon of bleach to one gallon of water. DS confirmed the concentration of the bleach solution used by [NAME] 3 was much stronger than needed. DS also stated bleach was used for a sanitizer when Quat (quaternary sanitizing solution) was not available. DS confirmed Quat was currently used in the kitchen and was available. DS confirmed according to the P&P Quat should be used to clean the carts. DS provided the container of bleach used. Review of the manufacturer's instruction on the container of bleach provided by DS showed in sanitizing work surfaces, dishes, glasses, utensils, refrigerators, and freezers, to mix one tablespoon of bleach to one gallon of water . During a concurrent interview and facility document review on [DATE] at 1:52 PM with DS, the facility provided document titled Food Carts dated 2023 was reviewed. DS stated, when the weekly deep cleaning was done with a power washer, the daily cleaning should also be completed with detergent and sanitizer.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent (5%) when 10 medication errors occurred out of 40 opportunities during the medication administration for four residents (Resident 53, Resident 43, Resident 219, and Resident 24, resulting in an error rate of 25%. 1. Licensed Vocational Nurse (LVN) 3 did not observe Resident 53 take her medications after leaving seven (7) of the prescribed medications on the bedside table. 2. Registered Nurse (RN) 1 administered Resident 43's Repaglinide (used to treat type 2 diabetes mellitus [high blood sugar]) during meals. 3. Insulin was not administered according to professional standard of practice for Resident 219 and Resident 24. In addition, insulin was administered without a prescribed blood sugar check for Resident 24. These failures resulted in medications not given according to the prescriber's orders and/or manufacturer's specifications and had the potential for residents not receiving the full therapeutic effects of the medications. Findings: 1. During medication pass observation on 10/15/24 at 9:50 AM, LVN 3 prepared ten (10) medications for Resident 53: a. 1 packet - MiraLAX powder (used to treat occasional constipation) 17 grams (g). b. 2 tablets (tabs) - Oxycodone (a controlled substance used to treat moderate to severe pain) Tablet 5 milligrams (mg). c. 1 tab - Simethicone (used to relieve painful pressure caused by excess gas in the stomach and intestines) 80 mg chewable tablet. d. 4 tabs - Metoprolol Succinate (used to treat chest pain, heart failure and high blood pressure) tablet 25 mg Extended Release (ER). e. 1 tab - Losartan Potassium (used to treat high blood pressure) tab 50 mg. f. Fluticasone Furoate Nasal Spray (used to prevent difficulty breathing, chest tightness, wheezing, and coughing caused by asthma in adults and children) 27.5 micrograms (mcg) per spray. g. 1/2 tab - Spironolactone (used to treat high blood pressure and fluid retention) 25 mg 1 tab, take 1/2 (12.5 mg) by mouth once daily. h. 1 tab - Trospium chloride (used to treat an overactive bladder) tab 20 mg. i. Docusate sodium (a stool softener medication used to treat occasional constipation) tab 100 mg which was refused by Resident 53. j. 3 patches - Aspercreme with 4% Lidocaine (used for pain relief) pain relief patch. On the same medication pass observation, LVN 3 administered 2 tabs of Oxycodone, MiraLAX powder that was mixed with Gatorade in a small cup full of ice cubes and applied 1 patch of Aspercreme on Resident 53's back. Resident 53 consumed three quarters of the mixture and left the remaining portion on the bedside table. Resident 53 told LVN 3 to leave the rest of the medications on the bedside table and that she will take them later since she was in a rush to use the bed pan and get her peri-care (also known as perineal care - means cleaning the private area of patients) done. During further observation, LVN 3 left the Fluticasone Furoate nasal spray and medicine cup that had the rest of the medications she prepared for Resident 53 on the bedside table and took the 2 Aspercreme patch and stored it in the medication (med) cart to be applied at a later time. During an interview on 10/15/24 at 10:05 AM, LVN 3 stated she was not supposed to leave the medications at the bedside and that she should observe the resident taking it. LVN 3 stated she take the medications with her and store it in the med cart while the resident is not yet ready. LVN 3 further stated, she would come back to check if Resident 53 took the medications she left on the bedside table. Furthermore, LVN 3 stated a total of seven medications were left at the bedside. Review of the manufacturer's instructions for MiraLAX indicated, the medication should be administered with 4 to 6 ounces (oz) of fluid and taken immediately after mixing. Waiting too long before consuming the mixture can cause it to thicken, potentially leading to choking. Review of Resident 53's electronic health record (EHR) indicated, there was no order obtained and assessment completed for Resident 53 to self-administer her medications. During concurrent interview on 10/15/24 at 12:47 PM, LVN 3 stated Resident 53 has no order for self-administration of medication. During an interview on 10/15/24 at 4:31 PM, Assistant Director of Nursing (ADON) stated, the nurse should observe the resident take the medications before leaving the room and that nurses are not supposed to leave any medications at the bedside. Review of facility's policy and procedure titled, Administering Oral Medications, revised October 2010, indicated, .Steps in the Procedure .9. Prepare the correct dose of medication: .c. For powdered medications. Mix with liquids at the bedside . 21. Remain with the resident until all medications have been taken . Review of facility's policy and procedure titled, Administering Medications, copyright 2001, indicated, .20. For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR (Medication Administration Record) may be 'flagged'. After completing the medication pass, the nurse will return to the missed resident to administer the medication . 27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary planning team, has determined that they have the decision-making capacity to do so safely . 2. During medication pass observation on 10/15/24 at 12:08 PM, Registered Nurse (RN) 1 prepared two medications for Resident 43 including Repaglinide (used to treat type 2 diabetes mellitus [high blood sugar]) tablet 0.5 mg. RN 1 administered the Repaglinide while Resident 43 was eating his lunch. During concurrent interview, RN 1 stated Repaglinide can be taken before or after meals. Review of Resident 43's active orders in the EHR indicated, Repaglinide Tablet 0.5 MG. Give 1 tablet by mouth two times a day for DM 2 Give 30 minutes before breakfast and lunch. According to the Food and Drug Administration (FDA, is a federal agency responsible for protecting the public health by ensuring the safety, efficacy, and security of human and veterinary drugs, vaccines and other biological products for human use, and medical devices) prescribing information for Repaglinide, .2. Repaglinide Tablets Dosage and Administration . The recommended starting dose for patients whose HbA1c is less than 8% is 0.5 mg orally before each meal. For patients whose HbA1c is 8% or greater the starting dose is 1 mg or 2 mg orally before each meal. The recommended dose range is 0.5 mg to 4 mg before meals, with a maximum daily dose of 16 mg. The patient's dose should be doubled up to 4 mg with each meal until satisfactory glycemic control is achieved. At least one week should elapse to assess response after each dose adjustment. Instruct patients to take repaglinide tablets within 30 minutes before meals. Repaglinide tablets may be dosed 2, 3, or 4 times a day in response to changes in the patient's meal pattern . Review of facility's policy and procedure titled, Administering Medications, copyright 2001, indicated, .4. Medications are administered in accordance with prescriber orders, including the required time frame. 5. Medication administration times are determined by the resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication; b. preventing potential medication or food interactions . 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . 3a. During medication pass observation on 10/15/24 at 12:13 PM, LVN 3 prepared to administer 4 units of Humulin R (also known as regular insulin, is a short-acting insulin used to treat diabetes) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) based on Resident 219's glucose (blood sugar) level of 206. During preparation, LVN 3 wiped the top of the vial, pushed the needle on top of the vial and immediately draw 4 units of Humulin R insulin from the vial. During insulin administration, LVN 3 held the back of Resident 219's right upper arm and injected the insulin in a 90 degree (0) and immediately removed the syringe from the injection site. During a follow up interview on 10/15/24 at 12:22 PM, LVN 3 stated, you don't need to pinch the site when injecting. 3b. During medication pass observation on 10/15/24 at 12:25 PM, LVN 3 went to Resident 24's room and saw the speech therapist sitting with a lunch tray in front of the resident. During concurrent interview, LVN 3 stated the speech therapist started to feed Resident 24 and that she will proceed with the blood sugar check since resident just started eating which will not affect the result. During further observation on 10/15/24 at 12:29 PM, LVN 3 obtained Resident 24's blood sugar level which was 202 and prepared to administer 4 units of Insulin Lispro (a fast-acting insulin used to control high blood sugar in adults and children with diabetes) per sliding scale (refers to the progressive increase in the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges). During preparation, LVN 3 wiped the top of the vial, pushed the needle on top of the vial and immediately draw 4 units of Insulin Lispro from the vial. During insulin administration, LVN 3 directly injected the insulin on the right upper quadrant of the abdomen in a 900 angle and immediately removed the syringe from the injection site. During a follow up interview on 10/15/24 at 12:36 PM, LVN 3 stated she knows that Resident 24 had already eaten but did not think it will have an effect on the blood sugar result and insulin administration. Review of Resident 24's active orders in the EHR, indicated, the following (ff) orders: Order date 10/6/24: Check blood glucose at bedtime. Order date 10/6/24: Insulin Lispro Injection 100 unit/ml (Insulin Lispro) Inject as per sliding scale: if 70-150 = 0 Do Not Hold if NPO. Give the ff insulin in addition to nutritional insulin; 151-200 = 2; 201-249 = 4; 250-300 = 6; 301-350 = 8; 351-400 = 10; BG (blood glucose) >400, give 12 units, subcutaneously with meals for DM2. During concurrent interview on 10/15/24 at 12:41 PM. LVN 3 stated, there is no order in the EHR for Resident 24's blood glucose to be checked before meals. I only see the bedtime order. LVN 3 added, there should be a separate order for the blood glucose check every meal. During an interview on 10/16/24 at 10:18 AM, ADON stated there should be an order in place for blood sugar checks and it should be done before meals, not during meals. During further interview, ADON was asked about their policy and procedure on insulin administration. ADON stated, the amount of air to be injected in the vial should be the same as to the dose of insulin to be drawn from the vial. Injecting of air and drawing insulin from the vial should be done within eye level. In addition, ADON stated to gently pinch the injection site, inject the insulin in a 45 or 90 degree angle depending on the injection site, leave the syringe for at least 5 to 10 seconds, then release and remove the syringe. ADON further stated that a 450 angle technique is followed when injecting on the upper and/or back of the arm while the 900 angle is followed when injecting on the abdomen. Review of facility's policy and procedure titled, Insulin Administration, updated 8/15/24, indicated, .Steps in the Procedure (Insulin Injections via Syringe) . 2. Check blood glucose per physician order or facility protocol . 6. Gently roll the insulin vial between the palms of both hands to resuspend the insulin . 10. Create a vacuum in the vial by injecting air into the vial in the amount equal to the dose of insulin . 18. Light grasp a fold of skin and insert the needle into the skin at a 900 angle. For very thin residents, insert at a 450 angle to avoid intramuscular injection. 19. Depress the plunge rand remove the needle after approximately five (5) seconds . According to the American Diabetes Association article titled, Insulin Administration, dated 1/1/23, indicated, .INJECTION TECHNIQUE . Dose preparation .For all insulin preparations, except rapid- and short-acting insulin and insulin glargine, the vial or pen should be gently rolled in the palms of the hands (or shaken gently) to resuspend the insulin. An amount of air equal to the dose of insulin required should first be drawn up and injected into the vial to avoid creating a vacuum . After the insulin is drawn into the syringe, the fluid should be inspected for air bubbles. One or two quick flicks of the forefinger against the upright syringe should allow the bubbles to escape. Air bubbles themselves are not dangerous but can cause the injected dose to be decreased. Injection procedures - Injections are made into the subcutaneous tissue. Most individuals are able to lightly grasp a fold of skin, release the pinch, then inject at a 90 angle. Thin individuals or children can use short needles or may need to pinch the skin and inject at a 45 angle to avoid intramuscular injection, especially in the thigh area. Routine aspiration (drawing back on the injected syringe to check for blood) is not necessary. Particularly with the use of insulin pens, the needle should be embedded within the skin for 5 s after complete depression of the plunger to ensure complete delivery of the insulin dose . Injection site - Insulin may be injected into the subcutaneous tissue of the upper arm and the anterior and lateral aspects of the thigh, buttocks, and abdomen (with the exception of a circle with a 2-inch radius around the navel) . Site selection should take into consideration the variable absorption between sites. The abdomen has the fastest rate of absorption, followed by the arms, thighs, and buttocks .

Based on interview and record review, the facility failed to furnish a completed written agreement for dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) services or transportation to dialysis that was being provided by an agency outside the facility. This failure has the potential for residents that require dialysis to not have services held to a standard agreed upon by the facility. Findings: During a concurrent interview and record review on 10/15/24 at 9:50 AM with the Administrator, a document titled INTERNAL AGREEMENT REQUEST PREP FORM NURSING HOME DIALYSIS TRANSFER AGREEMENT, dated 05/18/21. The documented indicated that This Agreement type is for nursing home residents who are transferred from a nursing home to a chronic dialysis facility for treatment .Once approved, agreement sent for signatures; you will receive a copy once all parties sign. The Administrator stated this is a request for an agreement but not an actual contract. During a concurrent interview and record review on 10/15/24 at 3:05 PM with the Administrator, a document titled Transportation Contract, dated 01/01/24, was reviewed. The document indicated that the facility was going to receive transportation services from an outside agency starting on 01/01/24 and terminating the contract on 12/31/24. The document further indicated that the contract was signed by Owner/CEO of the transportation agency on 01/01/24 but the signature for the Facility representative was blank. The Administrator stated that this is their current transportation contract but acknowledged that it is not a signed contract. During an interview on 10/16/24 at 9:37 AM with the Administrator, the facility's Dialysis contract was requested. The Administrator stated that it was still pending and not available for review at that time. During an interview on 10/17/24 at 10:33 AM with the Administrator, the facility's Dialysis contract was requested again. The Administrator stated that we don't have that on file, but stated that the facility is providing that [dialysis] service, to those that need it.

Based on observation, interview, and facility document review, the facility failed to provide palatable food for a lunch meal including: 1. Meatballs; and 2. Pureed green beans. The failure to provide palatable food had the potential to reduce residents' food and nutrient intake leading to weight loss and/or nutritional medical complications for 34 residents who received meatballs or pureed green beans according to diet orders on the lunch meal tickets out of 56 residents who received food from the kitchen. Findings: 1. Review of the facility policy and procedure (P&P) titled Meal Service dated 2023, showed the Food and Nutrition Services staff member will take the food temperature prior to service of the meal with a thermometer. It may be necessary to take the temperature in more than one location on the food item to confirm the proper temperature has been reached. The food temperatures will be recorded. The minimum hot holding temperature on steam table is 140 degrees F. Temperatures of the food when the resident receives it is based on palatability. The goal is to serve hot food hot. The document also showed the recommended temperature for hot entrees at delivery to the resident should be at or over 120 degrees F. Review of the facility's job description titled [NAME] prepared by Human Resources on 10/2016, showed the [NAME] essential duties included but were not limited to preparing tasteful meals, and recording food temperatures for meals. Review of the facility provided document titled Fall Menus spreadsheet dated 10/14/24 and used as the menu for lunch on 10/14/24, showed all regular textured diets received a meatball sandwich. Review of the lunch meal tickets dated 10/14/24, showed 34 residents received a regular textured diet. However, the tray tickets showed 2 of the 34 residents did not like beef, so according to the menu and tray tickets, 32 residents received meatballs for lunch. During a concurrent observation in the kitchen and interview on 10/14/24 at 11:45 AM with [NAME] 1 and the Dietary Supervisor (DS) , trayline was started for the lunch meal. [NAME] 1 started to plate the first tray. When DS was asked what the holding temperatures of the food were on trayline, DS stated the food temperatures were not measured before trayline was started. DS informed [NAME] 1 to measure the food temperatures on the trayline and handed her a thermometer. [NAME] 1 inserted the thermometer with cover over probe in a meatball. [NAME] 1 stated the thermometer was not working. When [NAME] 1 was informed, the thermometer probe cover was on, she removed it and started to measure the food temperature. [NAME] 1 measured the temperatures of two meatballs and stated the temperatures were 125 degrees Fahrenheit (F, temperature scale) and 126.4 degrees F. The surveyor also measured the temperature of meatballs with a calibrated thermometer the temperature of one meatball towards the bottom of the pan was 133 degrees F. The temperatures of three meatballs toward the top of the pan were 113.6 degrees F, 118.6 degrees F, and 102.2 degrees F. During a concurrent observation and interview with the Registered Dietitian (RD) on 10/14/24 at 1:22 PM, a regular texture meal was sampled immediately following the delivery of the last resident tray. The temperature of the food was measured. A meatball temperature measured with a calibrated thermometer was 105.1 degrees F. The RD stated the meatball was cool in the mouth, not cold but lower than ideal, The RD further stated all food temperature should be checked before trayline begins. 2. Review of the facility provided document titled Fall Menus Spreadsheet dated 10/14/24 and used as the menu for lunch on 10/14/24, showed regular textured diets received Southern [NAME] Beans and pureed diets received pureed Southern [NAME] Beans. Review of the lunch meal tickets dated 10/14/24, showed 2 residents received a pureed diet. Review of the facility's undated Recipe: Pureed Vegetables, showed to prepare the vegetables per the regular recipe, puree the vegetables (using a food processor or blender) to a paste consistency before adding any liquid. Gradually add a warm liquid such as low sodium broth if needed. Taste and adjust seasoning as needed. Review of the facility's job description titled [NAME] prepared by Human Resources on 10/2016, showed the [NAME] essential duties included but were not limited to preparing tasteful meals, and preparing pureed foods. During a concurrent observation and interview with the RD and DS on 10/14/24 at 1:22 PM, a regular and a pureed texture meal was sampled immediately following the delivery of the last resident tray. The regular green beans tasted like green beans and were not overly seasoned. The pureed green beans were extremely salty and did not taste like green beans. The RD stated the pureed green beans were a little salty. The RD tasted the regular green beans and said the regular and the pureed tasted different. When DS tasted the pureed green beans, she stated they tasted salty.

Based on observation, interview, and record review, the facility failed to ensure meals were plated in accordance with the approved menu when the incorrect scoop size was used for serving green beans to residents for a lunch meal. This failure to follow the planned menu had the potential to result in residents' diets not being given in accordance with the prescriber's order and diet specifications, resulting in residents not receiving the amount of nutrients to meet their nutritional needs to 49 residents who received regular textured green beans according to the menu and the lunch tray tickets. Findings: Review of the facility provided document titled Fall Menus spreadsheet dated 10/14/24, showed the serving size for regular textured Southern [NAME] beans was 1/2 cup. According to the facility's lunch tray tickets dated 10/14/24, showed 49 residents had a diet allowing regular textured green beans and did not have a dislike for beans/green beans. Review of the undated facility document titled Scoop Measurements, showed the gray color scoop (number 8) measures 1/2 cup, and the green color scoop (number 12) measures 1/3 cup. During a kitchen observation on 10/14/24 at 12:00 PM, [NAME] 1 used a green scoop to serve green beans during trayline. During an interview on 10/15/24 at 1:43 PM, DS acknowledged [NAME] 1 used an incorrect scoop size according to the menu to serve green beans and she used a green scoop (number 12), intended for 1/3 cup portions, instead of the gray scoop for 1/2 cup portions.

Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were labeled and stored according to manufacturer's instruction and facility policy and procedure; expired biologicals were removed from the active storage area; and medication cart was locked when left unattended. These deficient practices had the potential to compromise the integrity and effectiveness of the drugs and biologicals; and may jeopardize the health and safety of residents. Findings: 1A. During an observation on [DATE] at 10:25 AM, in resident's room, a medicine bottle was observed in plain sight in Resident 52's bedside drawer. The medication bottle indicated, FETILIDE 500 MCG (Generic for Dofetilide) ., a medication used to treat an irregular heartbeat (arrhythmia). During concurrent interview, Resident 52 stated she had asked the doctor to have her keep this medication at the bedside so she can take it on time to prevent her heart rate to increase. During concurrent interview and record review on [DATE] at 3:31 PM, Licensed Vocational Nurse (LVN) 3 reviewed Resident 52's active orders and did not find an order or documentation indicating resident can keep her medication (Dofetilide) at the bedside. LVN 3 stated, there was no order or assessment in the chart. I don't see it here. LVN 3 added, there should be an order to store or keep medications at the bedside. Review of facility's policy and procedure titled, Administering Medications, copyright 2001, indicated, .27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary planning team, has determined that they have the decision-making capacity to do so safely . 1B. During medication pass observation on [DATE] at 10:13 AM, LVN 3 prepared Adult Tussin DM (used to treat cough and congestion caused by the common cold or minor throat or bronchial irritation) 10 milliliters (ml) for Resident 50. The Adult Tussin DM bottle was opened and undated. During concurrent interview, LVN 3 stated, they're supposed to write an open date, either put a yellow sticker label or write the open date directly on the bottle. 1C. During medication pass observation on [DATE] at 12:08 AM, Registered Nurse (RN) 1 prepared two medications for Resident 43 including Sevelamer Carbonate (a phosphate binder medication used to control high blood level of phosphorous, a mineral found in food, in people with kidney disease who are on dialysis) 800 mg 1 tablet. The medication label indicated, take 2 tablets by mouth three times daily with meal. The medication label did not indicate a note or change of direction. During concurrent interview, RN 1 reviewed the order and stated, to administer 1 tablet only. Review of Resident 43's Order Summary Report dated [DATE], indicated, Sevelamer Carbonate Tablet 800 MG Give 2 tablet by mouth with meals for hypocalcemia was discontinued on [DATE]. The Order Summary Report also indicated a new order was entered on [DATE] for Sevelamer Carbonate Tablet 800 MG Give 2 tablet by mouth with meals for hypocalcemia. 1D. During an inspection of the Medication Cart (Med Cart) 1 and concurrent interview with LVN 1, on [DATE] at 10:47 AM, in station 1, one bottle of multi-dose insulin vial (Humulin R) was opened and undated. LVN 1 stated, it needs to be discarded 28 days after opening, therefore there should be an open date. 1E. During further inspection and concurrent interview with LVN 1, on [DATE] at 10:55 AM, in station 1, acknowledged the following were stored in the locked compartment of Med Cart 1: a. Multiple controlled drugs (a drug or chemical whose manufacture, possession, or use is regulated by a government) of discharged residents and those that were discontinued remained and were stored in the locked compartment. b. Resident's money in a plastic (Ziploc) bag was stored in the locked box together with the controlled drugs. During a concurrent interview, LVN 1 stated that resident's valuables including money, should not be in the medication cart because of infection control concerns and that it should be kept in a safe by the social services. During an interview on [DATE] at 11:23 AM, ADON stated, resident's money is given to social services, DON, or whoever has a locked box for safe keeping. ADON added, it should not be stored in the medication cart and that the locked compartment are only for narcotic drugs (controlled drugs). Review of facility's policy and procedure titled, Controlled Substances, revised [DATE], indicated, .13. Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are securely locked in an area with restricted access until destroyed. 16. The director of nursing services maintains and disseminates to appropriate individuals a list of staff who have access to medication storage areas and controlled substance containers . 2. During inspection of the medication cart and concurrent interview with LVN 1, on [DATE] at 10:50 AM, in station 1, one bottle of Assure Dose Control Solution (a testing solution to ensure your blood glucose monitor produces accurate results) was stored beyond the manufacturer's expiration date, Exp. [DATE]. LVN 1 acknowledged and stated, the control solution was past the expiration date. According to the manufacturer's information sheet for Assure Dose Control Solution, .Storage and Handling: . Use before the expiration date printed on the bottle. Use the control solution within 90 days (3 months) of first opening. It is recommended that you write the date of opening on the control solution bottle label (Date Open) as a reminder to dispose of the opened solution after 90 days . 3. During an observation on [DATE] at 10:03 AM, in resident's room, LVN 2 left the medication cart unlocked in the hallway during medication pass. During an interview on [DATE] at 10:09 AM, Assistant Director of Nursing (ADON) stated, the medication cart should not be left unlocked and unattended. Review of facility's policy and procedure titled, Medication Labeling and Storage, revised February 2023, indicated, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls . Medication Storage . 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 3. If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others . Medication Labeling - 1. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices . 5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial . 12. The nursing staff must inform the pharmacy of any changes in physician orders for a medication.

Based on interview and record review, the facility failed to develop an accurate comprehensive care for two of 18 sampled residents (Resident 20 and Resident 31) when: 1. Resident 20's care plan for Duloxetine (an anti-depressant medication that can also be used to treat nerve pain) had the incorrect indication (reason to give a medication) 2. Resident 31's care plan for indefinite use of Cephalexin (an antibiotic) was not developed. These failures have the potential for residents' care plans to not be person-centered and specific enough for residents to meet their medical and physical needs. Findings: 2. A review of Resident 20's face sheet (front page of the chart that contains a summary of basic information about the resident), dated 10/18/24, indicated that Resident 20 was admitted 2024 with multiple diagnoses including SPINAL STENOSIS (when the space inside the backbone is too small causing pressure and pain) and LOW BACK PAIN. A review of Resident 20's Order Summary Report (a list of a medical provider's orders for care), dated 10/18/24, indicated that Resident 20 was being given DULoxetine .by mouth one time a day for Chronic low back pain During a concurrent interview and record review on 10/17/24 at 2:31 PM Interim Director of Nursing (IDON), Resident 20's care plan for Duloxetine, initiated on 09/11/24, was reviewed. The care plan for Duloxetine indicated that Resident requires antidepressant medication related to diagnosis of depression as evidence by verbalization of feeling sad/depressed. The IDON stated that this is not an accurate care plan as it has the wrong indication. During a concurrent interview and record review on 10/17/24 at 2:31 PM Interim Director of Nursing (IDON), Resident 20's list of active diagnoses, dated 10/17/24, was reviewed. The list of active diagnoses indicated all the conditions that Resident 20 was being treated or cared for. The IDON stated that she did not see Depression as an active diagnosis. During a concurrent interview and record review on 10/18/24 at 12:07 PM Interim Director of Nursing (IDON), Resident 20's discharge summary, date 09/09/24, was reviewed. The discharge summary indicated a summary of the Resident's hospital course including Resident 20's past medical history. The IDON stated that she did not see Depression as a diagnosis at the hospital or on Resident 20's documented past medical history. 41545 2. Review of Resident 31's admission record indicated, was admitted to the facility on [DATE] with diagnoses including fracture of sacrum (a break in the sacrum, the large triangular bone at the base of the spine between the hipbones), osteoporosis (a progressive disorder of the joints, caused by a gradual loss of cartilage), dementia (a progressive state of decline in mental abilities), cancer of right breast, gastro-esophageal reflux disease (GERD - a chronic disease that occurs when stomach acid or bile flows into the food pipe and irritates the lining), and personal history of urinary tract infections (UTI - an infection in any part of the urinary system). Review of Resident 31's Medical Practitioner Narrative Note dated 9/10/24 indicated, .Cephalexin (an antibiotic used to treat infections caused by bacteria, including urinary tract infections) Oral Capsule 250 MG (milligrams) , Give 1 capsule by mouth in the evening every Mon, Wed, Fri for recurrent UTIs Take 1 cap (capsule) PO (per orem - orally or via the mouth) three times weekly . 9. UTI: This can cause discomfort, urinary frequency/urgency, and overall malaise (a general feeling of discomfort, uneasiness, or lack of well-being), potentially impacting patient participation in therapy . Be mindful of potential side effects of antibiotics, which may include fatigue, dizziness, or gastrointestinal issues . Review of Resident 31's Active Orders in the electronic health record (EHR) indicated, 9/7/24: Cephalexin Oral Capsule 250 MG (Cephalexin). Give 1 capsule by mouth in the evening every Mon, Wed, Fri for recurrent UTIs Take 1 cap PO three times weekly. Review of Resident 31's care plan indicated, has dx (diagnosis): Urinary Tract Infection Date Initiated: 09/07/2024 Revision on: 10/15/2024 . Give antibiotic therapy as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 09/07/2024 . During an interview on 10/18/24 at 1:47 PM, Licensed Vocational Nurse (LVN) 2 stated, Resident 31 was admitted with an order of cephalexin 200 mg three times a week for recurrent UTI with no stop date. During concurrent review, LVN 2 did not find a care plan for the use of cephalexin. Additionally, there was no monitoring for the side effects of the medications and signs and symptoms of UTI for Resident 31. During further interview, LVN 2 stated the care plan for the use of cephalexin was only added today and that it should have been completed when it was initiated. During an interview on 10/18/24 at 3:07 PM, Interim Director of Nursing (IDON) stated, indefinite use of antibiotic should be care planned as soon as the antibiotic is started. Review of Resident 31's Medication Regimen Review dated 9/9/24 indicated, CURRENT ORDER: Cephalexin Oral Capsule 250 MG - Give 1 capsule by mouth in the evening every Mon, Wed, Fri for recurrent UTIs Take 1 cap PO three times weekly. The above order does not include a stop date. RECOMMENDATION: Please update the above order with a stop date. If the order is to be continued indefinitely, please document to that effect below. Under section Physician/Prescriber Response indicated, Disagree - Family requested for PPX (prophylaxis - action taken to prevent disease). Review of facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised March 2022, indicated, .2. The Comprehensive person-centered care plan should be developed within the seven (7) days of the completion of the required MDS assessment .and should be completed within 21 days of admission .

Based on interview and record review, the facility failed to accurately encode one of 18 sampled residents' (Resident 20) Minimum Data Set (MDS - a federally mandated resident assessment tool) when Resident 20 was encoded has being diagnosed with Depression, but the Resident had no current or past medical history of that diagnosis. This failure has the potential to result in MDS assessments that inaccurately captures quality metrics and a resident's condition over time. Findings: A review of Resident 20's face sheet (front page of the chart that contains a summary of basic information about the resident), dated 10/18/24, indicated that Resident 20 was admitted 2024 with multiple diagnoses including SPINAL STENOSIS (when the space inside the backbone is too small causing pressure and pain) and LOW BACK PAIN. During a concurrent interview and record review on 10/17/24 at 2:31 PM with the MDS Director (MDSD), Resident 20's list of active diagnoses, dated 10/17/24, was reviewed. The list of active diagnoses indicated all the conditions that Resident 20 was being treated or cared for. The MDSD stated that she did not see Depression as an active diagnosis. During a concurrent interview and record review on 10/18/24 at 12:07 PM with the MDSD, Resident 20's discharge summary, date 09/09/24, was reviewed. The discharge summary indicated a summary of the Resident's hospital course including Resident 20's past medical history. The MDSD stated that she did not see Depression as a diagnosis at the hospital or on Resident 20's documented past medical history. During a concurrent interview and record review on 10/18/24 at 12:07 PM with the MDSD, Resident 20's MDS assessment, dated 09/11/24, was reviewed. The MDS assessment indicated that Resident 20 had an active diagnosis of depression. The MDSD stated that this was an inaccurate assessment as Resident 20 had no history of Depression. A review of a facility policy titled Certifying Accuracy of the Resident Assessment, last revised November 2019, indicated that Any person who completes any portion of the MDS assessment .is required to sign the assessment certifying the accuracy .The information captured on the assessment reflects the status of the resident during the observation.

Based on interview and record review, the facility failed to ensure a Physician Orders for Life-Sustaining Treatment (POLST, a written medical order that specifies the types of medical treatment a patient wants to receive in the event of a serious illness) was obtained on admission for one of 18 sampled residents (Resident 219). This failure had the potential to result in resident's wishes in an emergency situation and end-of-life choices not being honored. Findings: Review of Resident 219's admission record indicated, was admitted to the facility on [DATE] with diagnoses including fracture of head and neck of left femur (a break in the bone that connects the femoral head to the femoral shaft in the hip), abnormalities of gait and mobility (changes to a person's normal walking pattern), type 2 diabetes mellitus (high blood sugar), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and hypertension (high blood pressure). Review of Resident 219's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated [DATE] indicated, resident has no cognitive impairment. Review of Resident 219's History and Physical (H&P) dated [DATE] indicated, .LCP (Life Care Planning) Status Checked [No Goals of Care Discussion: Review of Life Care Planning Documentation: No existing LCP Documentation: Code status established with Patient . Review of Resident 219's Order Summary Report dated [DATE] indicated, DNR (Do Not Resuscitate- a medical order written by a doctor to instruct health care providers NOT to do cardiopulmonary resuscitation (CPR) if breathing stops or the heart stops beating) was ordered on [DATE]. During concurrent interview and record review on [DATE] at 2:02 PM, Licensed Vocational Nurse(LVN) 2 did not find an advance directive and/or POLST form in Resident 219's clinical record. LVN stated, I don't see it here. According to the California Emergency Medical Services Authority, .POLST does not replace the Advance Directive. When available, review the Advance Directive and POLST form to ensure consistency, and update forms appropriately to resolve any conflicts. o POLST must be completed by a health care provider based on patient preferences and medical indications .

Based on observation, interview, and record review, the facility failed to provide care and treatment according to facility policies and procedures and professional standards of practice for two of 18 sampled residents (Resident 291 and Resident 24) when: 1. Insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) injection was not prepared and administered according to current professional standard of practice and facility's insulin administration policy and procedure for Resident 219 and Resident 24. 2. Glucose (blood sugar) reading for Resident 24 was obtained during meals. Additionally, insulin was administered without a prescribed glucose check for Resident 24. These failures resulted in a medication error and had the potential to affect the absorption rate and efficacy of the insulin which could result in serious complications for Resident 219 and Resident 24. Findings: During medication pass observation on 10/15/24 at 12:13 PM, Licensed Vocational Nurse (LVN) 3 prepared to administer 4 units of Humulin R (also known as regular insulin, is a short-acting insulin used to treat diabetes) insulin based on Resident 219's glucose level of 206. During preparation, LVN 3 wiped the top of the vial, pushed the needle on top of the vial and immediately draw 4 units of Humulin R insulin from the vial. During insulin administration, LVN 3 held the back of Resident 219's right upper arm and injected the insulin in a 90 degree (0) and immediately removed the syringe from the injection site. During a follow up interview on 10/15/24 at 12:22 PM, LVN 3 stated, you don't need to pinch the site when injecting. During medication pass observation on 10/15/24 at 12:25 PM, LVN 3 went to Resident 24's room and saw the speech therapist sitting with a lunch tray in front of the resident. During concurrent interview, LVN 3 stated the speech therapist started to feed Resident 24 and that she will proceed with the blood sugar check since resident just started eating which will not affect the result. During further observation on 10/15/24 at 12:29 PM, LVN 3 obtained Resident 24's blood sugar level which was 202 and prepared to administer 4 units of Insulin Lispro (a fast-acting insulin used to control high blood sugar in adults and children with diabetes) per sliding scale (refers to the progressive increase in the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges). During preparation, LVN 3 wiped the top of the vial, pushed the needle on top of the vial and immediately draw 4 units of Insulin Lispro from the vial. During insulin administration, LVN 3 directly injected the insulin on the right upper quadrant of the abdomen in a 900 angle and immediately removed the syringe from the injection site. During a follow up interview on 10/15/24 at 12:36 PM, LVN 3 stated she knows that Resident 24 had already eaten but did not think it will have an effect on the blood sugar result and insulin administration. Review of Resident 24's active orders in the EHR, indicated, the following (ff) orders: Order date 10/6/24: Check blood glucose at bedtime. Order date 10/6/24: Insulin Lispro Injection 100 unit/ml (Insulin Lispro) Inject as per sliding scale: if 70-150 = 0 Do Not Hold if NPO. Give the ff insulin in addition to nutritional insulin; 151-200 = 2; 201-249 = 4; 250-300 = 6; 301-350 = 8; 351-400 = 10; BG (blood glucose) >400, give 12 units, subcutaneously with meals for DM2. During concurrent interview on 10/15/24 at 12:41 PM. LVN 3 stated, there is no order in the EHR for Resident 24's blood glucose to be checked before meals. I only see the bedtime order. LVN 3 added, there should be a separate order for the blood glucose check every meal. During an interview on 10/16/24 at 10:18 AM, ADON stated there should be an order in place for blood sugar checks and it should be done before meals, not during meals. During further interview, ADON was asked about their policy and procedure on insulin administration. ADON stated, the amount of air to be injected in the vial should be the same as to the dose of insulin to be drawn from the vial. Injecting of air and drawing insulin from the vial should be done within eye level. In addition, ADON stated to gently pinch the injection site, inject the insulin in a 450 or 900 angle depending on the injection site, leave the syringe for at least 5 to 10 seconds, then release and remove the syringe. ADON further stated that a 450 angle technique is followed when injecting on the upper and/or back of the arm while the 900 angle is followed when injecting on the abdomen. Review of facility's policy and procedure titled, Insulin Administration, updated 8/15/24, indicated, .Steps in the Procedure (Insulin Injections via Syringe) . 2. Check blood glucose per physician order or facility protocol . 6. Gently roll the insulin vial between the palms of both hands to resuspend the insulin . 10. Create a vacuum in the vial by injecting air into the vial in the amount equal to the dose of insulin . 18. Light grasp a fold of skin and insert the needle into the skin at a 900 angle. For very thin residents, insert at a 450 angle to avoid intramuscular injection. 19. Depress the plunge rand remove the needle after approximately five (5) seconds . According to the American Diabetes Association article titled, Insulin Administration, dated 1/1/23, indicated, .INJECTION TECHNIQUE . Dose preparation .For all insulin preparations, except rapid- and short-acting insulin and insulin glargine, the vial or pen should be gently rolled in the palms of the hands (or shaken gently) to resuspend the insulin. An amount of air equal to the dose of insulin required should first be drawn up and injected into the vial to avoid creating a vacuum . After the insulin is drawn into the syringe, the fluid should be inspected for air bubbles. One or two quick flicks of the forefinger against the upright syringe should allow the bubbles to escape. Air bubbles themselves are not dangerous but can cause the injected dose to be decreased. Injection procedures - Injections are made into the subcutaneous tissue. Most individuals are able to lightly grasp a fold of skin, release the pinch, then inject at a 90 angle. Thin individuals or children can use short needles or may need to pinch the skin and inject at a 45 angle to avoid intramuscular injection, especially in the thigh area. Routine aspiration (drawing back on the injected syringe to check for blood) is not necessary. Particularly with the use of insulin pens, the needle should be embedded within the skin for 5 s after complete depression of the plunger to ensure complete delivery of the insulin dose . Injection site - Insulin may be injected into the subcutaneous tissue of the upper arm and the anterior and lateral aspects of the thigh, buttocks, and abdomen (with the exception of a circle with a 2-inch radius around the navel) . Site selection should take into consideration the variable absorption between sites. The abdomen has the fastest rate of absorption, followed by the arms, thighs, and buttocks .

Based on interview and record review, the facility failed to ensure that one of 18 sampled residents (Resident 26) had the necessary language systems for translation accessible when Resident 26 requested a translator but multiple staff were not aware of resources except for family or the use of a communication board (a tool that helps people with limited language skills express themselves by pointing to images or symbols). This failure has the potential for staff to not properly assess residents who speak a different language or make it difficult for a resident to make their unique needs known. Findings: A review of Resident 26's face sheet (front page of the chart that contains a summary of basic information about the resident), dated 10/18/24, indicated that Resident 26 was admitted in 2024 with a primary language of Japanese. During an interview on 10/15/24 at 12:10 PM with Resident 26, Resident 26 stated that their English was not good, and they requested an translator to continue the interview. A review of Resident 26's Medical Practitioner Narrative Note titled, PHYSICAL MEDICINE & REHABILITATION FOLLOW UP EVALUATION, dated 10/24/24, indicated that on assessment by Medical Doctor (MD) 1, MD 1 documented that Resident 26 had precautions (a measure taken in advance to prevent something dangerous, unpleasant, or inconvenient from happening) including speaks Japanese > [greater than] English. During an interview on 10/15/24 at 12:20 PM with Registered Nurse (RN) 1, RN 1 stated that Resident 26 spoke Mandarin. RN 1 further stated that usually a staff member that speaks Mandarin can help translate for the resident. RN 1 also stated that if more complex communication is needed, he would need a translation line [an audio or audio-visual translation service]. During an interview on 10/15/24 at 2:10 PM with RN 1, a translator was requested. RN 1 stated that he does not know how to access a translation line and would need to follow up with social services. During an interview on 10/16/24 at 8:53 AM with RN 1, RN 1 stated that he that usually speaks to Resident 26 in English and Resident 26 can understand a little but if it's more complex questions . you'll have a more difficult time. During an interview 10/17/24 at 11:47 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that if she needs help with translation with Resident 26, she would talk to the family or use non-verbal actions to understand the Resident. LVN 1 further stated, I've never used a translator service. During an interview on 10/17/24 at 2:42 PM with the Director of Social Services (DSS), the DSS stated that staff will often use family for translation services. If the family is not available, the DSS stated that staff can use communication boards with set phrases. If family in unavailable and the Resident has more complex needs that go beyond the communication board, the DSS stated that staff could use translation applications like Google Translate. The DSS further stated that the facility is not subscribed to any medical translation services.

Based on interview and record review, the facility failed to monitor for behavioral symptoms, side effects and/or adverse consequences for one of 3 sampled residents (Resident 220) on psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications. Additionally, the informed consent for the use of psychotropic medication was signed seven days after Resident was admitted to the facility. This failure had the potential to place residents on psychotropic medications at risk for adverse health consequences which could negatively impact the resident's mental, physical, and psychosocial well-being. Findings: Review of Resident 220's admission record indicated, was admitted to facility on 10/10/24 with diagnoses including osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of right ankle and foot, schizophrenia, (a mental illness that is characterized by disturbances in thought), and type 2 diabetes mellitus (DM - high blood sugar). Review of Resident 220's SNF (skilled nursing facility) admission history and physical (H&P) dated 10/12/24, indicated, .Hx (history) schizophrenia: con (continue) amisulpride (an antiemetic and antipsychotic medication used at lower doses intravenously to prevent and treat postoperative nausea and vomiting; and at higher doses by mouth to treat schizophrenia and acute psychotic episodes) tab 400 mg (milligrams) po (per orem, meaning orally or via the mouth) qhs (every hours of sleep) with pt's (patient) own supply. Cont benztropine (treats symptoms that affect your movement caused by Parkinson's disease and other conditions) 0.5 mg po daily for TD (tardive dyskinesia - a chronic condition that causes involuntary, repetitive movements in the body) symptom control . PATIENT TAKES 400 QHS OF AMISULPRIDE TABLETS THESE ARE NOT AVAIALBLE IN USA, PLEASE ALLOW PATIENT TO TAKE HOME MEDICATIONS. DAUGHTER [Name] APPROVES . Review of Resident 220's active orders indicated, start date 10/10/24 AMISULPRIDE 400 MG TABLET. Take 1 tablet at bedtime for Schizophrenia. Daughter will supply the medication. Review of Resident 220's informed consent indicated, LN (licensed nurse) verified verbal or phone consent was received from daughter [Name] on 10/10/24. The informed consent also indicated was signed by the physician on 10/17/24, seven days after Resident 220 was admitted and started taking amisulpride at the facility. Review of Resident 220's Medication Regimen Review dated 10/12/24, indicated, AMISULPRIDE 400 MG TABLET. Take 1 tablet at bedtime for Schizophrenia. Daughter will supply the medication. Recommendation: Please enter orders in PCC to monitor target behavior and SE for the medication(s) listed above. During a concurrent record review and interview with Assistant Director of Nursing (ADON) on 10/18/24 at 11:59 AM, ADON stated, monitoring of behavior and side effects for residents on psychotropic medications should start as soon as soon as the medication was administered. Resident 220's active orders and medication administration record indicated, amisulpride was first administered on 10/10/24 and the side effects monitoring was started on 10/17/24. Review of facility's policy and procedure titled, Psychoactive/Psychotropic Medication Use, updated August 2022, indicated, .1. General Guidelines: .g. Prior to administration of Psychotropic medication, the prescribing clinician will obtain informed consent from resident (or, as appropriate, the resident representative), and document the consent in the medical record. 2. Psychotropic Medication Management - a. Psychotropic medication management for the resident will involve the facility interdisciplinary team consideration of the following: indication and clinical need for medication, dose, duration, and adequate monitoring for efficacy and adverse consequences. Management will also include preventing (where possible), identifying, and responding to adverse consequences .e. Monitoring of resident receiving Psychotropic medication will include evaluation of the effectiveness of the medication, as well as an assessment for possible adverse consequences. Behavioral symptoms are reevaluated periodically to determine the potential for reducing or discontinuing the drug based on therapeutic goals, and any adverse effects or functional impairment. f. Staff will monitor for potential adverse consequences, such as: .tardive dyskinesia . 3. Informed Consent . iii. Prior to administration of Psychotropic medication, the prescribing clinician will obtain informed consent from resident (or, as appropriate, the resident representative), and document the consent in the medical record . vii. The personal examination and signatures can be completed and signed using remote technology .

Based on interview and record review, the facility failed to ensure two out of 13 sampled residents (Residents 53 and 168) were free from neglect when: 1 . Resident 53 reported a staff was rude and failed to help him change out of his wet adult brief. As a result, Resident 53 still have ongoing unpleasant memory of this event and is fearful of working with this staff. 2. Resident 168's family requested pain medication from a nurse. This request was ignored for almost an hour while the Resident was in severe pain. As a result, Resident 168 continued to have severe pain for an hour. Findings: A thorough review of staff response to request for assistance was initiated during this survey due to two factors: i. There were three prior complaints alleging delay in staff response and/or substandard response to requests for assistance. ii. review of resident council meeting minutes for the last three months (November 2021 to January 2022) indicated slow response to requests for assistance may be a systemic issue. The meeting minutes indicated 10 out of 15 feedbacks (66.7%) identified slow call light response time as a problem within the facility. 1. Review of Resident 53's records titled Clinical Admission notes, dated 1/20/22, indicated he was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His Clinical Admission notes indicated he had .complaints of pain upon assessment 4/10 to left hip while moving, 4/10 right humerus (upper arm) while moving hand or arm patient has lots of discomfort. (this is a 10-point pain scale, with 4 to 6 = moderate pain and 10 = worst possible pain). Review of Resident 53's MDS (Minimum Data Set, a standardized clinical assessment), dated 1/23/22, indicated his had no problems with his cognition (brain-based skills) or his memory. According to his MDS, he required extensive assistance of one staff with bed mobility, dressing, toilet use, and personal hygiene. He was totally dependent on staff for bathing and was frequently incontinent of urine. During an interview, on 2/16/22 at 11:47 AM, Resident 53 was asked about call light response. Resident 53 said there was a pattern of staff neglect at the facility. Resident 53 stated About two and a half weeks (after admission) I had to wait (about) 45 minutes for help to change my (adult brief). When the CNA (Certified Nursing Assistant) finally came, she made me feel like I was just a burden. The CNA looked like she was pissed off when she came in. She threw the clean (adult brief) on the bed and said someone else will be in later to help. I was so angry. I was sitting in my wet (adult brief). Even though I was in pain when I move my arm and legs. I had to reach with my other good leg and grab the (adult brief) with my toes bring it up to my good arm. Then I have to take off my wet (adult brief) to put on the clean one. During a concurrent interview and record review, on 2/18/22 at 9:21 AM, Resident 53 was provided with his charting titled Progress Notes, dated 2/16/22 at 4:00 PM and 2/17/22 at 8:37 AM. Resident 53 stated these documentation were not an accurate account of his feelings about the incident. Resident 53 stated I'm still angry when I think back about what happened. This feeling of being helpless . it's painful to think about what happened. Resident 53 stated he is still on the lookout for this CNA. Resident 53 stated I don't know who she is because she was wearing a mask. I don't really want to work with her because of what she did. I feel scared. 2. Review of Resident 168's records titled Resident Face Sheet, dated 12/2/21, indicated she was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 168's MDS, dated [DATE], indicated her BIM (Brief Interview for Mental Status test used to determine cognition and memory condition) was 13/15 (a score of 13-15 indicated the subject was cognitively intact). According to her MDS, she required extensive assistance of two staff for bed mobility and transfers. She required extensive assistance of one staff for dressing, toilet use and personal hygiene. Additionally, she was assessed as being frequently incontinent of bowel and bladder. According to her MDS, she experienced pain almost constantly, making it hard for her to sleep at night and to do her day-to-day activities. Her pain level was assessed as 8 out of 10 (this is a 10-point pain scale, with 7 to 9 = very severe pain and 10 = worst possible pain) Review of Resident 168's Medication Administration records, dated 12/2/21 to 12/9/21, indicated she was experiencing severe pain almost on a daily and/or more frequent basis. Staff documented Resident 168 reported very severe pain levels (7-9 out of 10) at least 14 times during her stay. On 12/8/21 at 8:00 PM, staff documented Resident 168 had pain level 10 out of 10 (worst possible pain). During a telephone interview, on 2/16/22 at 12:20 PM, Resident 168's daughter stated when family visited, they witnessed numerous occasions when staff were slow in responding to call lights/request for assistance. Resident 168's daughter stated, You would buzz and buzz, but they never come. Then you would have to go out there looking for them. Sometimes you would see them at the nurse's station. They would be on their phones or just talking and laughing among themselves. On Saturday, December 4th, 2-3 PM, she was in terrible pain. My husband . went out to get help. My husband said a staff member told him 'I have 23 other patients. I'll get to her when it's her turn.' My husband stayed for about an hour after the request and no one ever came in to help her. On Sunday, December 5th, she called me crying and said I went to the bathroom, I've been laying in feces for over two hours. I told her to just use her call button. She said the call button was on the floor. Two hours? Are they even checking on her? We tried to give them a chance. But one day she called me crying in pain. We finally had to get her out of there. It just wasn't a safe place for her. Review of Resident Progress Notes, dated 12/9/21, indicated At approximately 09:30 am .daughter .of patient . (stated) that her mother was in severe pain. Daughter .insisted that her mother be transferred to . Hospital immediately for further evaluation/pain management. MD ordered to have her sent to (hospital). Review of the facility's Abuse Prevention Program (not dated) indicated Our residents have the right to be free from abuse, neglect, . (The facility will) Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well- being of Resident 1, when three facility nurses failed in three areas regarding assessment of Resident 1's [MEDICAL CONDITION]: 1. Registered Nurses (RN) 1 and 4 failed to rule out [MEDICAL CONDITION] when Resident 1's abdomen was distended. 2. RN 2 failed to document performance of a bladder scan procedure. 3. RN 2 was not provided with training before using the facility's table top bladder scanner. These failures resulted in a delayed treatment of [REDACTED]. Findings: Record review of Resident 1's medical record titled "HIMROI Scans", dated 8/30/13, indicated the resident was admitted to the facility on [DATE] after brain surgery to remove a tumor. The document indicated Resident 1 had a "moderate" decline in her cognition and required supervision and therapy to prevent "malnutrition, aspiration and falls." Record review of nursing documentation, dated 9/7/13 at 10:00 PM, indicated Resident 1 came back from a brain scan procedure and her abdomen was noted to be "firmed and distended ...". Staff documented the distention "might be ...(related to) constipation, ...". There was no documented evidence the facility staff performed other assessment(s) to rule out [MEDICAL CONDITION]. Record review of nursing documentation written by Registered Nurse (RN) 4, dated 9/8/13 at 3:19 AM, indicated Resident 1's "abdomen remains distended". There was no documented evidence facility staff performed other assessment(s) to rule out urinary distention. RN 4 documented Resident 1 was "incontinent of ...(bowel and bladder)". There was no documentation regarding how often Resident 1 was incontinent of bladder or any description regarding amount of urine in Resident 1's adult brief. During an interview on 3/3/15 at 11:00 AM, RN 4 stated she worked night shift and she did not remember taking care of Resident 1. RN 4 stated if a resident's abdomen was distended and she suspected [MEDICAL CONDITION], she would use the bladder scanner to assess the bladder. RN 4 stated she would also examine the "...(adult brief to) see how heavy it was, (if it was saturated with urine)". During an interview on 2/27/15 at 2:05 PM, RN 2 stated she used the facility's table top bladder scanner around "10-11 AM" on 9/8/13 to check Resident 1 for urine retention. RN 2 stated this was her first time using this particular model of bladder scanner. RN 2 stated a facility nurse showed her how to use the bladder scanner prior to 9/8/13. RN 2 stated she was unable to remember who or when the nurse showed her how to use the table top bladder scanner. RN 2 stated the Director of Staff Development (DSD) did not show her how to use the table top bladder scanner. RN 2 stated she did not document she performed a bladder scan on Resident 1. RN 2 stated the bladder scan on Resident 1 showed there was minimal amount of urine in the bladder and she did not document the reading from the machine. During an interview on 3/3/15 at 9:25 AM, the Director of Nursing (DON) stated her expectation was, if a bladder scan was performed, staff should document the procedure and the result in the resident's record. During an interview on 3/2/15 at 1:10 PM, RN 3 stated she was a charge nurse and she helped RN 2 assess Resident 1 on 9/8/13. RN 3 stated RN 2 told her Resident 1's abdomen was distended and Resident 1 "...has not voided...". RN 3 stated she was not in the room when RN 2 performed the bladder scan procedure on Resident 1. During an interview on 3/2/15 at 1:00 PM, the DSD stated she was not familiar with the facility's table top bladder scanner and has never trained any staff on the facility's table top bladder scanner. The DSD stated the table top bladder scanner belonged to the rehab department, and there were "2-3" nurses "informally" showing staff how to use the table top scanner. The DSD stated she did not have policies and procedures regarding training staff on how to use the table top bladder scanner. The DSD was unable to provide documented evidence RN 2 had received training regarding the facility's table top bladder scanner. Review of the bladder scanner company's "BVI 3000 Operators Manual" on page 6, "...indicated (the) Bladder Scan BVI 3000 should be used only by individuals who have been trained and authorized by a physician or the institution providing patient care." This was confirmed during a review of the bladder scanner company's website at: http://www.verathon.com/Portals/0/Uploads/ProductMaterials/0900-0383-11-60%20(BladderScan%20BVI% 0%20Operator's%20Manual).pdf and according to their "BVI 3000 Operator's Manual" on page 6, "...(the) BladderScan BVI 3000 should be use only by individuals who have been trained and authorized by a physician or the institution providing patient care." Review of Resident 1's x-ray of her abdomen titled "CT Abdomen Pelvis ..." (a computer generated image from various x-ray data), dated 9/8/13 at 12:40 PM, indicated Resident 1's "...urinary bladder is markedly distended ...". Review of an emergency room physician documentation, dated 9/8/13 at 9:17 PM, indicated Resident 1 "with a ...(history) of [MEDICAL CONDITION], who presented to the Emergency Department for decreased blood pressure noticed ...(approximately) 1-1.5 hours ago after relieving' ...(approximately) 2500 cc (cubic centimeter)' of urine earlier today. Per paramedics, the patient's abdomen was distended and nursing staff at her nursing facility ...inserted a ... (urinary) catheter to remove the urine. After voiding, the patient's blood pressure dropped ...". Review of RN 2 notes dated 9/08/13- 1551(3:51pm) indicated "Patient alert follows simple command, went out and come back from procedure no side effect noted. Inserted F/C (foley catheter) as ordered pt. tolerated procedure well. With clear amber output no odor, no sediments noted. Staff anticipate needs. Call light within reach." Review of RN 1 notes dated 9/08/13-1735 (5:35pm) indicated "Pt noted having hard of breathing, O2 (oxygen) sat(saturation) 94% on ra(room air), rechecked BP(blood pressure) twice with results 85/57 hr(heart rate) 83 and 86/60 hr 8 temp." Review of RN 1 notes dated 9/08/13-2043(8:43pm) indicated "Given i.v. (intravenous) [MEDICATION NAME] x 1 as ordered, iv bolus running x 1000 ml. Foley patent with adequate output. O2 at 2 L/min. (2 Liters per minute) for comfort, O2 sat 94%. Spouse at bedside. Pt. arousable. Ambulance called to send pt to ER per order. Bayshore ambulance staff came and took pt to ER for further evaluation, belongings with spouse. Per M.D., pt is going to be admitted in the hospital, no sign and held orders provided." According to "Anatomy and Physiology" 2nd edition, 2002, by Lippincott, Williams and Wilkins, it indicated on page 160, in "...a normal adult, bladder capacity ranges from 500 to 600 ...(cc). It's less in children and elderly people." During an interview on 3/5/15 at 4:18 PM, the Medical Doctor (MD) caring for Resident 1 stated given the amount of urine drained out of Resident 1 (2,500 cc), staff should have assessed her for [MEDICAL CONDITION]. The MD acknowledged staff should have assess Resident 1 for [MEDICAL CONDITION] on 9/7/13, evening shift, when staff documented Resident 1's abdomen was distended. The MD stated, given the large amount of urine drained out of Resident 1, a staff trained in the use of a bladder scanner should have discovered Resident 1 was retaining urine. During an interview on 3/2/15 at 1:30 PM, the DON acknowledged normal urine production was around 30 cc/hr. The DON acknowledged it would take approximately 33 hours to produce 1000 cc of urine (or approximately 83 hours to produce 2,500 cc of urine). The DON was unable to explain why nursing staff on 9/7/13 during evening shift and night shift did not assess Resident 1 to rule out [MEDICAL CONDITION]. Since 2,500 cc of urine was drained out of Resident 1's bladder on 9/8/13 during day shift, the DON was unable to explain why, the day shift nurse, RN 2 was not able to detect any significant amount of urine using the facility's table top bladder scanner.