Every finding on record at Pleasanton Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from physical abuse when Resident 2 struck Resident 1 on their right shoulder multiple times while Resident 1 was refilling their water at the facility's water fountain.This failure resulted in Resident 1 experiencing fear and pain, requiring medication and treatment.Findings:During a record review of Resident 1's admission record, the record indicated Resident 1 was admitted to the facility on [DATE].During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to identify problems to address in the plan of care) dated 8/14/25, the assessment indicated Resident 1's Brief Interview for Mental Status (BIMS, a short term memory screening tool) score was nine (9) out of 15, indicating moderate impairment in memory and decision making. The MDS also indicated Resident 1 had the ability to speak, understand others, make herself understood, and used a wheelchair for mobility.During an interview on 8/4/26 at 10:57 a.m., Resident 1's family member (FM 1) stated that on 9/21/25, they received a phone call from Resident 1, who was crying and in pain. Resident 1 reported that Resident 2 hit them on their shoulder and the back of their neck while they were refilling their cup at the water fountain near the nurse's station.During an interview on 8/5/26 at 11:43 a.m., Licensed Vocational Nurse (LVN 1) stated that on 9/21/25 at around 3:15 p.m., they were at the nursing station during shift change when they observed Resident 1 in their wheelchair refilling their water cup at the water fountain. Resident 2 approached the fountain at the same time, attempting to get water, when Resident 2 suddenly punched Resident 1's shoulder three (3) times, causing Resident 1 to scream. LVN 1 stated they separated both residents. LVN 1 stated Resident 1 was crying in pain, received Tylenol (pain medication) and ice packs, and became fearful of leaving their room after the incident.During a record review of Resident 2's admission record, the record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease (a disorder that gradually impairs memory, thinking, and daily functioning) and dementia (a decline in mental abilities caused by brain cell damage that affects thinking, memory, and self care).During a record review of Resident 2's MDS assessment dated [DATE], the assessment indicated Resident 2's Brief Interview for Mental Status (BIMS) score was three (3) out of 15, indicating severe cognitive impairment.During a record review of Resident 1's progress notes dated 9/21/25, RN 1 documented, Pt [Resident 1] was witnessed by staff to have been hit on their shoulder and right upper back region by the other pt [Resident 2]. LVN and social services visited pt [Resident 1] in their room at around 1530 (3:30 p.m.). At initial encounter, [Resident 1] was visibly crying. [Resident 1] complained of pain at rest. [LVN 1] offered ice packs to the area. [Resident 1] was upset and crying about returning to the room due to the incident.During a record review of Resident 1's Medication Administration Record (MAR) dated 9/1/25-9/30/25, printed on 8/5/26 at 1:13 p.m., the MAR indicated Resident 1 received two tablets of Tylenol 325 mg (total 650 mg) on 9/21/25 at 1550 (3:50 p.m.).During a review of the facility's Policy and Procedure (P&P) titled Abuse Prevention Program dated 7/1/20, the policy indicated: Residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

Based on observation, interview, and record review, the facility failed to ensure that one of three sample residents (Resident 3's) prescribed Oxycodone (strong, prescription-only pain medicine used to treat moderate-to-severe pain) was not sent home after discharge as ordered, instead, the facility directed Resident 3 to pick up the medication at an outside pharmacy.This failure resulted in Resident 3 leaving the facility without access to necessary pain medication, placing Resident 3 at risk for unmanaged pain.Findings:During a record review of Resident 3's admission record, the record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses of fracture of right femur (broken right thigh bone) and presence of right artificial hip joint (man-made hip part surgically placed in the right leg). During a record review of Resident 3's Minimum Data Set (MDS, a resident assessment tool used to identify problems to address in the plan of care) dated 7/1/26, the assessment indicated Resident 3's Brief Interview for Mental Status (BIMS, a short term memory screening tool) score was 15 out of 15, indicating intact memory and decision making. The MDS assessment indicated Resident 3 required supervision or touching assistance with walking.During a record review of Resident 3's Physician orders dated 6/16/26, indicated Resident 3's doctor prescribed an order for Oxycodone Oral Tablet 5mg: Give 1 tablet by mouth every four (4) hours as needed for moderate breakthrough (sudden, intense pain flare that breaks through regular daily pain medication) pain, and give 2 tablets by mouth every four (4) hours as needed for severe breakthrough pain.During a phone interview on 8/4/26 at 10:29 a.m., Resident 3 stated they were discharged from the facility on 7/1/26; however, the facility did not send their prescribed Oxycodone home with them. Resident 3 stated Licensed Vocational Nurse (LVN 2) ordered the Oxycodone the same day during discharge process, but it did not arrive in time at the facility, for Resident 3 to take home. Resident 3 stated LVN 2 instructed Resident 3 to pick up the medication at a local pharmacy instead. Resident 3 stated it was already hard for Resident 3 to walk due to pain in the right leg and knee, so it was more difficult to go to a pharmacy to pick up the medication, when it should have been dispensed at the facility.During an interview on 8/4/26 at 1:27 p.m., Licensed Vocational Nurse (LVN 2) stated that per protocol for ordered narcotics, the facility usually sends 30 tablets with residents at discharge, and residents are instructed to pick up refills at their local pharmacy. LVN 2 reported that on 7/1/26, there were no Oxycodone tablets available for Resident 3 to take home as ordered by the physician. LVN 2 explained that the night-shift nurse or the RN case worker typically verifies medications before discharge, but they were unaware of what occurred that day. LVN 2 stated that although Oxycodone 5 mg was ordered for Resident 3 for discharge, the medication did not arrive in time, so Resident 3 was instructed to obtain it from their local pharmacy after discharge.During a record review of Resident 3's Progress Notes, dated 7/1/2026, LVN 2 documented Resident 3 was informed to pick up Oxycodone from the pharmacy and was discharged at 11:15 a.m. to home. During a record review of Resident 3's Narcotic Count Sheet (Sheet (strict logbook used in healthcare facilities to track every single dose of strong, restricted medications like painkillers), record indicated there were zero (0) remaining Oxycodone 5mg on 6/30/26.During an interview on 8/5/26 at 11:10a.m. Director of Nursing (DON) stated it is important to send home, both routine and as needed (PRN) pain medications for proper pain management for any resident, as ordered.During a concurrent phone interview and record review on 8/26/26 at 2:13p.m. with DON, Resident 3's medical record titled Skilled Nursing Facility (SNF) Discharge Summary dated 7/1/26 was reviewed. The DON stated the discharge summary indicated the facility to dispense 30 tablets of Oxycodone. The DON stated Resident 3 did not receive Oxycodone tablets prior to discharge to home on 7/1/26. The DON stated discharging home, with an incomplete set of medications and making an extra effort to pick up missing medications from an outside pharmacy, placed Resident 3 at risk of being unhappy.During a review of the facility's Policy and Procedure (P&P) titled Discharge Medications, indicated Unless otherwise specified by facility policy, or contrary to current law or regulation, medications shall be sent with the resident upon discharge

Based on observation, interview and record review, the facility failed to ensure food service safety and sanitation requirements were followed when:1. A 7-pound can of cherry pie filling was observed to have a dent near the top of the can and was stored alongside regular cans outside the designated dented can area.2. A cheese grater, hung up with clean food preparation items, was found with a broken red plastic rim.3. A green cutting board, stored with clean food preparation items, was found with yellow debris and was marred (surface with deep gouges) on one side.These failures had the potential to cause food borne illness among vulnerable residents.Findings:1.During a concurrent observation and interview on 4/20/2026 at 3:00 p.m. with the Dietary Manager (DM), in the kitchen dry storage, a 7-pound can of cherry pie filling was observed to have a dent near the top of the can. The can was stored with items for use and not stored in the designated dented can area. The DM confirmed the can was dented. The DM stated the can did not belong with regular cans and that it should have been placed in the designated dented can area. During a review of the facility's policy and procedure (P&P) titled, General Food Preparation and Handling, [undated], the P&P indicated, 2. Food Storage. c. Food in broken packages or swollen or dented cans. will not be served Dented cans will be labeled and set aside in a designated area for return. 2. During a concurrent observation and interview on 4/20/2026 at 2:50 p.m. with the Dietary Manager (DM), in the kitchen, a red plastic rimmed cheese grater was observed with a crack in the red plastic. The red plastic was observed to be separated from the metal cheese grater. The cheese grater was stored with clean equipment. The DM confirmed that the red plastic around the cheese grater was broken and stated the cheese grater should not be stored for use. The DM further stated it should have been discarded as it can lead to an infection control issue. During a review of the facility's policy and procedure (P&P) titled, General Food Preparation and Handling, [undated], the P&P indicated, 5. Equipment. a. All food service equipment should be cleaned, sanitized, air-dried, and reassembled after each use. b. Plastic-ware or dishware that has lost its glaze or is chipped or cracked must be disposed of.3.During a concurrent observation and interview on 4/20/2026 at 2:54 p.m. with the Dietary Manager (DM), in the kitchen, a green plastic cutting board was observed stored on the shelving with clean equipment. The green cutting board was observed to have small yellow debris on it, as well as deep marring on one side of the board. The DM confirmed the yellow-colored debris and marring on the cutting board and stated it should have been replaced to prevent bacteria growth on the cutting board.During a review of the facility's policy and procedure (P&P) titled, General Food Preparation and Handling, [undated], the P&P indicated, 3. Food Preparation. Cutting boards will be cleaned and sanitized after each use.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure for one of 34 sampled residents (Resident 44) when a comprehensive assessment for self-medication administration was not completed prior to Resident 44 self-administering medications.This failure resulted in unmonitored medication use and had the potential to result in medication overuse and errors. Findings:During a review of Resident 44's Face Sheet (demographics), the face sheet indicated Resident 44 was admitted to the facility with a diagnosis of muscular dystrophy (progressive muscle weakness and loss of muscle mass over time).During a concurrent observation and interview on [DATE] at 9:39 a.m. with Resident 44 in her room, Resident 44 was lying in bed. Observed bottles of Biotin (nutrient the body needs in small amounts), Vitamin K2, Vitamin D3 (essential nutrients that work together), Vitamin E (nutrient the body needs in small amounts), and Magnesium Glycinate (dietary supplement), medication bottles on a shelf next to Resident 44's bedside. Resident 44 stated she took the medication supplements every day independently and those were stored on her shelf.During an interview on [DATE] at 9:09 a.m. with the Licensed Vocational Nurse (LVN 5), LVN 5 confirmed Resident 44 had medications at bedside and was self-administering the medications in her room.During an interview on [DATE] at 11:44 a.m. with the Case Manager (CM 1), CM 1 stated the Interdisciplinary Team (IDT) determined it was clinically appropriate for Resident 44 to self-administer Vitamin D and the physician wrote an order to do so. CM 1 further stated, however, the IDT did not determine if it was clinically appropriate for Resident 44 to self-administer Biotin, Vitamin E, or Magnesium Glycinate and there was no physician's order for Resident 44 to do so. CM 1 stated Resident 44 had been self-administering Biotin, Vitamin E and Magnesium Glycinate. CM 1 confirmed, that each individual medication needed an IDT assessment completed and a doctor's order for self-administration.During a review of Resident 44's Self-Administration Medication Safety Screen, dated for [DATE], the Self-Administration Medication Safety Screen indicated, Complete this assessment prior to resident initiating self-administration of medication and with any medication and with any medication order changes. The Self-Administration Medication Safety Screen further indicated that Resident 44 was not screened for the medications Biotin, Vitamin E, or Magnesium Glycinate for self-administration by the Interdisciplinary Team.During a review of Resident 44's Order Summary Report, for active orders as of [DATE], the Order Summary Report indicated, Resident 44 did not have self-administration orders for Biotin, Vitamin E, or Magnesium Glycinate. During a review of Resident 44's Medication Administration Record (MAR), dated [DATE], the MAR indicated, there was no documentation for Resident 44 to self administer the following medications, Biotin, Vitamin E, and Magnesium Glycinate.During a review of the facility's policy and procedure (P&P) titled, Self-Administration of Medications, dated February 2021, the P&P indicated, As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering is safe and clinically appropriate for the resident. The IDT considers the following factors when determining whether self-administration of medications is safe and appropriate for the resident: The medication is appropriate for self-administration;.the resident comprehends the medication's purpose, proper dosage, timing, signs of side effects and when to report these to staff. Any medications found at the bedside that are not authorized for self administration are turned over to the nurse in charge for return to the family or responsible party. The nursing staff routinely checks self-administered medications and removes expired, discontinued, or recalled medications.During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated [DATE], the P&P indicated, Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.

Based on interview, and record review, the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) within 2 hours for two of 34 residents (Resident 5 and Resident 223).This failure had the potential to result in serious adverse physical, psychosocial, and emotional harm for Resident 5 and Resident 223.Findings:During a review of Resident 5's Face Sheet (demographics), [undated], the face sheet indicated Resident 5 was admitted to the facility with diagnosis of fracture (broken bone) of the right talus (small bone that connects the lower leg to the foot).During a review of Resident 5's Minimum Data Set (MDS, standardized assessment tool), dated 3/25/2026, the MDS indicated, Resident 5 had a BIMS (brief interview for mental status) score of 13, cognitively intact.During a review of Resident 223's Face Sheet (demographics), [undated], the face sheet indicated Resident 223 was admitted to the facility with diagnosis of a displaced fracture (broken bone that has snapped into two or more pieces) of the left femur (thigh bone).During a review of Resident 223's admission MDS, dated 3/6/2026, the admission MDS indicated, Resident 223 had a BIMS score of 15, cognitively intact.During an interview on 4/21/2026 at 10:16 a.m. with Resident 5, Resident 5 stated that during the PM (afternoon) shift, on 3/20/2026, Certified Nursing Assistant (CNA 3), entered her room to change and clean her after a bowel movement. Resident 5 further stated that CNA 3 seemed upset and was rough while she was cleaning her back side. Resident 5 stated she informed CNA 3 that she was experiencing pain and asked CNA 3 not to clean her back side so roughly, however, CNA 3 continued to care in the same manner. Resident 5 stated that after CNA 3 finished her care, CNA 3 then helped her roommate Resident 223. Resident 5 further stated that CNA 3 was rude and used foul language while providing care to Resident 223. Resident 5 stated that Resident 223 was very upset after CNA 3 finished her care. Resident 5 stated the next morning (3/21/2026) when CNA 2 came to her bedside she informed CNA 2 about the incident the night before. Resident 5 declined to name CNA 3 who provided rough care to the surveyor when asked.During an interview on 4/23/2026 at 2:48 p.m. with CNA 2, CNA 2 stated Resident 5 informed her on 3/21/2026 during the AM (morning) shift that the night before on 3/20/2026, the PM shift CNA 3 was rough and rude with her and Resident 223 while providing care. CNA 2 stated that she informed the Licensed Vocational Nurse (LVN 6) about the incident, and LVN 6 asked her to get a statement about the allegation of abuse from Resident 5 and Resident 223. CNA 2 stated that after the statement was given to her, she asked the Clinical Coordinator (CC 1) what she should do with Resident 5's and Resident 223's allegation of abuse statement. CC 1 instructed CNA 2 to slide the allegation of abuse statement under the Director of Staff Development's (DSD) door. CNA 2 further stated she slid Resident 5's and Resident 223's shared statement under the DSD's door during her AM shift on 3/21/2026.During an interview on 4/23/2026 at 3:24 p.m. with the DSD, the DSD stated CNA 2, LVN 6, and CC 1 were made aware of Resident 5's and Resident 223's allegation of abuse on 3/21/2026, however, it wasn't reported to Social Services and to him until 3/26/2026. The DSD further stated that rough care is considered an allegation of abuse and the staff should have reported the allegation immediately to the abuse coordinator. The DSD confirmed that the allegation of abuse was not reported to CDPH within 2 hours.During an interview on 4/23/2026 at 3:58 p.m. with the Director of Social Services (DSS), the DSS stated Resident 5's and Resident 223's allegation of abuse was reported to her on 3/26/2026 and she reported it to CDPH on 3/26/2026.During an interview on 4/23/2026 at 4:48 p.m. with the Administrator (Admin), the Admin stated allegations of abuse should be reported immediately to him, as he was the abuse coordinator. The Admin further stated that rough care provided by a CNA was considered an allegation of abuse. The Admin confirmed that Resident 5's and Resident 223's allegation of abuse was not reported to CDPH within 2 hours, and that once the staff was aware of the allegation of abuse they should have reported it immediately to him.During a review of [Facility] Facsimile Transmittal Sheet, dated 3/26/2026, the Facsimile Transmittal Sheet indicated that CDPH was notified via fax of Resident 5's and Resident 223's allegation of abuse on 3/26/2026 at 5:20 p.m. (5 days after the allegation was reported by Resident 5 and Resident 223).During a review of the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting, dated 7/1/2020, the P&P indicated, Reports of abuse, neglect, exploitation.shall be promptly reported to local, state, and federal agencies.An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately but not later than: Two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury.

Based on interview and record review, the facility failed to provide a written bed hold notification to one of 34 sampled residents (Resident 142) and/or his representative upon Resident 142's transfer to an acute care hospital on 1/21/2026. This failure resulted in Resident 142 and/or his representative not informed of his rights to return to the facility following his hospitalization. Findings: During a review of Resident 142's admission Record (demographics), the admission record indicated Resident 142 was admitted to the facility with a diagnosis of congestive heart failure. During a review of Resident 142's Progress Notes, dated 1/21/2026 at 3:59 p.m., the progress notes indicated Resident 142 was having shortness of breath with his respiratory rate of 21-22 (high), oxygen saturation (the amount of oxygen you have circulating in your body) of 83 percent (low) and edema (swelling). Further review of the progress notes indicated Resident 142 was send out to the hospital on 1/21/2026. During a review of Resident 142's Transfer Orders, dated 1/21/2026, the transfer orders indicated Resident 142 was transfer to the emergency department. Further review of Resident 142's clinical record indicated there was no documented evidence of a bed hold notification provided to Resident 142 and/or his representative at the time of transfer. During an interview on 4/22/2026 at 2:56 p.m., with the Business Office Manager (BOM), the BOM stated there was no documented evidence of a written Bed Reservation Notification or any documentation of informing Resident 142 and/or his representative of the bed-hold upon Resident 142's transfer to the hospital on 1/21/2026. During a review of the facility's policy and procedure (P&P) titled, Bed-Holds and Returns, dated October 2022, the P&P indicated, 1. All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: a. notice 1: well in advance of any transfer (e.g., in the admission packet); and b. notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours).

Based on interview and record review, the facility failed to update the nursing care plan (an individualized plan that provides direction for a resident's medical care) for one of 34 sampled residents (Resident 95). This failure had the potential to affect the provision of care for Resident 95.Findings: During a review of Resident 95's admission Record (demographics), dated 4/21/2026, the admission record indicated Resident 95 had a diagnosis of Type 2 Diabetes Mellitus (when the body cannot properly use or produce enough insulin, leading to high blood sugar). During a review of Resident 95's Physician's Orders, dated 4/19/2026, the physician's orders indicated Resident 95 was on a soft and bite sized texture diet (tender, moist foods that require chewing but do not require biting-off). During an interview on 4/20/2026 at 4:04 p.m., with Resident 95, Resident 95 stated he was on a regular diet (normal, everyday foods of various texture). Resident 95 showed his teeth and stated he only had two bottom teeth. Resident 95 stated he cannot chew well and needed his food to be cut up. During a concurrent interview and record review on 4/22/2026 at 8:51 a.m., with the Case Manager (CM 1), Resident 95's At Risk for Altered Nutritional Status-Care Plan, last revised 4/10/2026 was reviewed. The care plan indicated Resident 95 had a regular texture diet. CM 1 stated Resident 95's altered nutritional care plan was not updated according to Resident 95's current physician's diet order. CM 1 stated the care plan should match the current diet order to avoid confusion. During an interview on 4/22/2026 at 9:14 a.m., with the Director of Nursing (DON), the DON stated the expectation was for the care plan to be updated to reflect the residents' current orders. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated March 2022, the P&P indicated, 11. Assessments of residents are ongoing and care plans are revised as information about the residents' and the residents' conditions change.

Based on observation, interviews and record review, the facility failed to implement physician orders for two of 34 sampled Residents (Resident 2 and Resident 135) when:1.A STAT (immediate) X-ray (medical imaging test to take pictures of the inside body) was not implemented timely per physician order, when the contract vendor did not show up to the facility and the facility failed to follow up with the vendor. This resulted in Resident 2 being transferred to an outside hospital for an X-ray, obtained approximately 28 hours later. 2.Resident 135' s PRN (as needed) pain medication was not administered according to physician's orders. These failures resulted in delayed treatment for Resident 2 and the potential to result in inadequate pain relief for Resident 135. Findings: 1.During a review of Resident 2's admission Record, dated 4/21/2026, the admission record indicated, Resident 2 was admitted to the facility with diagnosis that included muscular dystrophy (progressive muscle weakness) and first and second thoracic vertebrae fracture (broken of the top two bones of the mid-back, below the neck). During a review of Resident 2's Brief Interview for Mental Status (BIMS; a cognitive assessment tool), dated 2/9/2026, the BIMS indicated, Resident 2's score was 13 (which indicated an intact cognitive function). During a review of Resident 2's Progress Notes, dated 1/30/2026, the progress notes indicated, Resident 2 had a fall on 1/30/2026 at 1:13 p.m. During a review of the Provider Notification and Feedback, dated 1/30/2026, the provider notification indicated, the Medical Doctor (MD 1) ordered a STAT (immediately) X-ray on 1/30/2026 at 1:17 p.m. for Resident 2. During a review of Resident 2's Hospital X-ray Results, dated 1/31/2026, the X-ray results indicated, an X-ray was conducted on 1/31/2026 at 5:40 p.m. and the results indicated Resident 2 had a left foot fracture and right knee fracture. During an interview on 4/20/2026 at 4:46 p.m., with Resident 2, Resident 2 stated she requested an X-ray after she fell during therapy on 1/30/2026. Resident 2 further stated her request for the X-ray was not done immediately until her family member contacted the facility the following day on 1/31/2026. During an interview on 4/21/2026 at 2:05 p.m., with the Director of Nursing (DON), the DON stated a STAT X-ray order should be completed within six hours. The DON stated STAT X-ray orders indicated urgency, time-critical care and a delay could result in harm for Resident 2. The DON further stated there was a gap with their contract vendor and this was not an acceptable standard of practice. During an interview on 4/23/2026 at 8 a.m., with MD 1, MD 1 stated she ordered a STAT X-ray on 1/30/2026 for Resident 2 due to clinical symptoms of pain. MD 1 stated, her expectation for STAT X-rays must be done within four to six hours. MD 1 further stated receiving the STAT X-ray 26 hours later caused a delay in Resident 2's medical intervention and was an indication of poor quality of care. During a review of the facility's policy and procedure (P&P) titled, Request for Diagnostic Services, dated April 2007, the P&P indicated Orders for diagnostic services will be promptly carried out as instructed by the physician's order. Emergency request must labeled stat to assure that prompt action is taken. 2. During a review of Resident 135's Face Sheet (demographics), the face sheet indicated Resident 135 was admitted to the facility with a diagnosis that included spondylosis (wear and tear on the joints and disks of the spine that cause pain and stiffness) without myelopathy (impaired spinal cord function) or radiculopathy (compression, irritation, or injury of spinal nerve root), lumbosacral (lower back and tailbone) region; and unspecified dementia (progressive decline in cognitive function), unspecified severity. During a concurrent observation and interview on 4/20/2026 at 3:56 p.m. with Resident 135, in Resident 135's room, Resident 135 was observed sitting in his wheelchair with a blanket over his lap. Resident 135 complained of low back pain and stated he does not get pain medications. Resident 135's son was also in Resident 135's room and stated his dad had frequent back pain and was not sure his father had received pain medication. During a review of Resident 135's admission MDS (Minimum Data Set - an assessment tool), dated 4/6/2026, the admission MDS indicated Resident 135's BIMS (Brief Interview for Mental Status) was a 4, (on a scale of 00-15; 04 indicated severe cognitive impairment). Further review of the admission MDS indicated Section J - Health Conditions, that Resident 135 did not have any pain in the last five days but did receive PRN pain medication. Further review of the admission MDS indicated that Resident 135 did not have a scheduled pain medication regimen. During an interview on 4/22/2026 at 10:12 a.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated that Resident 135 had complained of lower back pain and confirmed that Resident 135 had a PRN medication of Tylenol (brand name for acetaminophen) ordered. LVN 1 stated she would administer pain medication to Resident 135 when needed. LVN 1 stated that Resident 135 received PRN Tylenol during the NOC (overnight) shift around 3:00 a.m. and that she gave him another dose of PRN Tylenol in the morning. LVN 1 stated if the PRN Tylenol was not effective, or if Resident 135 had moderate to severe pain, she would notify the doctor because Resident 135 did not have pain medications ordered for pain higher than a 4. During a review of Resident 135's Physician Orders, dated 3/30/2026 at 6:40 p.m. the physician orders indicated, an order for Acetaminophen Tablet 325 MG (milligram – unit of measurement), give 2 tablets by mouth every 6 hours as needed for Mild Pain (1-4). NTE (not to exceed) 3 GM (gram – unit of measurement) in 24HRS. Further review of the physician orders indicated no other pain medication was ordered for pain level higher than a 4. During a concurrent interview and record review on 4/22/2026 at 11:09 a.m. with LVN 1, Resident 135's Medication Administration Record (MAR), dated April 2026 was reviewed. The MAR indicated that on 4/21/2026 at 11:19 a.m., LVN 1 administered PRN acetaminophen to Resident 135 for pain rated at a 6. LVN 1 confirmed that yesterday 4/21/2026 Resident 135 had a pain level of a 6 and she still administered Tylenol. LVN 1 stated she did not notify the medical doctor that Resident 135's pain level was higher than 4. During a concurrent interview and record review on 4/22/2026 at 11:22 a.m. with the Director of Nursing (DON), Resident 135's MAR, dated April 2026, was reviewed. DON confirmed that Resident 135 had five occurrences in April 2026 where his pain was higher than a 4 and received acetaminophen. DON stated her expectations were that staff should have notified the physician to clarify the order and to have Resident 135 re-evaluated for pain management prior to administering acetaminophen. DON confirmed that administering acetaminophen for pain higher than a 4 could have led to ineffective pain management. During a review of Resident 135's Alteration in Musculoskeletal Status-Care Plan, r/t (related to) Lumbosacral Spondylosis w/o (without) myelopathy, dated 3/31/2026, indicated that Resident 135 would remain free from pain or at a level of discomfort acceptable to the resident. Interventions included: Give analgesics as ordered by the physician. Monitor and document for side effects and effectiveness. During a review of the facility's policy and procedure (P&P) titled, Pain Assessment and Management, dated April 2025, the P&P indicated, The medication regimen is implemented as ordered . Ongoing communication between the prescriber and the staff is necessary for the optimal and judicious use of pain medications.

Based on observation, interview, and record review, the facility failed to ensure: 1. A set of keys for a treatment cart (a cart with wound care medications and supplies), were left unattended, unsecured and not kept with the licensed nurses. This failure had the potential for unauthorized staff to have access to the treatment cart. 2. Self-administration medications, such as Vitamin D (essential nutrients that work together) were not stored in a locked compartment for one of 34 sample residents (Resident 44). In addition the following additional medications for Resident 44, Biotin (nutrient the body needs in small amounts), Vitamin K (essential nutrients that work together), Vitamin E (nutrient the body needs in small amounts), and Magnesium Glycinate (dietary supplement), were stored in an open shelf in Resident 44's shared room. This failure had the potential to result in unauthorized access to medication, inappropriate medication use, medication error, or accidental ingestion for the vulnerable resident population.Findings: 1.During a concurrent observation and interview on 4/23/2026 at 9:18 a.m., with Licensed Vocational Nurse (LVN 3), in Nursing Station 1, LVN 3 retrieved a set of keys from a black binder on top of the counter where the set of keys were left unattended and unsecured. LVN 3 stated the keys were for a treatment cart. During a concurrent observation and interview on 4/23/2026 at 9:21 a.m., with LVN 3, LVN 3 was standing in front of an open treatment cart. LVN 3 stated the set of keys that were retrieved from the black binder in Nursing Station 1 was for the treatment cart in front of her. The treatment cart had ointments, creams, and wound care supplies. During an interview on 4/23/2026 at 10:48 a.m., with the Director of Nursing (DON), the DON stated the expectation was for the treatment cart keys to be held by the nurses at all times. 2. During a review of Resident 44's Face Sheet (demographics), the face sheet indicated Resident 44 was admitted to the facility with a diagnosis of muscular dystrophy (progressive muscle weakness and loss of muscle mass over time). During a concurrent observation and interview on 4/21/2026 at 9:39 a.m., with Resident 44 in her shared room, the following medication bottles of Biotin, Vitamin K2 and D3, Vitamin E, and Magnesium Glycinate, were observed unsecured in an open shelf next to Resident 44's bedside. Resident 44 stated she took the medication supplements every day and those were stored on her shelf. During an interview on 4/23/2026 at 9:09 a.m., with Licensed Vocational Nurse (LVN 5), LVN 5 confirmed that Resident 44 had medications stored at her bedside that were not locked or secured. LVN 5 stated Resident 44 did not need to lock or secure her medications because they were over the counter medications and they were safe on Resident 44's open shelf at her bedside. During an interview on 4/23/2026 at 2:08 p.m., with the Director of Nursing (DON), the DON stated all medications should be stored in a locked box that can be accessed by the self-administering resident. The DON stated when medications are not secured and locked, an unauthorized person could access them. During a review of the facility's policy and procedure (P&P) titled, Self-Administration of Medications, dated February 2021, the P&P indicated, Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room. A licensed nurse transfers the unopened medication to the resident when the resident requests them.

Based on observation, interview, and record review, the facility failed to follow infection control practices for two of 34 sampled residents (Resident 150 and Resident 8) when:1. A Maintenance Assistant (MA 1) and a Certified Nursing Assistant (CNA 1) did not wear personal protective equipment (PPE, specialized clothing or equipment worn by individuals to minimize exposure to hazards that cause serious workplace injuries or illnesses), in Resident 150's room, who was on contact precautions (series of procedures designed to minimize the transmission of infectious organisms by direct or indirect contact with an infected person or his/her surrounding environment).2. A Licensed Vocational Nurse (LVN 5) did not wear appropriate personal protective equipment (PPE, specialized clothing or equipment worn by individuals to minimize exposure to hazards that cause serious workplace injuries or illnesses), while administering medications through Resident 8's gastric tube (G-Tube, tube inserted through the belly to bring nutrition directly to the stomach). Resident 8 was on Enhanced Barrier Precautions (EBP, infection control interventions designed to reduce the spread of multidrug-resistant organisms, MRDO-a germ that is resistant to many antibiotics).These failures had the potential to result in the spread of infectious diseases among residents, staff, and visitors.Findings: 1. During a review of Resident 150's admission Record (demographics), dated 4/21/2026, the admission record indicated Resident 150 had a diagnosis of displaced intertrochanteric fracture (hip fracture) of the left femur. During a review of Resident 150's Physician's Order, dated 4/20/2026 at 4:14 p.m., the physician's order indicated Resident 150 was on contact precautions related to pending test results for C. Diff. During a review of Resident 150's Laboratory results for C. diff toxin, dated 4/21/2026, the laboratory results indicated Resident 150 was positive for C. diff. During an observation on 4/20/2026 at 7:08 p.m., a Contact Precautions sign was observed hanging next to Resident 150's room door. The Contact Precautions sign indicated, Stop. Contact Precautions. Special Enteric (relating to or affecting the intestine). Visitors and Personnel: Must speak to nurse before entering. Perform hand hygiene before entering room and wash hands with soap and water before leaving room. Put on gown before entering room. Remove gown before exiting room. Put on gloves before room entry. Discard gloves before exiting the room. Resident 150 was in his room lying in bed. MA 1 was in the room, holding a remote control in front of the television and had gloves and a face mask, but no gown. During an interview on 4/20/2026 at 7:11 p.m., with MA 1 and Licensed Vocational Nurse (LVN 2), MA 1 stated he was trying to fix Resident 150's television. MA 1 stated he should have worn a gown while inside the room. LVN 2 stated Resident 150 was on contact precaution to rule out C. diff (Clostridioides difficile, a bacteria causing severe diarrhea and colitis, primarily affecting people on antibiotics in healthcare settings). During a concurrent observation and interview on 4/21/2026 at 9:03 a.m. with CNA1, in front of Resident 150's room, CNA 1 walked inside Resident 150's room without a gown and gloves. CNA 1 talked to Resident 150 and moved around the items on Resident 150's meal tray. CNA 1 then hand sanitized her hands before leaving Resident 150's room. CNA 1 stated she gave Resident 150 ice chips. CNA 1 looked at the Contact Precautions signage next to Resident 150's room door. CNA 1 stated Resident 150 was on Contact Precautions for C. diff. and was told to only wear PPE when doing direct care such as changing Resident 150's incontinent brief. CNA 1 further stated she can either sanitize her hands or wash her hands with soap and water before leaving the room of a resident with C. diff. During an interview on 4/21/2026 at 12:08 p.m., with the Infection Control Preventionist (ICP), the ICP stated MA 1 and CNA 1 should have worn the appropriate PPE including a gown before entering Resident 150's room as indicated on the Contact Precautions signage. ICP further stated staff should wash their hands with soap and water before leaving a room that was on Contact Precautions for C. diff. During a review of the facility's policy and procedure (P&P) titled, Clostridioides (Clostridium) Difficile, dated December 2024, the P&P indicated, 6. Steps toward prevention and early intervention include: . e. frequent hand washing with soap and water by staff and residents; f. wearing gloves and a gown when caring for residents with potential infectious diarrhea or when handling feces or articles contaminated with feces. 11. Residents with diarrhea and suspected CDI (Clostridioides difficile Infection) are placed on contact precautions while awaiting laboratory results . 12. When caring for residents with CDI, staff is to maintain vigilant hand hygiene. Hand washing with soap and water is superior to ABHR (alcohol based hand rub) for the mechanical removal of C. difficile spores from hands. 2.During a review of Resident 8's Face Sheet (demographics), the face sheet indicated Resident 8 was admitted to the facility with a diagnosis of esophageal obstruction (blockage in the tube connecting the mouth to the stomach). During a review of Resident 8's, Physician Orders, dated 3/25/2025, the physician orders indicated, an order for Enhanced Barrier Precautions (EBP) for high contact resident care activities r/t [related to] enteral feeding. Further review of the physician orders indicated, to perform hand hygiene and apply personal protective equipment (PPE) gloves, gown and/or goggle/face shield.every shift for prevent transmission of multidrug-resistant organisms (MRDO-a germ that is resistant to many antibiotics). During an observation on 4/22/2026 at 10:15 a.m. in Resident 8's room, there was an EBP signage posted on the doorway of Resident 8's shared room that indicated Resident 8 was on EBP. The EBP signage instructed Enhanced Barrier Precautions (EBP).: [NAME] (put on) gown and glove. Licensed Vocational Nurse (LVN 5) entered Resident 8's room with 2 cups of water and Resident 8's morning medications. LVN 5 donned gloves, no gown and accessed Resident 8's G-Tube to administer medications. During Resident 8's medication administration, LVN 5's clothes came into contact with Resident 8's bed and bedside table. LVN 5 finished Resident 8's medication administration on 4/22/2026 at 10:33 a.m. (total of 18 minutes in Resident 8's room). During an interview on 4/22/2026 at 10:42 a.m. with LVN 5, LVN 5 confirmed that she did not wear a gown during Resident 8's G-Tube medication administration. LVN 5 stated that she was not required to wear a gown for medication administration in an EBP room. During an interview on 4/23/2026 at 10:14 a.m. with the Infection Control Preventionist (ICP), the ICP stated that gowns should be worn when medications are administered through a G-Tube. The ICP further stated that if a gown was not worn when a resident's G-Tube was used, it was a risk for transmitting MDROs to the resident. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, dated December 2024, the P&P indicated, Enhanced Barrier Precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities.Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include:.device care or use (central line, urinary catheter, feeding tube.etc.) During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated July 2020, the P&P indicated, Staff shall follow established facility infection control procedures for the administration of medications, as applicable.

Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared in a clean environment, within standards for safety when: 1) Ice Machine floor drain was not maintained clean; 2) Food items stored in the refrigerator had expired with past use by dates; 3) Food items in the refrigerator did not have use by and expiration dates; 4) Food items in the pantry not labelled and stored properly; 5) Kitchenware (including pans, cutting boards, cooking utensils, ergo silverware, strainers, blender, food processor) were in poor condition; 6) The two-part sink, on the left side of sink, was being used for washing potatoes and the right side of the sink with a large cleaning bucket filled with rags, water and cleaning solution; 7) Drawers used to store cooking utensils were not maintained clean; 8) Industrial Can-Opener, Blender, Food Processer not maintained clean; 9) Stove and Oven with built up residue, large amounts of food particles and grease, accumulated underneath and on sides of stove; 10) A kitchen oven mitt was found on the top surface of the stove; 11) Tile on the right side of the dishwashing area not sealed and was separated against the wall; 12) The center of the floor, in the dishwashing area, was dirty with black slimy greasy material underneath the rubber mats. These failures had the potential to result in contamination of food leading to food borne illness, for 133 Residents who resided in the facility. Findings: During an observation on [DATE], at 9:25 a.m., with Certified Dietician (CD1), the white ice machine drain was dirty, covered in black film and debris. During a review of the facility's policy and procedure (P&P) titled, Cleaning Instructions; Ice Machine and Equipment, dated 2017, the P&P indicated the ice machine and equipment will be cleaned and sanitized on a regular bases. During an observation on [DATE], at 9:30 a.m., with CD1, located in the walk-in refrigerator and available for use were the following food items stored beyond the facility identified use-by dates: -Twenty-five fruit cups of melon, pineapple, cantaloupe, and watermelon with an expired use-by date of [DATE]. - Opened package of turkey bacon and chicken salad with use-by date of [DATE]. - One box of (25) cream cheese packages with use-by date of [DATE]. In addition, the main refrigerator had the following items without labeling of use-by/expiration dates: -Five dinner rolls -Peanut butter and Jelly sandwich -Cups of drinks (cranberry juice, thickened apple juice, and milk.) -Three quarts of Tuna salad with no prepared or use-by date. -One quart of Tuna salad with no prepared or use-by date. -One quart of peaches CD1 confirmed the food items were stored beyond the use-by date. CD1 stated staff should discard items by the use-by date daily and that all food items needed to have a prepared by date and a use-by date. During an observation on [DATE], at 9:40 a.m., with CD1, the walk-in fridge had one box of basil and one box of rosemary with no received date and no use-by date. During a concurrent observation and interview on [DATE], at 9:50 a.m., with CD1, the pantry had 34 loaves of sliced bread with no received date, expiration date, or use-by date. On the wire rack shelf was an open 1.5 quart jar of Real Mayonnaise, ,d+[DATE] full. CD1 stated these items should have a clearly identified label of received and use-by date and did not think the mayonnaise needed to be refrigerated after opening. According to the United States Department of Agriculture (USDA), for food safety, the USDA recommends refrigerating mayonnaise after opening to slow down the growth of bacteria and recommends discarding opened mayonnaise that has been at room temperature for more than eight hours. During a concurrent observation and interview on [DATE], at 10:00 a.m., in the main pantry, with CD1, the bottom level shelf contained a large cardboard box with an opened plastic bag, unsealed, with 25 pounds (lbs) of white powder. CD1 stated it was thickener used for pureed food and stated the box in the packaging should not be open and exposed, and should be in a container with a used-by and opened date. During a review of the kitchen policy and procedure (P&P) manual, dated 2023, the P&P indicated, 1) All foods should be covered, labeled and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their use-by dates or discarded. 2) All food items should be stored upon delivery, and careful rotation procedures should be followed. 3) Food should be dated as it is placed on the shelves, and date marking should be visible and 4) Plastic containers with tight fitting covers or sealable plastic bags must be used for storing lots of bulk foods or opened packages. During a concurrent observation and interview on [DATE], at 10:15 a.m., with CD1 and [NAME] 1, [NAME] 1 soaked approximately 60 potatoes on the left side of a two-compartment sink in a pool of cloudy water. [NAME] 1 stated a potato was placed in the drain to soak the potatoes. On the right side of the two-compartment sink [NAME] 1 stated there was a blue bucket of cleaning solvent with dish rags used for wiping down surfaces. CD1 stated there should not be cleaning solvent next to the food prep area as it could result in cross-contamination of solvent onto food. During observation on [DATE], at 10:45 a.m., the two-compartment sink had a build-up of food and debris on the corners of the sink and sink drain. During an observation on [DATE], at 10:25 a.m., with CD1, there were 12 large resting trays with dirty greasy film, and 14 flat sheet roasting trays and one large roasting pan, which were all considered clean, with metal flakes and grease build-up. There was one large and one medium size saute pan, with protective coating coming off, and all the pans observed were in poor condition with dents and grease build up. The food strainer had an orange build up on the rim and a 3 inch gap on the strainer. The large green cutting board was being used with an accumulation of scrapes and black marks. During an observation on [DATE], at 10:30 a.m., with CD1, a large industrial can opener base was filled with food and oil with food particles on the rotary blade. During a review of the facility's P&P titled, Cleaning Instructions, dated 2017, the P&P indicated, The can opener will be cleaned after each use. During an observation on [DATE], at 10:40 a.m., with CD1, the roasting oven was dirty on the outside with grease and food build up as well as on the metal grates inside the oven. During an observation on [DATE], at 10:45 a.m., with CD1, the stove top grill had thick food and grease buildup on all 8 of the metal grills and underneath the stove, and on the sides of the stove was a thick accumulation of both sticky substance and food debris stuck throughout the rim of the stove. During an observation on [DATE], at 12:30 p.m., the blender and food processor had an accumulation of debris and food particles stuck to the equipment. The food processor had a 2 x 3 inch broken piece on the side of the machine that had built up accumulation of dried debris. During a review of the facility's P&P titled, Cleaning Instructions, dated 2017, the P&P indicated, Food preparation appliances, small appliances such as mixers and food processors will be cleaned and sanitized after each use. During an observation on [DATE], at 10:40 a.m., with CD1, the serving and cooking spoons and utensils were in poor condition. The plastic handles on the cooking utensils had been melted and the metal scoops were indented. There was one ergonomic spoon and one knife in the clean bucket that was visibly dirty with food remaining on the utensil. According to the 2022 Federal Food Code, multiuse food-contact surfaces are to be smooth and food-contact equipment and utensil surfaces are to be clean to sight and touch. During an observation on [DATE], at 11:50 a.m., the drawers next to the two-compartment sink had accumulated large particles of food on the borders and on the side of the drawer. There were two shredding contraptions that had food particles on the grading slicers. The second drawer to the left was also dirty and stored one dirty spatula and one masher in poor repair, with plastic melted on the handle of the masher and brown substance inside the holes, not able to come off with a cloth. During a review of the facility's P&P titled, Cleaning Instructions: Cabinets and Drawers, dated 2017, the P&P indicated, Cabinets and drawers will be free of food particles and dirt. They should be cleaned at least twice a month and as needed when spills occur. According to the 2022 Federal Food Code, food-contact equipment and utensil surfaces are to be clean to sight and touch, and nonfood-contact surfaces of equipment are to be free of an accumulation of dust, dirt, food residue, and other debris. During an observation on [DATE], at 10:35 a.m., there was a large gray/black oven mitt on the stove top. During a review of the facility's P&P titled, Safety in Food Preparation, dated 2017, the P&P indicated, Towels or mitts will not be placed on stove top, and grease should be considered a fire hazard. Do not allow grease to build up on equipment. During a concurrent observation and interview on [DATE], at 10:25 a.m., with [NAME] 2 and CD1, [NAME] 2 was using the extra-large roasting pan to prepare the meat on top of the stove. [NAME] 2 stated the pan was old, but it was what he had to cook large portions. The stove are had copious amounts of food and grease debris on the sides of the stove and large amounts of food particles and grease underneath the metal grates. [NAME] 2 stated that was not good. During a review of the facility's P&P titled, Cleaning Instructions Ovens, dated 2017, the P&P indicated, Ovens will be cleaned as needed and according to the cleaning schedules (at least once every two weeks). Spills and food particles will be removed after each use. During an observation on [DATE], at 10:30 a.m., with CD1, the dishwashing area had a large dirty grease trap, and the white drain below the industrial washer contained a black slimy build up and food particles. There were food peelings in the drain. The tile on the floor to the right of the cleaning area had a large open gap separating the tile from the wall for an approximate five foot (ft) length. During a concurrent observation and interview on [DATE], at 10:40 a.m., with Director of Maintenance (DM) and CD1, in the dishwashing area, the floor underneath the mats had an accumulation of dark and slimy sludge and the grease trap underneath the sink was dirty with accumulation of grease around the perimeter on the floor. Both DM and CD1 stated having an unclean kitchen could lead to illness and attract animals. According to the 2022 Federal Food Code, floors and floor coverings are to be constructed so they are smooth and easily cleanable. In addition, when cleaning methods other than water flushing are used for cleaning floors, the floor and wall junctures are to be covered and closed to no larger than 1 mm (millimeter). If water flush cleaning methods are used, wall junctures are to be covered and sealed. According to the Annex, pooling liquid wastes could attract pests such as insects and rodents or contribute to problems with certain pathogens. According to the 2022 Federal Food Code, if used, grease traps are to be easily accessible for cleaning. According to the Annex, failure to properly maintain and clean a grease trap can result in the harborage of vermin and/or failure of the sewage system. In addition, pooling of floor drains could attract pests such as insects and rodents or contribute to problems with certain pathogens such as Listeria monocytogenes (a type of bacteria that can cause infection).

Based on observation, interview, and record review, the facility failed to verify gastrointestinal tube (GT - digestive tract and related organs) placement for one of five residents (Resident 10) prior to medication administration. This failure had the potential for medications not to be safely and effectively delivered into the stomach and may lead to serious complications such as aspiration pneumonia. Findings: During a review of Resident 10's Admission Record, printed 3/26/25, the record indicated Resident 10 was admitted in 2020 with diagnoses including hemiplegia (muscle weakness on one side of the body) and dysphagia (difficulty swallowing foods or liquids) leading to GT placement. During an observation on 3/25/25, at 12:53 p.m., Licensed Vocational Nurse (LVN) 1 prepared (crushed) two medications separately for Resident 10. LVN 1 placed each medication (med) in a med cup and diluted each with 30 ml (milliliter) of water. LVN 1 did not check if the GT was in the right position in the stomach. LVN 1 then attached a syringe to the feeding tube of Resident 10, started with water flush of 30 ml water, poured each med into the syringe using gravity flow, and poured 15 ml in between the meds. During a review of Resident 10's order summary report with order date 1/18/25, the order summary report indicated, Check GT placement before administering feeding/medication . During an interview on 3/26/25, at 12:34 p.m., with LVN 1, LVN 1 confirmed she did not check GT placement for Resident 10 before administration of the medications on 3/25/25. LVN 1 stated the only time she checked the GT placement was at 8 a.m. before water flush for Resident 10 via the GT and that was what she had always done. During an interview on 3/26/25, at 12:39 p.m., with LVN 1, LVN 1 stated GT placement must be verified before administering meds to ensure the GT is in place and not dislodged, which could result in complications that would lead to sending the resident to the hospital. During an interview on 3/27/25, at 7:50 a.m., with the Director of Nursing (DON), DON stated the GT placement should be verified before administration of medication or feeding to ensure the GT is in place. During a review of the facility's policy and procedure (P&P) titled, Administering Medications through an Enteral Tube, revised November 2018, the P&P indicated, The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral (related to intestines) tube .Verify placement of feeding tube: If you suspect improper tube positioning, do not administer feeding or medication . During a review of the National Institutes of Health National Library of Medicine titled, Enteral Tube Management, dated 2021, indicated, According to the American Association of Critical-Care Nursing recommends that the positions of a feeding tube should be checked and documented every four hours and prior to the administration of enteral feedings and medications . https://www.ncbi.nlm.nih.gov/books/NBK593216/

Based on observation, interviews, document review, and facility policy review, the facility failed to follow the recipe when they prepared pureed chopped beef steak for 11 (Residents #10, #13, #41, #60, #67, #69, #74, #82, #84, #104, and #111) of 11 residents who received pureed diets from the kitchen. Findings included: A review of the facility policy titled, Texture and Consistency Modified Diets, with a copyright date of 2023, revealed, 5. The food and nutrition services department will be responsible for preparing and serving the correct consistency of food and beverages as ordered. A review of a facility document titled, Diet Type Report, dated 04/23/2024, revealed 11 (Residents #10, #13, #41, #60, #67, #69, #74, #82, #84, #104, and #111) residents were ordered a pureed diet. A review of facility Recipe Information, for Chopped Beef Steak (Puree), directed staff to prepare the chopped beef steak according to recipe, then add two and three-fourth pounds of chopped beef steak and one and five-eighths pint of low sodium beef stock in a food processor and process for two to three minutes, or until smooth. On 04/23/2024 at 10:20 AM, the Dietary Director stated 11 residents were ordered a pureed diet. On 04/24/2024 at 10:15 AM, [NAME] #1 was observed to prepare pureed beef. [NAME] #1 poured an unmeasured amount of water and beef base into a pan of ground beef located on a cooktop and continued to allow the mixture to cook. After a few minutes, [NAME] #1 poured all the beef and an unmeasured amount of beef broth into a blender. [NAME] #1 stated he was supposed to follow the recipe, but acknowledged he did not when asked how much both and beef should be used. During an interview on 04/24/2024 at 10:30 AM, the Dietary Director stated when a lot of thickener is added it decreased the nutritional value of the food item and that caused the residents to not get what they were supposed to receive. During an interview on 04/24/2024 at 12:07 PM, the Registered Dietitian (RD) stated the cooks should follow the recipes. The RD stated if the cook added too much liquid to pureed food, it would dilute the nutritional value of the food. During an interview on 04/24/2024 at 1:16 PM, the Director of Nursing stated she expected the cooks to follow the recipes when they prepared pureed foods. During an interview on 04/24/2024 at 2:34 PM, the Administrator stated he expected the cooks to follow the recipe when they prepared pureed food.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure a fall intervention was implemented as documented on the resident care plan for 1 (Resident #19) of 3 sampled residents reviewed for accidents. Findings included: A review of the facility undated policy titled, Fall Prevention Program, revealed 2. A care plan will be developed to include preventative measures that target the specific safety recommendation derived from the risk factors identified in the fall assessment. The goal for the resident will be to prevent future fall and to allow the resident to achieve the highest functioning ability. A review of Resident #19's Admission Record revealed the facility readmitted the resident on 11/24/2023, with diagnoses to include hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. A review of Resident #19's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/12/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident required substantial/maximal assistance with sit to stand, chair/bed-to transfer, and toilet transfers. A review of Resident #19's care plan, revised on 11/24/2023, revealed the resident was at high risk for falls related to impaired balance during transition and weakness. An intervention initiated on 04/20/2024, directed the staff to place a floor//landing pad next to the resident's bed when the resident was in bed. On 04/22/2024 at 10:57 AM, Resident #19 was observed in bed and there was no floor/landing pad next to the resident's bed. On 04/22/2024 at 3:52 PM, Resident #19 was observed in bed and there was no floor/landing pad next to their bed. On 04/23/2024 at 7:22 AM, 9:15 AM, 11:09 AM, 12:24 PM, and 1:59 PM, Resident #19 was observed in bed and there was no floor/landing pad next to the resident's bed. During an interview on 04/23/2024 at 12:42 PM, Licensed Vocational Nurse (LVN) #3, the charge nurse assigned to provide care to Resident #19, stated she was not aware Resident #19 was care planned to have a floor/landing pad next to their bed. During an interview on 04/23/2024 at 12:55 PM, Certified Nurse Aide (CNA) #4, the CNA assigned to provide care to Resident #19, stated he was not aware of an intervention to place a fall mat or landing pad on the floor while the resident was in bed. During an interview on 04/23/2024 at 3:16 PM, LVN #2 stated she implemented the floor/landing pad next to Resident #19's bed after the resident sustained a fall. LVN #2 stated she expected the floor/landing pad to be always in place. During an interview on 04/25/2024 at 9:22 AM, the Administrator stated he expected the staff to follow the policy and procedure.

Based interviews, record review, and facility policy review, the facility failed to ensure a resident's use/need for hearing aids were included on the baseline care plan for 1 (Resident # 180) of 3 sampled residents reviewed for communication/sensory. Findings included: A review of the facility policy titled, Hearing Aid, Care of, revised in February 2018, revealed Purpose The purpose of this procedure is to maintain the resident's hearing at the highest attainable level. Preparation Review the resident's care plan to assess for any special needs of the resident. According to a section of the policy titled documentation, 3. Update care plan, as appropriate with usage and preference for usage. A review of Resident #180's Admission Record revealed the facility admitted the resident on 04/15/2024, with diagnoses that included a need for assistance with personal care. A review of Resident #180's care plan, with an admitted [DATE], revealed no evidence to indicate the resident required hearing aids. A review of Resident #180's Admission Data Collection and Baseline Care Plan Tool, electronically signed by Licensed Vocational Nurse (LVN) #2 and dated 04/16/2024, revealed the resident had clear speech and was alert and oriented to person, place, date, and time/situation. The Admission Data Collection and Baseline Care Plan Tool revealed the resident did not have any assistive/medical devices. During an interview on 04/25/2024 at 8:34 AM, Certified Nurse Aide #5 stated Resident #180 wore hearing aids. During an interview on 04/23/2024 at 3:32 PM, LVN #2 stated Resident #180 admitted to the facility with hearing aids. LVN #2 stated Resident #180's baseline care plan did not reflect the resident used hearing aids. During an interview on 04/24/2024 at 2:30 PM, the Director of Nursing stated she expected nursing staff to include a resident's use of hearing aids on their care plan. During an interview on 04/25/2024 at 9:17 AM, Resident #180 stated they brought their hearing aids to the facility when admitted and staff had ensured their hearing aids were in place. During an interview on 04/25/2024 at 9:22 AM, the Administrator stated the nursing staff should follow the facility policy regarding hearing aids.

Based on observation, interview and record review, the facility failed to ensure outside consultant healthcare practitioners followed PPE requirements for transmission-based precautions during a COVID-19 (a respiratory illness) outbreak for one of three sampled residents. This failure placed Resident 1 at risk of respiratory infection and urinary tract infection (UTI, infection that can affect the bladder, kidneys and connecting components) potentially leading to morbidity and mortality. Findings: A review of Resident 1's admission record, indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of dementia and neuromuscular dysfunction of the bladder (condition which bladder does not drain naturally). A review of Resident 1's physician's orders, indicated Resident 1 had an order, dated 2/6/23, for a foley catheter (tubular device inserted in the urethra to drain urine) and an order for enhanced barrier protection, dated 1/2/23, related to the foley catheter. A review of facility's list of COVID-19 positive residents, dated 7/14/23, indicated the facility had 10 residents that were positive for COVID-19 and the residents were quarantined in a redzone. During an observation and interview on 7/14/23, at 11:00 a.m., with Licensed Vocational Nurse 1 (LVN 1), ultrasound consultant (UC) was observed in Resident 1's room sitting on a chair by Resident 1's bed typing on a computer. UC was not wearing a gown while she was in the room. Resident 1 was in her bed sitting up with no facemask on and had a foley catheter. LVN 1 observed UC in Resident 1's room with a standard facemask and no gown. LVN 1 stated UC was required to wear an N95 respirator because of the COVID outbreak. LVN 1 stated Resident 1 was on enhanced barrier precautions to prevent contamination of her foley catheter and UC needed to wear a protective gown for patient contact activities. During an observation on 7/14/23, at 11:05 a.m., a sign outside of Resident 1's door indicated Resident 1's room was on enhanced barrier protection. The sign indicated staff must wear a protective gown for high contact resident care activities. During an interview on 7/14/23, at 11:15 a.m., with UC, UC stated she was in Resident 1's room and performed a kidney ultrasound (diagnostic procedure to visualize the kidneys using a device placed on the back against the skin). UC stated Resident 1 was on an enhanced barrier protection precaution and for her procedure, a protective gown needed to be worn. UC stated she did not wear a protective gown when she was in Resident 1's room during the procedure. UC stated she did not know why Resident 1 was on enhanced barrier protection. UC stated she was expected to wear a standard mask while in the facility. UC stated she was not given instructions to wear an N95 respirator when she entered the facility because there were no signs or front desk staff to provide instructions. During an interview and record review on 7/14/23, at 12:40 p.m., with Infection Preventionist (IP), the facility's policy and procedure (P&P), titled Enhanced Barrier Protection, dated 7/22/22, was reviewed. The P&P indicated residents with a foley catheter need to be on enhanced barrier precautions as an infection prevention intervention for residents with a foley catheter. The P&P further indicated residents with a foley catheter were at high risk for developing infections. The P&P indicated gowns were required for any care activity where close contact with the resident is expected to occur. During an interview and record review on 7/14/23, at 10:20 a.m. with IP, the facility's P&P titled Mitigation Plan for Testing, Quarantine, Isolation and Vaccination of Health Care Personnel and Residents, dated 4/3/23, was reviewed. IP stated the P&P was used when there was a COVID outbreak. The P&P indicated staff were expected to wear N95 respirators in resident care areas with potential COVID exposure when the facility had a COVID outbreak. IP stated staff including outside consultants were expected to follow the same P&P.

Based on interview and record review, the facility failed to evaluate increased pain and provide pain relief for one of three sampled residents (Resident 1). This failure resulted in Resident 1 experiencing unrelieved, moderate pain when standing and walking during rehabilitative care for one month and 5 days. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility for pneumonitis (infection and inflammation of the lungs), abnormality of gait and mobility, and Parkinson's Disease (a disease resulting in loss of control of limbs and motor functions.) A review of Resident 1's Physical Therapy (PT) Assessment, dated 10/17/22, indicated Resident 1 received physical therapy five times a week which included standing and walking. During a phone interview on 2/23/23, at 2:47 p.m., with Resident 1, Resident 1 stated he did not get adequate pain relief for his left hip during his admission at the facility. Resident 1 stated he frequently rated his left hip pain a five or six on the pain scale (a verbal report of pain level, zero indicating no pain, one to three indicating mild pain, four to six indicating moderate pain and seven to ten indicating severe pain) and only received acetaminophen (a drug to relieve pain) for pain relief. Resident 1 stated he did not always get pain medication as requested, and the acetaminophen was not enough to relieve his hip pain. Resident 1 stated the pain was at its worst when standing and walking during physical therapy sessions. Resident 1 stated the facility frequently made him walk while he was in pain and did not provide him pain relief. During a concurrent interview and record review on 3/22/23, at 1:10 p.m., with Physical Therapy Aide (PTA), Resident 1's Physical Therapy Encounter note, dated 11/7/22, was reviewed. PTA stated the note indicated Resident 1 was unable to walk due to pain and there was a recommendation made to nursing to provide pain medication before physical therapy. During an interview and record review on 3/22/23, at 2:28 p.m., with Registered Nurse (RN 1), Resident 1's physician's order for acetaminophen, dated 10/18/22, Nursing Progress Note , dated 11/7/22, and Medication Administration Record (MAR), dated 11/2022, were reviewed. RN 1 stated Resident 1 had a physician's order for two tablets of acetaminophen to be given as needed for general discomfort and was not specifically ordered for Resident 1's hip pain. RN 1 stated the Nursing Progress Note indicated Resident 1 had left hip pain and could not complete physical therapy. Resident 1's progress note indicated Resident 1 be pre-medicated with pain medication before physical therapy. A review of Resident 1's MAR indicated Resident 1 did not receive acetaminophen on 11/7/22 but had received acetaminophen seven times in November 2022 for pain levels of five to six. During a concurrent interview and record review, on 3/23/23, at 1:30 p.m., with physiatrist (PA, physical therapy specialist), Resident 1's physiatrist assessment, dated 12/12/22, was reviewed. The PA stated the assessment indicated Resident 1 reported frequent, unrelieved pain at his left hip for the past 24 hours and rated his pain at three (mild pain). The assessment indicated Resident 1 experienced increased pain with movement and physical exertion. A review of Resident 1's MAR, dated 12/2022, indicated Resident 1 received did not receive acetaminophen on 12/11 or 12/12. During a phone interview on 3/23/23, at 2:15 p.m. with Resident 1's physician (MD), MD reviewed his progress notes for Resident 1. MD 1 stated he did not recall getting reports of Resident 1's left hip pain from staff and did not document Resident 1's report of pain until 12/7/22. A review of facility's policy and procedure (P&P), titled Pain - Clinical Protocol, dated 7/1/2020, indicated the nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated. The P&P indicated staff will evaluate and report the resident/patient's use of standing and PRN (as needed) analgesics (pain medication).

Based on interview and record review, the facility failed to honor the decision to refuse treatment for one of three sampled residents (Resident 1) when Resident 1 was given an enema (an injection of liquid into the intestine) against the wishes of Resident 1 and Resident 1 ' s responsible party (RP). This failure resulted in Resident 1 and RP feeling helpless in the ability to control healthcare decision-making and caused pain and suffering for Resident 1. Findings: A review of Resident 1 ' s Admission Record, undated, indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including abnormalities of gait and mobility, muscle weakness and epilepsy. A review of Resident 1 ' s Minimum Data Set (MDS, an assessment tool to guide care), dated 6/14/21, indicated Resident 1 had a score of eleven on the Brief Interview for Mental Status (BIMS, an assessment tool for a resident ' s orientation to time and capacity to remember. A BIMS score of eight to twelve is an indication of moderate impairment). During an interview on 7/12/22, at 12:34 p.m., with the Social Services Director (SSD), SSD stated Resident 1 could speak and make her wishes known, and Resident 1 ' s RP was the decision maker for Resident 1. A review of Resident 1 ' s Acute Care Hospital (ACH) Emergency Department (ED) Record, dated 7/10/21, at 4:46 p.m., indicated Resident 1 arrived at the ACH ED from the facility with a chief complaint of rectal (area of the intestine where a person holds solid waste before it exits the body) bleeding, and was diagnosed with a perirectal abscess (a painful, pus-filled cavity in the rectum). A review of Resident 1 ' s ACH Surgical Service Clinical Notes, dated 7/10/21, at 10:40 p.m., indicated Resident 1 underwent a surgical procedure to open and drain Resident 1 ' s perirectal abscess. A review of Resident 1 ' s Progress Notes, dated 7/12/21, at 4:40 p.m., indicated Resident 1 was readmitted to the facility, alert and oriented. A review of Resident 1 ' s Order Summary Report, dated 7/15/21, indicated, Warm water enema x1 now one time only for constipation (solid waste which becomes hard and dry in the rectum and difficult to pass through the digestive system). A review of Resident 1 ' s Progress Notes, dated 7/15/21, at 3:35 p.m., by Licensed Vocational Nurse 1 (LVN 1), indicated Resident 1 complained of constipation, but Resident 1 refused warm water enema. During an interview on 7/12/22, at 1:10 p.m., with Registered Nurse 1 (RN 1), RN 1 stated Resident 1 had strongly refused to have the enema. During an interview on 7/12/22, at 2:00 p.m., with Charge Nurse 1 (CN 1), CN 1 stated residents have the right to refuse a treatment or procedure, and the resident may not be treated against his or her wishes. During an interview on 6/2/22, at 10:51 a.m., with RP, RP stated she was Resident 1 ' s medical decision maker. RP stated she spoke by phone with CN 1 on 7/15/21, at 1:59 p.m., and when asked by CN 1 about administering an enema to Resident 1, RP stated she responded no because Resident 1 had a surgical wound, and that area was still too sore, sensitive, and delicate. A review of Resident 1 ' s Progress Notes, dated 7/16/21, at 4:09 p.m., by LVN 1, indicated, Lidocaine 25%/Prilocaine 25% ointment applied to rectal area prior to enema administration at 12:15 p.m. Ointment applied at 2:45 p.m. and enema administered thereafter. During an interview on 7/12/22, at 3:00 p.m., with LVN 2, LVN 2 stated Resident 1 had severe rectal pain following the enema, and LVN 2 administered Norco (a medication used to relieve moderate to severe pain) to Resident 1. During an interview on 6/2/22, at 10:51 a.m., with RP, RP stated she had clearly told staff, No enemas or suppositories for Resident 1. RP stated when she observed Resident 1 on 7/17/21 following the enema, Resident 1 was emotionally shut down, and was refusing food, medication and a diaper change. A review of the facility ' s policy and procedure (P&P) titled, Resident Rights Guidelines for all Nursing Procedures, dated 7/1/21, indicated, Resident has right of refusal (medications and treatments) .Ask permission to implement the procedure. If the resident refuses, notify your supervisor.

Based on observation, interview and record review, the facility failed to ensure certified nursing assistants completed annual mandatory training when: 1. Four of six sampled certified nursing assistants (CNA 3, 4, 5, and 6) did not complete required annual training for care of residents with dementia (an impairment in memory, communication and thinking). 2. Two of six sampled certified nursing assistants (CNA 3 and CNA 6) did not complete required annual training for prevention of abuse. These failures had the potential for employees to provide improper or inadequate resident care provision. Findings: During an interview with the Director of Staff Development (DSD) on 5/11/21 at 9:15 a.m., DSD stated CNA 3, 4, 5, and 6 had not completed annual dementia training, and CNA 3 and CNA 6 had not completed annual abuse training. DSD stated there was no documentation of training classes offered during 2020. A review of Personnel Records for CNA 3, 4, 5, and 6 on 5/14/21 at 9:00 a.m., indicated the most recent completion dates for dementia and/or abuse trainings were as follows: CNA 3: Dementia training on 4/2/2020; abuse training on 3/21/2020. CNA 4: Dementia training on 10/28/2019. CNA 5: Dementia training on 10/29/2018. CNA 6: Dementia training 4/4/19; abuse training on 2/7/19. A review of the facility's policy and procedure titled, Staff Development Program, undated, reflected, All personnel must participate in initial orientation and regularly scheduled in-service training classes . Each program shall include, but not be limited to: .Abuse Program .Dementia.

Based on observation, interview, and record review, the facility failed to ensure that drugs were stored and labeled in accordance with currently accepted professional standards when: 1. Inside the medication room, a bottle of [MEDICATION(S)] (treats [CONDITION(S)] disease) [MEDICATION(S)] 50 milligram (mg.)/5 milliliter (ml.) syrup was not stored according to manufacturer's recommendation. This failure had the potential to result in decreasing efficacy of the medication. 2. Inside medication cart, 3 North, multiple medications were either stored beyond the expiration date or not labeled with open-on dates. This failure had the potential to result in medication's decreased therapeutic efficacy. 3. An opened and unlabeled bag of 0.9 % normal saline for injection was left at Resident 48's bedside. This failure had the potential to result in confusion and medication errors. Findings: 1. During an observation of the facility's medication room and concurrent interview with Director of Nursing (DON) on 5/11/21 at 11:15 a.m., there was an unopened bottle of [MEDICATION(S)] [MEDICATION(S)] 50 mg./5 ml. stored inside the medication refrigerator. The refrigerator's interior temperature was 40 degrees Fahrenheit 40 deg. F. The bottle did not have a sticker refrigerate. DON stated, she was not sure whether the medication was supposed to be stored inside the refrigerator or at room temperature. During a follow-up interview and concurrent review of the manufacturer's drug information with DON on 5/12/21 at 10:49 a.m., DON stated, [MEDICATION(S)] was to be stored at room temperature. The manufacturer's literature indicated, Store at 20 to 25 deg. Centigrade (68 to 78 deg. F). 2. During an observation of medication cart 3 North and concurrent interview with Licensed Vocational Nurse (LVN) 1 on 5/11/21 at 11:55 a.m., the following were observed: - [MEDICATION(S)] HFA (treats asthma or breathing difficulty) 90 microgram (mcg.) inhaler, with expiration date 1/29/21. - Three opened [MEDICATION(S)] 100-20 mcg (treats asthma) inhalers with no opened-on dates. - [MEDICATION(S)] (treats asthma)160/4.5 inhaler, opened, with no opened-on date. - [MEDICATION(S)] (lowers eye pressure) eye drops, opened, with no opened-on date. LVN 1 stated she did not know when the medications were opened. LVN 1 also stated, once opened and did not have any date, LVN 1 would not know if medication was still good to use. Review of the manufacturer's information provided by the DON on 5/13/21 at 1:30 p.m., indicated the following: - After assembly, [MEDICATION(S)] respimat inhaler should be discarded at the latest 3 months after first use or when the locking mechanism is engaged (120 actuations), whichever comes first. -Throw away [MEDICATION(S)] when the counter reaches zero (0) or 3 months after you take [MEDICATION(S)] out of its foil pouch, whichever comes first. - For [MEDICATION(S)] eye drops, once a bottle is opened for use, [MEDICATION(S)] may be stored at room temperature up to 77 deg. F for 6 weeks. 3. During an observation and concurrent interview with Director of Staff Development on 5/10/21 at 12:35 p.m., there was an an opened, unlabeled bag of [MEDICATION(S)] 5% in Normal Saline that was still attached to an IV pole at Resident 48's bedside. DSD stated, Resident 48 did not have an intravenous line on either arms. DSD also stated, because the IV bag was not labeled, DSD did not know for sure if that was for Resident 48, or when the IV was opened. DSD stated, the bag should have been labeled with Resident 48's name and date of opening. DSD stated Resident 48 was not verbal and not aware of the surroundings. During an interview with DON on 5/10/21 at 1:46 p.m., DON stated Resident 48 had been on intravenous (through the vein) hydration on and off depending on oral fluid intake. DON stated she did not know the last time Resident 48 had an order to get intravenous hydration.

Based on interviews, and record reviews, the facility failed to provide the necessary care for one (Resident 1) of three sampled residents. Resident 1 had an oxygen saturation level of 98% on room air on 4/16 which dropped to 94% the next 3 days and to 92% on 4/20/14. By 3:30 p.m. on 4/21/14 her oxygenation level was 89% on room air. Staff did not call the physician until 6:45 p.m. on 4/21/14 and physician responded at 8:05 p.m. directed staff to call an ambulance. Staff did not call 911 and Resident 1 waited another 35 min for ambulance to arrive. Resident 1 was admitted to the hospital, intubated and placed on mechanical ventilation(mechanical ventilation: tube placed down the throat and into the lungs in order to deliver oxygen emergently} and treated for [REDACTED]. Resident 1 remained in the hospital for 2 1/2 weeks. Findings: The facility admitted Resident 1 on 4/16/13 with a [DIAGNOSES REDACTED]. Record review of the physician admission orders [REDACTED]. (oxygen saturation: concentration of oxygen in the blood) Record review of the nursing notes showed the following: 4/16/13 - Resident 1 was alert, responsive, with an oxygen saturation of 98% on room air. (room air: no oxygen provided) 4/17/13 - Resident 1 was alert and in no distress. Oxygen saturation was 93% on room air. 4/18/13 - Resident 1 had no shortness of breath and was verbally responsive with oxygen saturation at 94% on room air. 4/19/13 - Resident 1's oxygen saturation was 94% on room air. 4/20/13 - 2:00 p.m. - Resident 1's oxygen saturation was 92% on room air. 10:00 p.m. - Resident 1 appeared tired and weak. Oxygen saturation was 94% on 2 Liters of oxygen. There was no documented assessment of lung sounds. Record review of the nursing notes dated 4/21/13, showed the following: 5:00 a.m. - Resident 1 was placed on 2 Liters/minute of oxygen with saturations at 92% 2:30 p.m. - Resident 1 was nauseated. Oxygen saturation was 92% on 2 Liters of oxygen. 3:30 p.m. - Resident 1 appeared weak. Oxygen saturation was 89% on room air. Two liters of oxygen was administered. Oxygen saturation was rechecked at 92%. There was no documented vital signs, lung sounds, or calls made to the physician. In an interview on 4/3/14 at 2:17 p.m., the physician, (MD 1) was asked if the on-call physician should have been contacted regarding Resident 1's desaturation, (drop in oxygen level). MD 1 stated that, "Yes. The staff should have called when the oxygen saturation dropped to 89% at 3:30 p.m." On 4/21/13 between the times of 3:30 p.m. and 6:30 p.m., nursing notes showed no documentation of oxygen saturation level checks, vital signs, or lung sound assessments. Record review of the nursing notes dated 4/21/13 at 6:30 p.m., showed that Resident 1's oxygen saturations were between 86 and 89% on 2 Liters of oxygen. At 6:45 p.m., the nursing notes showed that a call was placed to the physician. Record review of the nursing notes dated 4/21/13 at 8:05 p.m., showed that the physician called back and directed staff to send Resident 1 to the Hospital emergency room for further evaluation. The ambulance was called and would arrive at the facility in 30 to 35 minutes. (ambulance transport, not 911) In an interview on 4/3/14 at 2:17 p.m., MD 1 was asked about the timing of the call, (6:45 p.m.), to the physician. MD 1 stated that it was, "Not okay to wait 3 hours to call the physician. The physician should have been called earlier so that a Chest X-Ray and possible diuretics could have been given for heart failure." (Diuretics: medication which helps rid the body of excess fluid and salts which then improves circulation and breathing) In an interview on 3/14/14 at 9:45 a.m., the Charge Nurse, (CRN), was asked to describe the steps she took in caring for Resident 1 on 4/21/13. The CRN stated that she, "Could not remember the patient or what was going on at the time. " CRN stated that she therefore, "Could not answer," any questions regarding Resident 1's care. In an interview on 4/3/14 at 10:30 a.m., the Director of Nursing, (DON), was asked if staff responded appropriately to Resident 1's declining oxygen levels. The DON stated that she, "Would have had to have been there," in order to answer the question. The DON was then asked if, based on the nursing documentation regarding a decreasing level of oxygen, did the staff respond appropriately. The DON stated that she, "Would not answer the question." In an interview on 3/14/14 at 11 a.m., Resident 1's family member, (Family 1), stated that he had arrived at the facility at 5:30 p.m. on 4/21/13. Family 1 stated that Resident 1, " Could hardly breath. No one was paying attention. She was aspirating, (choking), on her own saliva. I talked to the charge nurse. She did not know what to do. They, (the staff), did not want to call 911. They said it was their protocol to call for an ambulance transport to the hospital. They were not realizing the seriousness of the situation. The charge nurse was working on the paperwork and said that the transport ambulance would be there in 30 minutes. I insisted that they call 911." Record review of the nursing notes dated 4/21/13 at 8:10 p.m., showed that Resident 1 appeared weaker with pale, cold skin. Hand grasps were equal but weak. Oxygen saturation was 82 to 85% on 4 Liters of oxygen. At 8:27 p.m., 911 was called and Resident 1 was transported emergently to the hospital. Record review of the emergency room record dated 4/21/13, showed that Resident 1 was diagnosed with [REDACTED]. [MEDICAL CONDITION] with [MEDICAL CONDITION] Pneumonia Kidney Injury Resident 1 was pale and cold in the emergency room and placed on 100% oxygen. Resident 1 was placed on a [MEDICATION NAME] Intravenous drip. (Intravenous: directly into the veins) ([MEDICATION NAME]: medication used to raise dangerously low blood pressure up to a safe level) In an interview on 4/3/14 at 2:17 p.m., MD 1 was asked about the timing of the 911 call. MD 1 stated that, "911 should have been called at 8:10 p.m. Staff should not have waited another 17 minutes to call." MD 1 was asked if he thought that Resident 1's status and medical interventions in the emergency room would have had a different outcome if the physician had been called earlier. MD 1 stated that, due to Resident 1's baseline heart problems, she would have still needed to to to the hospital. She had, "Heart failure [MEDICAL CONDITION] which caused her kidneys to fail. If she had been caught earlier, she would not have crashed. Studies show that, if you [MEDICAL CONDITION] quickly, there is a better outcome. she had a delay from her oxygen desaturations and weakness at 3:30 p.m. until the 911 call at 8:27 p.m. There was time for intervention. For example, we could have spared her the damage to her kidneys." (Sepsis: generalized infection throughout the body) Record review of the facility's policy and procedure entitled, Guidelines for Notifying Practitioners of Clinical Problems, and dated 2001, showed that immediate notification problems include sudden onset or a marked change. (for example, much more severe), compared to usual, (baseline status), and are unrelieved by measures which have already been prescribed. Record review of the facility's policy and procedure entitled, Making an Emergency Transfer - 911, and dated 2007, showed that the facility should make an emergency transfer or discharge when it is in the best interest of the resident. Record review of the care plan dated 4/16/13, identified Resident 1 as being at risk for cardiac and respiratory distress. Interventions included monitoring of lung sounds, cardiac-respiratory distress and to notify the doctor. One of the first signs of heart failure is fatigue and an inability to adequately oxygenate. The heart is failing and is unable to do its work; it has lost its' pumping efficiency. Failure of the heart can lead to congestion in the bodies' circulation. The [MEDICAL CONDITION], (lung), circulation becomes congested. Symptoms include crackling lung sounds and dyspnea. ( shortness of breath) Excess fluid in the circulation can be relieved by the use of diuretics, which help rid the body of excess fluid and salts, thus improving systemic circulation and increasing urinary output. Acute [MEDICAL CONDITION] occurs when the cardiovascular system fails to perfuse the kidneys adequately with blood. (Textbook of Basic Nursing: Wolters/Kluwer, 2008) ______________________________________________________________________ Class "B" Citation No. 02-2569- 52-F The facility violated this regulation by its failure to: 1. Consult with the physician promptly when Resident 1's condition changed from not needing oxygen on admission, to oxygen desaturation at 89%, nausea and weakness on 4/21/13 at 3:30 p.m.2. Call for emergency transport to take Resident 1 to the emergency room immediately on 4/21/14 at 8:10 p.m., when she was weaker, with pale cold skin.3. Prevent Resident 1's deterioration to the point of acute [MEDICAL CONDITION], requiring mechanical ventilation for breathing, treatment for [REDACTED].The facility admitted Resident 1 on 4/16/13 with a [DIAGNOSES REDACTED].Record review of the physician admission orders [REDACTED]. (oxygen saturation: concentration of oxygen in the blood)Record review of the nursing notes showed the following:4/16/13 - Resident 1 was alert, responsive, with an oxygen saturation of 98% on room air. (room air: no oxygen provided)4/17/13 - Resident 1 was alert and in no distress. Oxygen saturation was 93% on room air.4/18/13 - Resident 1 had no shortness of breath and was verbally responsive with oxygen saturation at 94% on room air.4/19/13 - Resident 1's oxygen saturation was 94% on room air.4/20/13 - 2:00 p.m. - Resident 1's oxygen saturation was 92% on room air. 10:00 p.m. - Resident 1 appeared tired and weak. Oxygen saturation was 94% on 2 Liters of oxygen. There was no documented assessment of lung sounds.Record review of the nursing notes dated 4/21/13, showed the following:5:00 a.m. - Resident 1 was placed on 2 Liters/minute of oxygen with saturations at 92%2:30 p.m. - Resident 1 was nauseated. Oxygen saturation was 92% on 2 Liters of oxygen.3:30 p.m. - Resident 1 appeared weak. Oxygen saturation was 89% on room air. Two liters of oxygen was administered. Oxygen saturation was rechecked at 92%.There were no documented vital signs, lung sounds, or calls made to the physician.In an interview on 4/3/14 at 2:17 p.m., the physician, (MD 1) was asked if the on-call physician should have been contacted regarding Resident 1's desaturation, (drop in oxygen level). MD 1 stated that, "Yes. The staff should have called when the oxygen saturation dropped to 89% at 3:30 p.m."On 4/21/13 between the times of 3:30 p.m. and 6:30 p.m., nursing notes showed no documentation of oxygen saturation level checks, vital signs, or lung sound assessments.Record review of the nursing notes dated 4/21/13 at 6:30 p.m., showed that Resident 1's oxygen saturations were between 86 and 89% on 2 Liters of oxygen. At 6:45 p.m., the nursing notes showed that a call was placed to the physician.Record review of the nursing notes dated 4/21/13 at 8:05 p.m., showed that the physician called back and directed staff to send Resident 1 to the Hospital emergency room for further evaluation. The ambulance was called and would arrive at the facility in 30 to 35 minutes. (Ambulance transport, not 911)In an interview on 4/3/14 at 2:17 p.m., MD 1 was asked about the timing of the call, (6:45 p.m.), to the physician. MD 1 stated that it was, "Not okay to wait 3 hours to call the physician. The physician should have been called earlier so that a Chest X-Ray and possible diuretics could have been given for heart failure." (Diuretics: medication which helps rid the body of excess fluid and salts which then improves circulation and breathing)In an interview on 3/14/14 at 9:45 a.m., the Charge Nurse, (CRN), was asked to describe the steps she took in caring for Resident 1 on 4/21/13. The CRN stated that she, "Could not remember the patient or what was going on at the time. " CRN stated that she therefore, "Could not answer," any questions regarding Resident 1's care.In an interview on 4/3/14 at 10:30 a.m., the Director of Nursing, (DON), was asked if staff responded appropriately to Resident 1's declining oxygen levels. The DON stated that she, "Would have had to have been there," in order to answer the question. The DON was then asked if, based on the nursing documentation regarding a decreasing level of oxygen, did the staff respond appropriately. The DON stated that she, "Would not answer the question."In an interview on 3/14/14 at 11 a.m., Resident 1's family member, (Family 1), stated that he had arrived at the facility at 5:30 p.m. on 4/21/13. Family 1 stated that Resident 1, "Could hardly breath. No one was paying attention. She was aspirating, (choking), on her own saliva. I talked to the charge nurse. She did not know what to do. They, (the staff), did not want to call 911. They said it was their protocol to call for an ambulance transport to the hospital. They were not realizing the seriousness of the situation. The charge nurse was working on the paperwork and said that the transport ambulance would be there in 30 minutes. I insisted that they call 911."Record review of the nursing notes dated 4/21/13 at 8:10 p.m., showed that Resident 1 appeared weaker with pale, cold skin. Hand grasps were equal but weak. Oxygen saturation was 82 to 85% on 4 Liters of oxygen. At 8:27 p.m., 911 was called and Resident 1 was transported emergently to the hospital.Record review of the emergency room record dated 4/21/13, showed that Resident 1 was diagnosed with [REDACTED].Resident 1 was pale and cold in the emergency room and placed on 100% oxygen. Resident 1 was placed on a [MEDICATION NAME] Intravenous drip. (Intravenous: directly into the veins) ([MEDICATION NAME]: medication used to raise dangerously low blood pressure up to a safe level.)In an interview on 4/3/14 at 2:17 p.m., MD 1 was asked about the timing of the 911 call. MD 1 stated that, "911 should have been called at 8:10 p.m. Staff should not have waited another 17 minutes to call." MD 1 was asked if he thought that Resident 1's status and medical interventions in the emergency room would have had a different outcome if the physician had been called earlier. MD 1 stated that, due to Resident 1's baseline heart problems, she would have still needed to go to the hospital. She had, "Heart failure [MEDICAL CONDITION] which caused her kidneys to fail. If it had been caught earlier, she would not have crashed. Studies show that, if you [MEDICAL CONDITION] quickly, there is a better outcome. She had a delay from her oxygen desaturations and weakness at 3:30 p.m. until the 911 call at 8:27 p.m. There was time for intervention. For example, we could have spared her the damage to her kidneys." (Sepsis: generalized infection throughout the body)Record review of the facility's policy and procedure entitled, Guidelines for Notifying Practitioners of Clinical Problems, and dated 2001, showed that immediate notification problems include sudden onset or a marked change. (For example, much more severe), compared to usual, (baseline status), and are unrelieved by measures which have already been prescribed.Record review of the facility's policy and procedure entitled, Making an Emergency Transfer - 911, and dated 2007, showed that the facility should make an emergency transfer or discharge when it is in the best interest of the resident.Record review of the care plan dated 4/16/13, identified Resident 1 as being at risk for cardiac and respiratory distress. Interventions included monitoring of lung sounds, cardiac-respiratory distress and to notify the doctor.One of the first signs of heart failure is fatigue and an inability to adequately oxygenate. The heart is failing and is unable to do its work; it has lost its' pumping efficiency. Failure of the heart can lead to congestion in the bodies' circulation. The [MEDICAL CONDITION], (lung), circulation becomes congested. Symptoms include crackling lung sounds and dyspnea (shortness of breath). Excess fluid in the circulation can be relieved by the use of diuretics, which help rid the body of excess fluid and salts, thus improving systemic circulation and increasing urinary output. Acute [MEDICAL CONDITION] occurs when the cardiovascular system fails to perfuse the kidneys adequately with blood. (Textbook of Basic Nursing: Wolters/Kluwer, 2008)Therefore the facility failed to:1. Consult with the physician promptly when Resident 1's condition changed from not needing oxygen on admission, to oxygen desaturation at 89%, nausea and weakness on 4/21/13 at 3:30 p.m.2. Call for emergency transport to take Resident 1 to the emergency room immediately on 4/21/14 at 8:10 p.m. when she was weaker, with pale cold skin.3. Prevent Resident 1's deterioration to the point of acute [MEDICAL CONDITION], requiring mechanical ventilation, treatment for [REDACTED].