Every finding on record at Providence Little Co of Mary Transitional Care CTR

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 90) received a self administration assessment, education, and a physician order prior to self administering an albuterol puff inhaler (a medication used for shortness of breath). This failure resulted in Resident 90 keeping and using an albuterol inhaler at the bedside and placed the resident at risk for improper medication use and potential unsafe clinical outcomes.Findings:During a review of Resident 90's admission Record, the admission Record indicated, Resident 90 was admitted to the facility on [DATE], with diagnosis including chronic obstruction pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), cataract ( chronic disease-causing blurred vision) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing)During a review of Resident 90's History and Physical (H&P), dated 4/27/2026, the H&P indicated, Resident 90 was alert and oriented.During a concurrent observation and interview on 4/29/2026 at 9:35 a.m. in Resident 90's room, Resident 90 was observed holding an albuterol puff inhaler in her hand. Resident 90 stated she used the inhaler at least one to three times per day and described it as her lifeline, stating it helped her feel safe. Resident 90 stated she became very nervous when she did not have the inhaler with her because she relied on it when experiencing difficulty breathing.During a concurrent interview and record review on 4/30/2026 at 2:57 p.m. with Registered Nurse 1 (RN 1), Resident 90 did not have a self administration of medication assessment or a physician order for an albuterol puff inhaler in the medical record. RN 1 stated residents may self administer medications only after being assessed for their ability to safely do so and after receiving education on the facility's self administration process. RN 1 stated Resident 90's safety was at risk because she had not been properly assessed or educated prior to self administering the medication.During an interview on 4/30/2026 at 2:39 p.m. with the Director of Nurses (DON), the DON stated she was aware Resident 90 had not been properly assessed to keep an albuterol puff inhaler at the bedside. The DON stated nursing staff were required to complete an assessment with the resident prior to allowing a resident to store or self administer their medication to ensure the resident does not overuse or improperly use the medication.During a review of the facility's policy and procedure (P&P) titled, Self-Administration of Medication dated 3/2024, the P&P indicated, self-administration of medications by patients may be allowed when ordered by a physician/ provider and for medications deemed appropriate for safe self-administration. Patients or designated caregivers must be assessed by licensed patient care providers and felt to be competent to be allowed to self-administer medications. Patients must be able to understand and properly perform self-administration procedures. All self-administered medications must be documented on the patient's Medication Administration Record [MAR]) by the nurse or other licensed care. The P&P indicated, medications not ordered and/or approved by pharmacy to be stored at bedside will be stored in the proper medication storage area on the patient's nursing unit.and will be accessed by nursing or another authorized licensed patient care provider.

Based on observation, interview, and record review, the facility failed to maintain a comfortable and safe environment when the overhead light in Resident 17's room was found to be non-functional, providing inadequate lighting for daily activities.This failure resulted in Resident 17's having limited visibility during evening hours, increasing the risk of falls, injury, or difficulty accessing the call light.Findings:During a review of Resident 17's admission Record, the admission Record indicated Resident 17 was admitted to the facility on [DATE].During a review of Resident 17's History and Physical (H&P) dated 4/16/2026, the H&P indicated Resident 17 with diagnoses of hypertension (HTN- high blood pressure) and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 17's Minimum Data Set (MDS- a resident assessment tool) dated 4/22/2026, the MDS indicated Resident 17 cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 17 required touching assistance (helper provides verbal cues and/or touching assistance as resident completes the activity) with activities of daily living (ADLs- routine tasks such as bathing, dressing, and toileting a person performs daily to care for themselves).During a review of Resident 17's Work Order dated 4/25/2026, the Work Order indicated Resident 17's overhead light was not working. The Work Order also indicated the overhead light was completed as requested on 4/27/2026 by Plant Operations and Maintenance (POM).During a concurrent observation and interview on 4/27/2026 at 11:26 a.m., in Resident 17's room, Resident 17 stated she informed the staff her overhead light had not been working. Resident 17 stated she would prefer it if her overhead light worked so at night she could read her paperwork.During a concurrent observation and interview on 4/27/2026 at 1:17 p.m., with Registered Nurse (RN) 5, in Resident 17's room, RN 5 tried turning on Resident 17's overhead light but it did not turn on. RN 5 stated the light should be working for Resident 17's safety when it's dark.During a concurrent interview and record review on 4/29/2026 at 9:45 a.m., with POM, POM stated the Work Order indicated Resident 17's overhead light was completed. POM stated he made a mistake and thought it was the other rooms bed overhead light that needed to be fixed and marked as completed. POM stated Resident 17's overhead light not working could cause Resident 17 to feel unhappy because she is unable to see properly.During an interview on 4/30/2026 at 2:35 p.m., with the Director of Nursing (DON), the DON stated Resident 17's overhead light not working could cause Resident 17 to feel frustrated that her needs are not being met because she likes to read the paper.During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 5/2024, the P&P indicated, The resident has the right to a safe, clean, comfortable, and homelike environment. The facility must provide adequate and comfortable lighting levels in all areas.

Based on interviews, and record review the facility failed to ensure one of three sampled residents (Resident 69) had timely physician notification and appropriate nursing interventions when Resident 69's experienced a change of condition([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) when Resident 69 blood pressure (a measurement of the force exerted by circulating blood against the wall of the arteries) dropped to 98/43 millimeters of mercury (mm/Hg) on [DATE] at 3:57 p.m.This failure resulted in a delay in care and led to Resident 69 becoming non responsive, requiring Cardiopulmonary Resuscitation (CPR-an emergency lifesaving procedure performed when the heart stops beating or breathing ceases), and being pronounced dead on [DATE] at 10:30 p.m.Findings:During a review of Resident 69's admission Record (Face Sheet-front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 69 was admitted to the facility on [DATE].During a review of Resident 69's History and Physical (H&P) dated [DATE], the H&P indicated Resident 69 was admitted to the facility with diagnoses of hypertension (HTN-high blood pressure), coronary artery disease (the blood vessels that supply the heart with blood, oxygen, and nutrients become damaged or diseased), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dysphagia(difficulty swallowing) and acute kidney injury (a sudden episode of kidney damage or failure that happens within a few hours or a few days) on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). The H&P indicated the plan for Resident 69 was Physical therapy (PT, licensed professional aimed in the restoration, maintenance, and promotion of optimal physical function), Occupational therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities), and Speech therapy ( ST-assessment and treatment of communication, language, voice, fluency, and swallowing disorders ) secondary to dysphagia.During a review of Resident 69's Minimum Data Set (MDS-a resident assessment tool), dated [DATE], the MDS indicated Resident 69 usually had the ability to understand and express ideas and wants. The MDS indicated Resident 69 usually had the ability to understand others. The MDS indicated Resident 69 was dependent (helper does all the effort) on nursing staff dressing, personal hygiene, toileting, and rolling from left to right. The MDS indicated Resident 69 needed substantial to moderate assistance (helper does more than half the effort) from nursing staff with eating, and oral hygiene.During a concurrent interview and record review on [DATE] at 8:47 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 69's vital signs dated [DATE] at 3:57 p.m. were reviewed. The vital signs indicated a blood pressure of 98/43 mm/Hg, temperature of 95.7 degrees Fahrenheit ( F), heart rate of 96 beats per minute, respirations of 18 breaths per minute, and an oxygen saturation (O2 sat-a measurement of how much oxygen the blood is carrying as a percentage) of 98%. LVN 1 stated the blood pressure was abnormally low. LVN 1 stated she did not see any documentation in Resident 69's medical record indicating the physician had been notified of the low blood pressure. LVN 1 stated licensed nurses were required to notify the registered nurse supervisor immediately of any change of condition. LVN 1 stated when vital signs are low, the nurse should notify the physician right away, elevate the resident's legs, offer fluids, wait for medical orders, recheck the blood pressure, and transfer the resident to general acute care hospital (GACH) emergency room if necessary. LVN 1 stated Resident 69 was in danger of dying with a blood pressure that low.During an interview on [DATE] at 9:47 a.m. with Registered Nurse (RN) 7, RN 7 stated certified nursing assistants (CNA) obtain residents' vital signs at the start of the shift, and if the physician was not notified of an abnormally low blood pressure, the issue will not be properly addressed. RN 7 stated Resident 69 was on dialysis, was fragile, and required prompt medical orders and interventions. RN 7 stated medication or other interventions should have been administered to address the low blood pressure, or it would continue to drop.During an interview on [DATE] at 1:50 p.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 69's blood pressure reading of 98/43 mm/Hg was abnormally low and required immediate reporting to the charge nurse because such a low blood pressure could lead to breathing problems and potentially result in a Code Blue (a life threatening medical emergency). CNA 4 stated he reported the blood pressure to Licensed Vocational Nurse (LVN) 2, who stated he would check on Resident 69. CNA 4 stated he did not recheck the resident's blood pressure. CNA 4 stated the next time he saw Resident 69, the resident appeared pale, and he informed LVN 2. CNA 4 stated LVN 2 then called a code blue and initiated chest compressions (the application of rapid, forceful pressure to the chest to manually circulate blood when the heart has stopped) to Residente 69.During an interview on [DATE] at 2:27 p.m. with LVN 2, LVN 2 stated on [DATE] at approximately 3 p.m., Resident 69 had just returned from dialysis and appeared weak. LVN 2 stated at 3:57 p.m. the resident's blood pressure was 98/43 mm/Hg. LVN 2 stated he did not remember calling the physician and did not document the change of condition or complete an Situation, Background, Assessment, Response (SBAR a structured communication tool which enhances the communication between members of the healthcare team) in the progress notes. LVN 2 stated licensed nurses are required to recheck low vital signs and notify the physician because the resident is experiencing a change of condition and could die.During a review of Resident 69's Nursing Progress Notes, dated [DATE], the Nursing Progress notes indicated on [DATE] at 9:10 p.m. Resident 69 was non-responsive, cold clammy, not breathing and pulseless. The Nursing Progress Notes indicated Resident 69 was a full code and CPR was started. The Nursing Progress Notes indicated 911 was called and arrived at 9:30 p.m. The Nursing Progress Notes indicated Resident 69 was pronounced dead at 10:30 p.m.During an interview on [DATE] at 2:59 p.m. with the Director of Nursing (DON), the DON stated the licensed nurse should have made sure Resident 69 was stable and rechecked the vital signs and notified the Resident 69's doctor immediately. During a review of the facility's policy and procedure (P&P), titled Transitional Care Center: Notification of Change in Resident Status, dated 7/2025, the P&P indicated .The physician shall be notified promptly of the following types of events in the facility. Any sudden and/or marked adverse change in signs, symptoms of behavior exhibited by a resident, such as abnormal vital signs, signs of redness, bloody stool, sputum or urine, drainage from wounds, sleeping too much, lethargy, signs of upper respiratory infection.

Based on interviews, record review, and policy review, the facility failed to ensure effective and appropriate pain management for one of one sampled residents (Resident 40). The facility failed to:1.Ensure pain medications were administered according to the physician's orders and pain level parameters.2.Ensure appropriate assessment and communication with the physician regarding the resident's pain.This failure placed Resident 40 at risk for receiving medication stronger than clinically indicated and experiencing adverse side effects (unwanted, uncomfortable, or dangerous reactions to medication). Findings:During a review of Resident 40's admission Record (Face Sheet-front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 40 was admitted to the facility on [DATE].During a review of Resident 40's Physician Orders, the Physician Orders indicated Hydrocodone-acetaminophen (Norco-a brand name prescription that combines hydrocodone and acetaminophen used to treat severe pain) 5-325 milligrams (mg-unit of measurement) every four hours as needed for pain level of 4-6 (numeric pain scale/moderate pain,) was discontinued on 4/15/2025.During a review of Resident 40's History and Physical (H&P), dated 4/17/2026, the H&P indicated Resident 40 was admitted to the facility with diagnoses of but not limited to thoracic 3 (T3) toT4 compression fracture ( third and fourth vertebrae of the upper to mid back [the thoracic spine] collapse or break), prostatitis (inflammation or infection of the prostate gland), and urinary retention (inability to completely or partially empty the bladder).During a review of Resident 40's Minimum Data Set (MDS-a resident assessment tool), dated 4/22/2026, the MDS indicated Resident 40 had the ability to understand others and express wants and ideas. The MDS indicated Resident 40 used a walker and a wheelchair. The MDS indicated Resident 40 needed partial to moderate assistance (helper does less than half the effort) from nursing staff with lying down, sitting, and transferring from a bed to a chair. The MDS indicated Resident 40 needed supervision or touching assistance (helper provides verbal cues and or touching, steadying, and or contact guard assistance as resident completes activity) with toileting, dressing personal hygiene and rolling from left to right. The MDS indicated Resident 40 described his pain as mild.During an interview on 4/27/2026 at 11:37 a.m. with Resident 40, Resident 40 stated he gets Tylenol (brand-name for acetaminophen, a medication used for pain relief and fever reduction) and hydrocodone (an opioid medication used to treat severe pain) for pain to his right leg. Resident 40 stated the nursing staff does not follow the manufacturers recommendations for his pain medication. During an interview on 4/30/2026 at 10:39 a.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated Resident 40 complained of pain in the morning. CNA 3 stated Resident 40 stated his pain level was a 7/10 on the pain scale (pain screening tool using numerical value to assess the level of pain ranging from 0 to 3-mild pain, from 4 to 6- moderate pain, and from 7 to 9- severe pain, and 10- the worse pain possible) rating from zero to ten all over his body and received pain medication on 4/30/2026.During a concurrent interview and record review on 4/30/2026 at 10:53 a.m. with Registered Nurse (RN) 3, the Medication Administration Record (MAR) for 4/2026 was reviewed. The MAR indicated that on 4/26/2026, Resident 40 received Norco 10/325 mg, which was ordered for severe pain rated seven to ten. RN 3 stated Resident 40 had a pain level of 5 and should not have received Norco 10/325 mg for that level of pain. RN 3 stated the licensed nurse should have notified the physician that the resident's pain level was 5 and requested a different medication appropriate for that level of pain. RN 3 stated Resident 40 received a stronger dose of pain medication than warranted, which could cause side effects such as respiratory distress (a condition in which the body cannot get enough oxygen and requires immediate medical attention) and increase the resident's pain tolerance.During an interview on 4/30/2026 at 2:12 p.m. with the Director of Nursing (DON), the DON stated the nurse should have contacted Resident 40's physician to obtain an order for the appropriate pain medication based on the resident's reported pain level. The DON stated licensed nurses were not following the physician's orders and were administering a higher dose of pain medication that did not match the resident's pain level.During a review of the facility's policy and procedure (P&P), titled Pain Management Standards of Care, dated 12/2022, the P&P indicated The licensed independent practitioner will ensure an effective pain management plan is in place and is documented. All healthcare providers will coordinate and initiate interventions as ordered within their scope of practice to prevent/relieve pain. These interventions may include but are not limited to. pharmacological as ordered.

Based on observation, interview and record review, the facility failed to ensure infection control measures were observed for one of three sampled residents (Residents 87 ). The facility failed to:1.Ensure facility staff wore required personal protective equipment (PPE-equipment used to prevent or minimize exposure to hazards) prior to providing care to Resident 87, who was on enhanced barrier precautions (EBP-an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO], microorganisms resistant to one or more classes of antimicrobial agents) for a pressure injury (PI-injury to the skin and underlying tissue caused by prolonged pressure).This failure put Resident 87 at risk for cross contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products).Findings:During a review of Resident 87's admission Record, the admission Record indicated, Resident 87 was admitted to the facility on [DATE], with diagnosis including anemia (a condition where the body does not have enough healthy red blood cells), hypertension (HTN-high blood pressure) and osteoarthritis (degenerative joint disease)During a review of Resident 87's History and Physical (H&P), dated 4/29/2026, the H&P indicated Resident 90 was alert and oriented to person, place and time.During a review of Resident 87's Minimum Data Set (MDS -resident assessment tool) dated 4/4/2026, the MDS indicated Resident 87 had severe cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 90 needs substantial/ maximal assistance (helper does more than half the work) with activities of daily living (ADLs] daily self-care activities like toileting, dressing and personal hygiene).During a review of Resident 87's Active Order Summary dated 4/30/2026, the Active Order Summary indicated, Resident 87 had an order for a sacral spine (lower back) PI, clean with normal saline (NS-wound cleanser) apply foam (soft material) dressing daily.During a review of Resident 90's Care plan titled On Enhanced Barrier Precautions dated 4/9/2026, the Care Plan indicated, Resident 90 was on EBP for a Stage II (a partial-thickness skin loss involving the outer layer and part of the inner layer of the skin) sacral (tail bone) PI.During an observation on 4/28/2026 at 11:10 a.m. in Resident 87's room, Registered Nurse 2 (RN 2) and RN 3 were observed changing Resident 87's gown and bed linen after Resident 87 vomited (throw up). RN 2 and RN 3 were observed not wearing PPE (gown).During an interview on 4/28/2026 at 11:25 a.m. with RN 2, RN 2 stated Resident 87 was on EBP for a Stage II pressure injury. RN 2 stated she should have been wearing appropriate PPE, including a gown, when providing direct care or touching Resident 87 because of the resident's Stage II pressure injury. RN 2 stated PPE should be used to help prevent the spread of infection and reduce the risk of cross contamination.During an interview on 4/28/2026 at 11:32 a.m. with RN 3, RN 3 stated Resident 87 was on EBP for a Stage II pressure injury. RN 3 stated she should have been wearing appropriate PPE, including a gown, when cleaning Resident 87 to prevent the resident from being exposed to germs that could potentially cause an infection.During an interview on 4/30/2026 at 2:39 p.m. with the Director of Nurses (DON), the DON stated Resident 87 was on EBP for a pressure injury and nursing staff were required to wear PPE whenever providing direct care to the resident. The DON stated EBP is used as a preventive measure to reduce the spread of infection.During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions dated 9/2024, the P&P indicated, Enhanced Barrier Precaution is the practice used for the prevention of the spread of MDROs. EBP is used during high resident care activities of residents with indwelling medical devices (e.g., central line, urinary catheter, feeding tube), wounds, colonization or infection with a MDRO regardless of their diagnosis and continues even when Standard and/or Transmission-Based Precautions are implemented. EBP is intended to reduce the risk of transmission of resistant microorganisms through healthcare workers and healthcare environment in a long-term care setting.

Based on observation, interview and record review the facility failed to ensure one of four sampled residents (Resident 40) had a functioning call light readily accessible to request assistance.This failure placed Resident 40, who is at high risk for falls, at increased risk for injury due to the inability to summon staff assistance.Findings:During a review of Resident 40's admission Record (Face Sheet-front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 40 was admitted to the facility on [DATE].During a review of Resident 40's History and Physical (H&P), dated 4/17/2026, the H&P indicated Resident 40 was admitted to the facility with diagnoses of but not limited to thoracic 3 (T3) toT4 compression fracture ( third and fourth vertebrae of the upper to mid back [the thoracic spine] collapse or break), prostatitis (inflammation or infection of the prostate gland), and urinary retention (inability to completely or partially empty the bladder).During a review of Resident 40's Minimum Data Set (MDS-a resident assessment tool), dated 4/22/2026, the MDS indicated Resident 40 had the ability to understand others and express wants and ideas. The MDS indicated Resident 40 used a walker and a wheelchair. The MDS indicated Resident 40 needed partial to moderate assistance (helper does less than half the effort) from nursing staff with lying down, sitting, and transferring from a bed to a chair. The MDS indicated Resident 40 needed supervision or touching assistance (helper provides verbal cues and or touching, steadying, and or contact guard assistance as resident completes activity) with toileting, dressing personal hygiene and rolling from left to right.During a concurrent observation and interview on 4/27/2026 at 11:37 a.m. with Resident 40 in Resident 40's room, two call lights were observed in the resident's bed. Resident 40 pressed both call light buttons, but the light outside the room did not activate to alert nursing staff and the staff at the nurses station that assistance was needed. Resident 40 stated the call light was not working.During a concurrent observation and interview on 4/27/2026 at 11:46 a.m. with Registered Nurse (RN) 6, RN 6 tested Resident 40's call light. RN 6 pressed both call light buttons and noted that one call light was not plugged into the wall outlet. After plugging it in, the orange light outside of Resident 40's room lit up, indicating the call light was functioning. RN 6 stated the call light was now working.During an interview on 4/27/2026 at 11:49 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 4/27/2026 at approximately 7:30 a.m. Resident 40's call light was not working and she had been informed it needed to be replaced. CNA 1 stated she checked to ensure Resident 40 had a functioning call light and noted CNA 2 conducts call light checks in the morning. CNA 1 stated call lights must be operational for residents who require assistance, and if a call light is not answered, residents may attempt to get out of bed and potentially fall. CNA 1 stated Resident 40 was high risk for falls.During an interview on 4/27/2026 at 11:56 a.m., with CNA 2, CNA 2 stated on 4/27/2026 at approximately 7:30 a.m., Resident 40's call light was not working. CNA 2 stated she obtained another call light for Resident 40 and placed it on the resident's bed, but the cord repeatedly fell out of the wall outlet. CNA 2 stated without a functioning call light, Resident 40 could attempt to get up without assistance and potentially fall and injure himself.During an interview on 4/30/2026 at 2:09 p.m., with the Director of Nursing (DON), the DON stated the nursing staff would not be able to meet Resident 40's needs if the resident's call light was not functioning properly. The DON stated without a working call light, the resident would be unable to call for assistance when needing to ambulate or when requiring any other help.During a review of the facility's policy and procedure (P&P), titled Transitional Care Center - admission of Patients / Residents, dated 11/2024, the P&P indicated .Use of call light will be explained and call light will be placed within easy reach of resident. Resident will be instructed to press the call light button whenever necessary. All caregivers are aware of importance of timeliness to call light responses. If assistance is not immediately available caregiver will escalate to primary nurse and charge nurse on duty as quickly as possible.Defective call lights will be reported to charge nurse and Plant Operations immediately.

Based on interview and record review, the facility failed to implement the discharge plan to ensure a safe discharge for one of three residents (Resident 1) by not providing the resident with a written discharge notice 30 days prior to discharge.This deficient practice placed Resident 1 at risk for an unsafe discharge.During a review of Resident 1's History and Physical (H&P), dated 9/26/2025, the H&P indicated the facility admitted Resident 1 on 9/25/2025 for rehab with diagnoses that included failure to thrive (a syndrome characterized by a rapid decline in physical, functional, and cognitive abilities), right renal mass (an abnormal growth in the kidney), and chronic diastolic congestive heart failure (when the left ventricle becomes stiff and cannot relax to fill with enough blood, leading to high pressure and fluid buildup). The H&P indicated Patient 1's neurologic status was alert and oriented times three (awake and aware of who they were, where they were, and what time or date it was), with normal strength, sensation and reflexes throughout, and adequate insight and judgement.During a review of Resident 1's Hospital Medicine Progress Note, dated 2/9/2026, the Progress Note indicated that Resident 1's admission had been markedly prolonged due to profound debility (a serious and lasting state of physical weakness and loss of strength), need for 24/7 assistance, and inability to safely discharge home, requiring ongoing transitional care. The Progress Note further indicated that care had focused on nutritional optimization, pressure injury management, and intensive PT/OT (physical therapy/occupational therapy - physical therapy: exercise based treatment to improve strength, movement, and mobility; occupational therapy: therapy that helps people relearn everyday activities and adapt environments to support self care and daily living) with slow but measurable functional gains, and that case management remained involved for long-term placement planning.During a review of Resident 1's Interdisciplinary Team Care (IDT - a collaborative documentation entry created by a team including nurses, providers, case management [healthcare professionals who assess the patient's needs, develop and coordinate a personalized plan of care, facilitate access to services like placement and community resources, advocate for the patient, monitor progress, and support smooth transitions across care settings], and physical therapy to review, update, and plan care for complex patients, particularly in hospice, palliative, or long-term care settings) Conference Note, dated 2/19/2026, the Conference Note indicated that Resident 1 was 100% incontinent in both bowel and bladder (unable to control bladder or bowel functions) and unable to perform toileting. The Conference Note further indicated Resident 1 needed maximum assistance with feeding, grooming, dressing, bathing, and transferring from bed to chair.During a review of Resident 1's Social Worker Note, dated 2/19/2026, the Social Worker Note indicated case management e-mailed Resident 1's responsible party (RP 1) and proposed a discharge date of 2/26/2026 to RP 1's home with home health. The Social Worker Note indicated RP 1 sent an e-mail to case management that expressed RP 1 did not appreciate the discharge date being pushed onto RP 1 and stated that a 30 days' notice of discharge needed to be presented to Patient 1 and/or Patient 1's family. The Social Worker Note further indicated that case management updated leadership.During a review of Resident 1's Hospital Medicine Discharge summary, dated [DATE], the Discharge Summary indicated Resident 1 was discharged from the facility on 2/21/2026.During an interview on 3/5/2025 at 12:52 p.m. with RP 1, RP 1 stated the facility did not provide the 30-day written discharge notice prior to the discharge.During an interview on 3/5/2025 at 11:58 p.m. with Social Worker (SW) 1, SW 1 stated that there was no written notice provided to Resident 1 or RP 1 and SW 1 did not know if they were required to provide a 30-day written notice to patients prior to the discharge.During an interview on 3/5/2025 at 2:00 p.m. with the Director of Nursing (DON), the DON stated they did not provide the 30-day written notice to Resident 1 or Resident 1's family. DON 1 stated that the facility's policy did not mention the 30-day discharge written notice. DON further stated they were not aware of this regulation and they would revise the policy per regulation and provide training to staff.

Based on interview and record review, the facility failed to ensure the care plan was updated for one of three sampled residents (Resident 1) who demonstrated the behavior of uncovering self, which was necessary to maintain Resident 1's dignity and rights.This deficient practice resulted in Resident 1 not receiving specific interventions to address the uncovering behavior, leading to exposure of private areas and a failure to maintain Resident 1's dignity and rights.During a review of Resident 1's History and Physical (H&P), dated 9/26/2025, the H&P indicated the facility admitted Resident 1 on 9/25/2025 for rehab with diagnoses that included failure to thrive (a syndrome characterized by a rapid decline in physical, functional, and cognitive abilities), right renal mass (an abnormal growth in the kidney), and chronic diastolic congestive heart failure (when the left ventricle becomes stiff and cannot relax to fill with enough blood, leading to high pressure and fluid buildup). The H&P indicated Patient 1's neurologic status was alert and oriented times three (awake and aware of who they were, where they were, and what time or date it was), with normal strength, sensation and reflexes throughout, and adequate insight and judgement.During a review of Resident 1's Hospital Medicine Progress Note, dated 2/9/2026, the Progress Note indicated that Resident 1's admission had been markedly prolonged due to profound debility (a serious and lasting state of physical weakness and loss of strength), need for 24/7 assistance, and inability to safely discharge home, requiring ongoing transitional care. The Progress Note further indicated that care had focused on nutritional optimization, pressure injury management, and intensive PT/OT (physical therapy/occupational therapy - physical therapy: exercise based treatment to improve strength, movement, and mobility; occupational therapy: therapy that helps people relearn everyday activities and adapt environments to support self care and daily living) with slow but measurable functional gains, and that case management remained involved for long-term placement planning.During a review of Resident 1's Interdisciplinary Team Care (IDT - a collaborative documentation entry created by a team including nurses, providers, case management [healthcare professionals who assess the patient's needs, develop and coordinate a personalized plan of care, facilitate access to services like placement and community resources, advocate for the patient, monitor progress, and support smooth transitions across care settings], and physical therapy to review, update, and plan care for complex patients, particularly in hospice, palliative, or long-term care settings) Conference Note, dated 2/19/2026, the Conference Note indicated that Resident 1 was 100% incontinent in both bowel and bladder (unable to control bladder or bowel functions) and unable to perform toileting. The Conference Note further indicated Resident 1 needed maximum assistance with feeding, grooming, dressing, bathing, and transferring from bed to chair.During an interview on 3/5/2025 at 12:05 p.m. with the Assistant Nurse Manager (ANM), ANM stated that staff observed Resident 1 tended to uncover themselves sometimes. ANM stated that staff should have interventions for this behavior and update Resident 1's care plan to maintain resident dignity.During an interview on 3/5/2025 at 12:52 p.m. with Resident 1's responsible party (RP 1), RP 1 stated she observed Resident 1's private area from the waist down to the lower extremities was exposed to the public when she was outside Resident 1's room in the hallway. RP 1 stated that she talked to the staff and the staff informed RP 1 that the facility was a diaper-free clinic to prevent residents having skin and infection problems.During a communication email with the Regulatory Accreditation Program Manager (RARM), dated 3/9/2026, RARM indicated that no intervention or care plan was found regarding Resident 1's tendency to uncover himself during Resident 1's admission to the facility.During a review of Resident 1's care plan audit trail (a record that tracks all updates made to the care plan, including who made the changes and when) from 10/28/2025 to 2/21/2026, the audit trail indicated there was no care plan updated regarding Resident 1's behavior of uncovering self.During a review of the facility's policy and procedure (P&P) titled, TCC/TCU: Minimum Data Set [MDS] and Care Planning, last approved 3/2025, indicated, The Care Plans will be initiated within 24 hours of admission. It is reviewed and updated on specified times/dates, and as needed whenever there is a new order or change of intervention, and when interventions become ineffective or not applicable; it is discontinued when a problem is resolved or when a patient is discharged .

Based on interviews and record review, the facility failed to obtain informed consent and provide written notice for one of two sampled residents (Resident 1), prior to a facility-initiated room change for Resident 1 in accordance with the facility's policy and procedure on resident rights.This deficient practice had the potential to result in Resident 1's emotional distress or physical decline due to Resident 1 becoming unhappy with their living arrangements or developing distrust in the facility.Based on interview and record review, the facility failed to obtain informed consent and provide written notice for one of two sampled residents (Resident 1), prior to a facility-initiated room change for Resident 1 in accordance with the facility's policy and procedure on resident rights.This deficient practice had the potential to result in Resident 1's emotional distress or physical decline due to Resident 1 becoming unhappy with their living arrangements or developing distrust in the facility. Findings: During a review of Resident 1's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 6/23/25, Resident 1's H&P indicated that Resident 1 had a past medical history of hypertension (HTN, high blood pressure), hyperlipidemia (high levels of fat in the blood), cardiomyopathy (a disease causing the heart muscle to become thick stiff, or enlarged, making it harder for the heart to pump blood to the body), and chronic back pain (persistent pain, stiffness, or discomfort in the back that lasts for more than three month) after a fall. Resident 1 was admitted for further physical therapy and rehab.During a concurrent interview and record review on 9/22/25 at 2:43 p.m. with the Nursing Director, the list of residents with room changes for the month of August and September was reviewed. The list did not indicate Resident 1 had a room change. ND stated that Resident 1 was moved on 6/26/25 from room A to room B to accommodate a male resident. Resident 1 was assigned to a room with another female resident. On 7/21/25, Resident 1 requested to be moved from room B to room D due to a confused resident across from room B. On 8/28/25, Resident 1 was moved to room C to accommodate a Federal Correctional Institute (FCI, inmate) resident that required continuous observation by two guards. On 8/29/25, Resident 1 requested to be moved from room C to room A to be closer to a patio exit door for easier access during smoke breaks (outdoor time accompanied by staff to allow smoking residents personal time for cigarettes). On 9/5/25, Resident 1 requested to move from room A and was placed in room E with two other female residents. ND stated that Resident 1 did not like room E and requested to return to room A.During a concurrent interview and record review on 9/22/25 at 3:27 p.m., the facility's Room Change Notification forms were reviewed. There were no forms for Resident 1's room changes. ND stated Resident 1 did not sign the room change notification form and that this was an identified gap which is being corrected. ND further stated this deviation in practice has been identified with immediate corrective actions taken.During an interview on 9/22/25 at 3:15 p.m. with Charge Nurse (CN) 1, CN 1 stated, when a room change is needed, if the resident is alert and oriented, the resident is asked permission for the room change with the reason for the change explained. If the resident is not alert, the family/responsible party is notified. If the room change is refused by the resident/family/responsible party, the room change is stopped. Most room change notifications are documented in the resident's digital chart. Each resident's room have signage notifying the residents that their room is not permanent during their stay at the facility, per CN 1. During an interview on 9/22/25 at 3:31 p.m. with CN 2, CN 2 stated, if a room change is required, the resident and/or family are alerted for consent. If the resident/family agrees to the change, the room change notification form is completed. If the resident/family refuse, the room change notification form is still completed, indicating the resident's/family's refusal, but no room change would take place as the resident's/family's decision is honored. Changing a resident's room against their will could lead to the resident's distrust of the facility and a violation of the resident's rights. During an interview on 9/22/25 at 3:46 p.m. with the Nursing Director, the ND stated all resident room changes followed a structured process. The residents are asked for their consent, with their preferences carefully considered. The families/responsible parties are informed of the planned room change and the reason for the change. A Room Change Notification form is completed, and written notice is provided to the resident and/or family member/responsible party. This process ensured compliance with regulations while protecting residents' rights, dignity, and comfort. Unauthorized room changes may result in a resident's physical decline or cause emotional distress due to the lack of control over their own decisions and unhappiness with their living arrangements, which may contribute to the resident giving up. In this case, several room changes were made; however, the Room Change Notification form was not completed and signed by Resident 1, which the facility recognized as a deviation from the standard process. During a review of the facility's policy and procedure (P&P), titled Transitional Care Center: Notification of Change in Resident Status, effective 07/2025, page one of three, the Policy section indicated, In keeping with the mission and core values of Providence, it will be the policy of the facility to assure that the physician and family member or legal authorized representative are promptly notified in the event of a change in the Resident's status. The Procedure section indicated: The facility will also promptly notify the resident or resident's legal representative designated family member/next of kin when there is: a. A change in room or room assignment b. A change in residents' rights under Federal or State law. During a review of the facility's P&P, titled Transitional Care Center: Transfer, Discharge, Bed Hold Notification and Requirements, effective 09/2024, the Procedure/General Instructions section indicated, Except in an emergency, residents will not transfer to another room against his or her wishes, unless given prior reasonable written notice.

Based on interview and record review, the facility failed to ensure residents' medical records updated to show documentation that advance directives (a legal document indicating resident preference on end-of-life treatment decisions) were discussed and written information was provided to the residents and /or responsible parties for two of five residents (Residents 89 and 195). This failure violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care. Findings: During a review of Resident 89's Admission Record, the Admission Record indicated Resident 89 was admitted to the facility on [DATE]. During a review of Resident 89's History and Physical (H&P), the H&P indicated Resident 89 was admitted with diagnoses including congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and Diabetes Mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 89's Minimum Data Set (MDS- a resident assessment tool) dated 3/23/2025, the MDS indicated Resident 89's cognition (ability to think, understand, learn, and remember) was severely impaired and required maximal assistance with toileting and personal hygiene and lower body dressing. During a review of Resident 195's Admission Record, the Admission Record indicated Resident 195 was admitted to the facility on [DATE]. During a review of Resident 195's H&P, the H&P indicated Resident 195 was admitted with diagnoses including atrial fibrillation (an irregular and often and very rapid heart rhythm) and hypertension (HTN- high blood pressure). During a review of Resident 195's MDS dated [DATE], the MDS indicated Resident 195's cognition was intact and dependent with toileting hygiene and lower body dressing. During a concurrent interview and record review on 3/27/2025 at 11:59 a.m. with the Social Worker (SW), the SW stated advance directives are discussed with each resident upon admission. SW stated residents are asked if they have an advance directive or would like to form one. SW stated there was no documentation that an advance directive was offered or discussed for Resident's 89 and 195. During an interview on 3/28/2025 at 12:13 p.m. with the Director of Nursing (DON), the DON stated all residents should be offered to formulate an advance directive for their protection, choices, and rights. The DON stated the advance directive is important to have so the staff are aware of what the resident's wishes are or who would make the decision for their care if they were unable to do so for themselves. During a review of the facility policy and procedure (P&P) titled, Advance Directives, dated 7/2018, the P&P indicated, In compliance with the Patient Self-Determination Act, all adult patients admitted to the medical center as inpatients, or their surrogates/family members, will be given specific information concerning Advance Directives unless they specifically state they do not need or want information on the topic. 49145 49889

Based on observation, interview, and record review, the facility failed to ensure Resident 20's physician orders for losartan (a medication used to treat hypertension [HTN - high blood pressure]) and hydrochlorothiazide (a medication used to treat HTN) indicated hold parameters for medications based on resident's blood pressure readings, affecting one of five sampled residents reviewed for medication administration. This deficient practice had the potential to result in medication errors, blood pressure abnormalities and heart complications for Resident 20. Findings: During a review of Resident 20's Admission Record, dated 3/26/2025, the Admission Record indicated, Resident 20 was admitted to the facility on [DATE]. During a review of Resident 20's Minimum Data Set (MDS - a resident assessment tool), dated 3/4/2025, the MDS indicated, Resident 20's cognition (ability to think, understand, learn, and remember) was severely impaired. The MDS indicated, Resident 20 needed supervision level assistance from facility staff for Activities of Daily Living (ADLs) such as eating, oral hygiene and personal hygiene, moderate assistance for upper body dressing, and dependent for toileting hygiene, showering, lower body dressing and putting on/taking off footwear. During a concurrent observation and interview on 3/26/2025 between 8:46 a.m. and 8:57 a.m. with the Registered Nurse (RN) 2, RN 2 prepared five medications to be administered to Resident 20 that included, but not limited to, the following: 1. One tablet of losartan 50 milligrams ([mg] a unit of measurement for mass) 2. One-half tablet of hydrochlorothiazide 25 mg (12.5 mg dose) RN 2 then conducted blood pressure check for Resident 20 using an automatic blood pressure monitor. RN 2 stated Resident 20's systolic blood pressure ([SBP] the pressure with which the heart pumps blood into the arteries) was 114 millimeters of mercury ([mmHg] a unit of measurement for blood pressure) and diastolic blood pressure ([DBP] the pressure in arteries when the heart is relaxed between beats) was 44 mmHg. RN 2 stated, the bottom BP reading (DBP) was low so she would recheck resident's blood pressure. During a concurrent observation and interview on 3/26/2025 at 8:57 a.m. with RN 2, RN 2 conducted blood pressure check again for Resident 20. RN 2 stated Resident 20's BP reading was 117(SBP) mmHg / 44 (DBP) mmHg. RN 2 stated she would hold losartan and hydrochlorothiazide and would determine later if able to administer them after rechecking Resident 20's blood pressure after his rehabilitation therapy. RN 2 stated she did not have physician orders or hold parameters to hold the losartan and hydrochlorothiazide but in her judgement, she would hold them because the DBP was lower than 50 mmHg. During a review of medication reconciliation and review of Resident 20's Physician Order Summary Report, dated 3/26/2025, the Physician Order Summary Report indicated, but not limited to, the following medications: 1. Hydrochlorothiazide 12.5 mg, take one tablet by mouth daily, order date 2/25/2025, start date 2/26/2025. 2. Losartan tablet 50 mg, take one tablet by mouth daily, order date 2/25/2025, start date 2/26/2025 During a review of Resident 20's Nursing Progress Notes, signed date 3/26/2025 timed at 3:21 p.m., the RN 2's Nursing Progress Notes indicated, BP was checked at 8:55 a.m., 114/44 mmHg and medication was held .BP rechecked at 11:00 a.m., and medication was given, BP at the time was 130/56 . During a review of Resident 20's Nursing Progress Notes, edited date 3/26/2025 4:06 p.m., RN 2's Nursing Progress Notes indicated, parameter for losartan 50 mg and hydrochlorothiazide 12.5 mg, hold for DBP less than 50, hold for SBP less than 100, put it in MAR. During a concurrent interview and record review on 3/27/2025 at 10:44 a.m. with the Assistant Nurse Manager (ANM) and the Registered Nurse (RN) 6, the order audit trail for Resident 20's hydrochlorothiazide 12.5 mg and losartan 50 mg were reviewed. The initial order details (after action #3, after action #2 and after action #1) for hydrochlorothiazide 12.5 mg and losartan 50 mg did not indicate hold parameters. Order details after action #4 which was a modified order, indicated the hold parameters for hydrochlorothiazide 12.5 mg daily and losartan 50 mg indicating to hold if SBP less than 100 or DBP less than 50. ANM stated if there was a hold parameter for resident's high blood pressure medications from the physician's order, then the nurse should follow that. ANM stated if the nurse did not feel comfortable administering the medication because of low blood pressure, she should have escalated the situation by calling the physician to ask if he/she could hold the blood pressure medication. ANM stated she did not have a facility specific protocol to show for blood pressure monitoring. ANM stated the facility nurse should have called the physician to get an order of 'hold parameters' when she decided to hold the medications due to low blood pressure. During an interview on 3/26/2025 at 1:45 p.m. with RN 2, RN 2 stated she knew she would need physician orders for medications before they can be administered or held if needed. RN 2 stated, in the past, doctor was okay with the medications being held if the nurse thought of doing so in her clinical judgement. RN 2 stated she did not contact the physician before holding administration of Resident 20's blood pressure medications. RN 2 stated if physician orders were not followed for blood pressure medications, it could have caused abnormal blood pressure. RN 2 stated she did not see any parameters for Resident 20's blood pressure medications. RN 2 stated she could not describe or explain if there was a facility protocol or guidelines that she was following but usually saw parameters such as hold if BP less than 110. During a review of the facility's policy and procedure (P&P) titled, Medication Management, applicability includes TCC, dated 7/2023, the P&P indicated, Medication Orders: medication may only be administered by an RN and LVN on the order of a licensed physician The P&P indicated, Protocol orders are performed only on order of the physician as a patient's condition warrants. Titrate orders include specific limits and guidelines for dosage adjustment and frequency of patient assessment. Taper orders include specific dosage adjustments and frequency of change.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5 percent (%) during medication pass for two of five reviewed residents for medication errors (Residents 95 and 296) by failing to: a. Administer Resident 95's Vimpat ([generic name - lacosamide] a medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), gabapentin (a medication used to treat nerve pain and seizures), levetiracetam (a medication used to treat seizures) and metoprolol tartrate (a medication used to treat high blood pressure), within one hour before or after the scheduled administration time of 9:00 a.m., per facility's policy and procedure (P&P) titled, Medication Management, dated 7/2023. b. Administer Resident 296's furosemide (a medication used to treat fluid retention and high blood pressure), amlodipine (a medication used to treat high blood pressure), metoprolol tartrate and amiodarone (a medication used to treat heart complications), within one hour before or after the scheduled administration time of 9:00 a.m., per facility's P&P titled, Medication Management, dated 7/2023. These deficient practices of medication error rate of 26.67 percent (%) exceeded the five (5) % threshold and placed Residents 95 and 296 at risk for adverse medical consequences such as seizures, high blood pressure and cardiac complications. Findings: a. During a review of Resident 95's Admission Record, the Admission Record indicated, Resident 95 was admitted to facility on 3/5/2025. During a review of Resident 95's History and Physical (H&P), dated 3/5/2025, the H&P indicated Resident 95's diagnoses including to, history of multiple sclerosis ([MS]- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), possible status epilepticus (seizure), hypertension ([HTN] high blood pressure), history of depression and anxiety, and deep venous thrombosis ([DVT] a medical condition characterized by blood clots in deep vein, in the leg) risk. During a review of Resident 95's Minimum Data Set (MDS -resident assessment tool), dated 3/12/2025, the MDS indicated, Resident 95's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated, Resident 95 needed maximal assistance from facility staff for activities of daily living (ADLs) such as eating and upper body dressing, moderate assistance for oral hygiene and personal hygiene, and activities such as toileting, showering, and lower body dressing. During an observation on 3/26/2025 at 8:32 a.m. with Registered Nurse (RN) 2, RN 2 prepared and administered one tablet of lorazepam (a medication used to treat anxiety) 1 milligrams ([mg] a unit of measurement for mass) to Resident 95 before moving on to the next resident during medication administration. During the process of medication reconciliation and review of Resident 95's Physician Order Summary Report, dated 3/27/2025, the Physician Order Summary Report indicated, the following medications were also scheduled to be administered starting at 9:00 a.m. daily, in addition to Lorazepam administered during medication administration observation: 1. Gabapentin capsule 300 mg, take 1 capsule by mouth three times daily, order date 3/5/2025, start date 3/5/2025. 2. Lacosamide 200 mg, take 1 tablet by mouth two times daily, order date 3/5/2025, start date 3/5/2025. 3. Levetiracetam 1000 mg, take 1 tablet by mouth two times daily, order date 3/5/2025, start date 3/5/2025. 4. Lorazepam 1 mg, take 1 tablet by mouth two times daily, 0800 (8:00 a.m.) & 1800 (6:00 p.m.), order date 3/16/2025, start date 3/17/2025. 5. Metoprolol tartrate 12.5 mg, take 1 tablet by mouth two times daily, hold if systolic blood pressure ([SBP] the pressure with which the heart pumps blood into the arteries) less than 105 or heart rate (HR) less than 65, order date 3/6/2025, start date 3/6/2025 During a review of Resident 95's Medication Administration Record (MAR), dated 3/26/2025, the MAR indicated the following medications were administered at 10:36 a.m. which was one hour and 36 minutes after the scheduled medication administration time of 9:00 a.m.: 1. One capsule of gabapentin 300 mg (300 mg dose) administered on 3/26/2025 at 10:36 a.m. 2. Four tablets of lacosamide 50 mg (200 mg dose) administered on 3/26/2025 at 10:36 a.m. 3. Two tablets of levetiracetam 500 mg (1000 mg dose) administered on 3/26/2025 at 10:36 a.m. 4. One-half tablet of metoprolol tartrate 25 mg (12.5 mg dose) administered on 3/26/2025 at 10:36 a.m. b. During a review of Resident 296's Admission Record, the Admission Record indicated Resident 296 was admitted to the facility on [DATE]. During a review of Resident 296's H&P dated 3/24/2025, the H&P indicated Resident 296's diagnoses including chronic kidney disease (CKD a gradual, progressive loss of kidney function) and non-ST elevation myocardial infarction (MI - heart attack). During a concurrent observation and interview on 3/26/2025 at 10:22 a.m. with RN 4, RN 4 removed the following five medications from automated dispensing machine to be administered to Resident 296. 1. One tablet of furosemide 20 mg 2. One tablet of amlodipine 2.5 mg 3. One tablet of metoprolol tartrate 25 mg, but dose of one-half tablet (12.5 mg) to be given 4. One tablet of amiodarone 200 mg 5. One tablet of aspirin 81 mg chewable tablet RN 4 stated Resident 296 left for his therapy upon reaching Resident 296's room to administer medications. RN 4 stated she would need to return to administer medications to Resident 296 after he returned from therapy. RN 4 stated Resident 296's medications were scheduled for 9:00 a.m. and were supposed to be given latest by 10:00 a.m. RN 4 stated it was important to administer medications on time to ensure stable blood concentrations. RN 4 stated Resident 296 was on a few blood pressure medications as listed above, so Resident 296 was at risk for high blood pressure, and could get symptoms of headache. RN 4 stated high blood pressure could place Resident 296 at risk for stroke (loss of blood flow to a part of the brain) and hospitalization . RN 4 stated, sometimes medications could be administered late because there were a lot of activities during medication administration task and all residents have therapy. During an observation on 3/26/2025 at 10:59 a.m., RN 4 administered Resident 296's medications after checking his blood pressure. During a review of Resident 296's Physician Order Summary Report, dated 3/26/2025, the Physician Order Summary Report, indicated the following medications scheduled to be administered starting at 9:00 a.m. daily, unless specified otherwise: 1. Amiodarone 200 mg, take 1 tablet by mouth two times daily, order date 3/24/2025, start date 3/25/2025. 2. Amlodipine 2.5 mg, take 1 tablet by mouth daily for radial artery spasm prevention, order date 3/24/2025, start date 3/25/2025. 3. Aspirin chewable tablet 81 mg, take 1 tablet by mouth daily, initiate within 6 hours of arrival in the intensive care unit, if aspirin was not administered preoperatively. If unable to take by mouth tablet, may give rectal aspirin, if ordered, order date 3/24/2025, start date 3/25/2025. 4. Furosemide 20 mg, take 1 tablet by mouth daily, order date 3/24/2025, start date 3/25/2025. 5. Metoprolol tartrate 12.5 mg, take 1 tablet by mouth daily, hold for HR less than 60, SBP less than 100, order date 3/24/2025, start date 3/25/2025. During a review of Resident 296's MAR, dated 3/26/2025, the document indicated the following medications were administered at least two hours after the scheduled medication administration time of 9:00 a.m.: 1. One tablet of amiodarone 200 mg (200 mg dose) administered on 3/26/2025 at 11:07 a.m. 2. One tablet of amlodipine 2.5 mg (2.5 mg dose) administered on 3/26/2025 at 11:08 a.m. 3. One tablet of aspirin chewable tablet 81 mg (81 mg dose) administered on 3/26/2025 at 11:08 a.m. 4. One tablet of furosemide 20 mg (20 mg dose) administered on 3/26/2025 at 11:06 a.m. 5. One-half tablet of metoprolol tartrate 25 mg (12.5 mg dose) administered on 3/26/2025 at 11:08 a.m. During a concurrent interview and record review on 3/27/2025 at 11:23 a.m. with Assistant Nurse Manager (ANM), Resident 95's MAR for 9:00 a.m. was reviewed. ANM stated, Resident 95's gabapentin, lacosamide, levetiracetam and metoprolol tartrate were due at 9:00 a.m. and should have been administered within one hour time frame from scheduled administration time. ANM stated Resident 95's medications were administered on 3/26/2025 at 10:36 a.m., which was late by at least 35 minutes. ANM stated it was important that facility nurses gave Resident 95's medications on time to be able to manage pain and seizures. ANM stated if the medications were not administered on time, there was a risk of hospitalization due to seizures, high blood pressure and stroke. During a concurrent interview and record review on 3/27/2025 at 11:37 a.m. with ANM, Resident 296's MAR for 9:00 a.m. was reviewed. ANM stated, Resident 296's aspirin, amlodipine, metoprolol tartrate, amiodarone and furosemide were due at 9:00 a.m. and were administered late after 11:00 a.m. which was beyond the allowed one hour after scheduled administration time of 9:00 a.m. ANM stated facility nurse was supposed to follow the policy to administer medications within one hour before and one hour after the scheduled time of administration. ANM stated facility nurse should have called the physician by 10 a.m. to get authorization whether to administer medications late. During a concurrent interview and record review on 3/27/2025 at 11:23 a.m. with the Director of Risk and Regulatory (DRR), the facility's P&P, titled, Medication Management was reviewed. The DRR stated, medications due at 9 a.m., could be given as early as 8 a.m. and as late as 10 a.m. The DRR stated, there was an addendum to the Medication Management policy titled, 'Addendum B Missed Dose and 1st Dose Home Medication Decision Guide - Post-EPIC,' that supposed to act as a guide for facility staff for retiming of missed doses - If a medication was missed daily for 9 a.m. dose, then could give dose now (then) and resume at 9 a.m. tomorrow (next day). The DRR stated, by policy, it was considered a missed dose, and then the policy gave instructions on when it could be safely given and resumed. The DRR stated, this addendum was followed for all skilled nursing facility medications as well as for hospital medications. During a concurrent interview and record review on 3/27/2025 at 12:29 p.m. with ANM, Resident 296's physical therapy schedule and notes were reviewed. ANM stated Resident 296's physical therapy start time on 3/26/2025 was at 10:21 a.m. During an interview on 3/27/2025 at 2:27 p.m. with RN 2, RN 2 stated, she thought that it was okay to administer 9:00 a.m. medications until 10 a.m. to 10:30 a.m. RN 2 then stated she could have administered Resident 95's medications on 3/26/2025 along with her lorazepam, to prevent their late administration at 10:36 a.m. RN 2 stated there was a risk for Resident 95 to experience seizures, nerve pain and high blood pressure because she received her medications late. During an interview on 3/27/2025 at 4:48 p.m. with the Director of Nursing (DON), the DON stated, the medications scheduled for 9:00 a.m. administration and given at 10:36 a.m. and 11:00 a.m. would be considered late administration. The DON stated, licensed nurse should follow one hour before and one hour after the scheduled administration time window. The DON stated if medications like amiodarone and others such as those for high blood pressure and seizures were given later than scheduled time, it would place residents at increased risk for seizures, high blood pressure, stroke and hospitalization . During a review of the facility's P&P, titled, Medication Management, applicability includes TCC, dated 7/2023, the P&P indicated, Medication Administration Procedures: Refer to Lippincott's Nursing Procedures and Skills for Medication Administration Procedures and Safe Medication Practices. For Non- Time-Critical Scheduled Medications - medication prescribed with a minimum frequency of every four (4) hours and not greater than every 24 hours, the goals for timely administration - within one (1) hour before or after the scheduled time.

Based on interview and record review the facility failed to ensure Certified Nursing Assistant's (CNA's) annual skills competencies were completed for CNA 2 and CNA 3 . These failures had the potential to put the resident's safety at risk during care. Findings: During a concurrent interview and record review on [DATE] at 10:45 a.m. with the Director of Staff Development (DSD), CNA 2 and CNA 3's Education & Professional Practice Competency Checklists. The DSD stated CNA 2 was hired on [DATE] and her last competency was done on [DATE]. The DSD stated CNA 3 was hired [DATE] and that her last skills competency was done on [DATE]. The DSD stated competencies are done annually. DSD stated we need to make sure that the staff are still preforming their skills appropriately. DSD stated CNA's can develop wrong habits and residents could receive poor care and be re-hospitalized if the CNAs are not providing good quality care. During an interview on [DATE] at 12:17 p.m. with the Director of Nursing (DON). The DON stated the DSD is responsible for education in the facility and that the CNAs should have annual skills competencies to ensure that the staff are performing their skills accurately and not missing anything . The DON stated there is a risk for the residents to develop an infection when not providing proper care. During a review of the facility's policy and procedure (P&P) titled Transitional Care Center Scope of Service - Education. Dated ,d+[DATE], the P&P indicated, in keeping with the mission and core values of St. [NAME] Health Services Transitional Care, it is the policy of the facility to provide quality care for residents/customer satisfaction by individualizing, teaching, and coordination with other health services to assure continuity of care and to provide safe delivery of patient care to a culturally diverse young adult to geriatric community. A. The education department/ staff development assess and maintain the educational needs of the nursing staff and the interdisciplinary health team of Providence Little Company of [NAME] Transitional Care Center. B. Provides educational programs, in-services in accordance with the requirement of the federal and state regulations of Title XXII and TJC (The joint commission) C. Develops coordinates and implements competency based educational programs which are in compliance with the applicable standards and regulations. D. Maintains updated licenses, CPR certificates & health/physical exams. Validates and maintains competencies required for the nursing staff and other members of the health care team as required.

Based on observation, interview, and record review, the facility failed to ensure Resident 196's medical information was kept private from unintended public view, affecting one of five residents observed during survey task observations. This deficient practice had the potential for anyone to access Resident 196 medical records that are confidential. Findings: During a review of Resident 196's Admission Record, undated, the Admission Record indicated, Resident 196 was admitted to the facility on [DATE]. During a review of Resident 196's Minimum Data Set (MDS - a resident assessment tool), undated, the MDS indicated diagnoses that included but not limited to, hypertension (HTN - high blood pressure) and seizure [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] disorder or epilepsy. During an observation on 3/25/2025 at 2:05 p.m. in the facility's floor hallway near the nurses' Station 2, the computer screen was unattended and open on a mobile workstation showing Resident 196's medical information. There was no facility nurse near the computer screen. The computer screen indicated, but not limited to, Resident 196's name, date of birth, age, medical record number, code status, and medication administration record (MAR). The MAR indicated medications such as hydralazine (a medication used to treat HTN) tablet 50 milligrams ([mg] a unit of measurement for mass) three times daily along with doses given versus what was due, lamotrigine (a medication used to treat seizures) tablet 50 mg two times daily along with doses given versus what was due, and levetiracetam (a medication used to treat seizures) tablet 1000 mg two times daily. During a concurrent observation and interview on 3/25/2025 at 2:16 p.m. with the Unit Coordinator (UC) at Nurses' Station 2, the computer screen with Resident 196's medical information was reviewed. The UC stated the computer screen should be always locked to protect resident privacy. During an interview on 3/27/2025 at 3:58 p.m. with the Director of Nursing (DON), the DON stated, it is never okay to keep the patient information visible for public view because that can compromise patient privacy.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 20) had side rails (bars or rails attached to the sides of a bed) were in up position. This failure had the potential to put Resident 20 at risk for injuries such as falls, strangulation and death. Findings: During a review of Resident 20's Admission Record, the Admission Record indicated the resident was admitted on [DATE] to the facility. During a review of Resident 20's History and Physical (H&P) dated 2/26/2025, the H&P indicated the resident had history of recurrent falls, hypertension (HTN- high blood pressure), and left clavicular fracture ( a break in theft left collarbone) after a fall at home. During a review of Resident 20's Minimum Data Set ( MDS- a resident assessment tool ) dated 3/4/2025, the MDS indicated the resident had severely impaired cognitive skills( a person has a significant difficulty in thinking, learning, remembering , using judgement, and making decisions affecting daily activities) and was dependent (helper does all the effort) on the staff with dressing, toileting hygiene, and bathing. The MDS indicated the resident required partial/moderate assistance (helper does less than half the effort) with bed mobility and transfer to and from a bed to chair. During an observation on 3/25/2025, at 11:10 a.m. in Resident 20's room, Resident 20 had bed side rails up times four. Bruises were observed in both arms. During an interview on 3/27/2025, at 9:30 a.m. and at 3:12 p.m. with Certified Nursing Assistant (CNA 1), CNA1 stated Resident 20 should have three side rails in up position because four side rails up is a form of restraint and required a physician's order. CNA1 stated she had seen the resident when he came back from physical therapy and all the four side rails were in up position on 3/25/2025. CNA 1 stated she should have placed the other side rail down to ensure Resident 20's movement will not be restricted. During a concurrent observation and interview on 3/25/2025, at 11:27 a.m. in Resident 20's room and subsequent interview on 3/27/2025, at 9:19 a.m. with Registered Nurse (RN 1), RN 1 stated Resident 20 stated Resident 20's had four bed rails in up position because the resident was a high risk for fall. Observed Resident 20 tries to climb out of bed. RN 1 stated four bed rails up was considered a restraint ( any manual method, physical or mechanical device, equipment, or material that limits a resident's freedom of movement and cannot be removed by the resident) because it limits the mobility of a resident and could lead to injury. RN 1 stated four side rails in up position required a consent and a physician order. RN 1 stated the Physical Therapist (health care professional who helps people improve their movement and function through exercises) might have placed all four side rails up because he did not see the resident when he came back from physical therapy (healthcare profession that focuses on helping people with conditions or injuries that limit their ability to move and do physical activities). During an interview on 3/27/2025 at 2:26p.m., with Physical Therapist (PT 1), PT 1 stated Resident 20 was taken out of bed around 9 a.m. on 3/25/2025 and upon return to Resident 20's room at around 11:00 a.m., the resident was left sitting on the side of the bed because the resident wanted to use the restroom. PT 1stated he handed off Resident 20 with the nursing staff who was present in the room before he left. During an interview on 3/28/2025 at 11:45 a.m., with the Director of Nursing (DON), DON stated four side rails up was considered a restraint and can have a negative outcome. The DON stated the resident could get climb out of the bed and this would lead to fall and injury. During a review of the facility's policy and procedure (P&P) titled, TCC/TCU: Bedrails last revised 3/2020, the P&P indicated, Bed rails will not be used when a resident cannot raise and lower them easily, thereby meeting the definition of a physical restraint. During a review of the facility's P&P titled, Restraint for Non-Violent /Non-Self-Destructive Behavior revised on 5/2022, the P&P indicated all patients have the right to be free from any form of restraint that are imposed as a means of coercion, discipline, convenience, or retaliation by staff. The P&P indicated the facility will protect and preserve the rights , dignity , safety of the residents and eliminate inappropriate use of restraints.

Based on observation, interview, and record review, the facility failed to ensure Registered Nurse (RN) 2 crushed and administered each oral medication separately for one of five sampled residents (Resident 94) during medication administration observation. This failure had the potential to place Resident 94 at risk for drug interactions (occur when two or more drugs taken simultaneously affect each other's actions in the body) or intolerability to one or more medications without possibly knowing which medication caused intolerability. Findings: During a review of Resident 94's Admission Record (a document containing demographic and diagnostic information), dated 3/27/2025, Resident 94 was admitted to the facility on [DATE] with diagnoses including, but not limited to, swallowing impairment and gastroesophageal reflux disease ([GERD] a condition where stomach contents flow back up to esophagus causing irritation). During a review of Resident 94's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 3/13/2025, the MDS indicated Resident 94's cognition was moderately impaired. The MDS indicated, Resident 94 needed supervision level assistance from facility staff for Activities of Daily Living (ADLs) such as for eating and oral hygiene, moderate assistance for personal hygiene, maximal assistance for upper body dressing, dependent for lower body dressing, putting on/taking off footwear and showering, and toileting hygiene not attempted due to medical condition or safety concerns. During a concurrent observation and interview on 3/26/2025 at 9:10 a.m. with RN 2, RN 2 prepared the following five medications to be administered to Resident 94. RN 2 stated she would need to crush Resident 94's four medications and administer docusate sodium (a medication used to treat constipation) oral liquid with a thickening agent. 1. One tablet of amlodipine (a medication used to treat high blood pressure) 5 milligrams ([mg] a unit of measure for mass) 2. One tablet of ferrous gluconate (a medication used to treat low level of iron) 324 mg 3. One tablet of bisoprolol (a medication used to treat high blood pressure and heart complications) 5 mg 4. One tablet of multivitamin with iron 5. 10 milliliters ([mL] a unit of measure for volume) of docusate sodium oral liquid 50 mg per 5 mL RN 2 placed four medications (amlodipine, ferrous gluconate, bisoprolol, multivitamin with iron) in a clear bag and crushed them together using a crushing device before pouring the powder mixture into a paper cup. RN 2 stated she would administer the powder mixture of four medications to Resident 94 with apple sauce. RN 2 stated if it was a gastrostomy tube (g-tube - a surgically placed tube used to administer medications or food directly into the stomach) then she should have crushed each medication separately and administered each medication separately. RN 2 stated because the medications were to be administered orally to Resident 94 it was okay to crush all medications together and administer altogether by mouth with apple sauce. RN 2 did not ask Resident 94 if she preferred to take crushed medications together before administering medications to the resident. During a review of Resident 94's Order Summary Report (a document containing a summary of all active current physician orders), dated 3/27/2025, the document did not indicate a physician order to crush oral medications. During a concurrent interview on 3/27/2025 at 3:27 p.m. with the Director of Nursing (DON) and pharmacist (RPH) 3, DON stated if medications were to be crushed and given by mouth, then facility nurse should have crushed one medication at a time, then mix with apple sauce and administer one medication at a time .second medication same way, crush it, mix it and give it. DON stated each medication should have been crushed separately and mixed with apple sauce one by one. DON and RPH 3 stated it was important to administer each crushed medication separately to be able to determine which medication caused an allergic reaction if the resident was allergic to a medication or had absorption issues with a certain medication. During a review of the facility's policy and procedure (P&P), titled, Oral drug administration, dated 5/20/2024, the P&P indicated, cardiovascular agents, antibiotics .are the most common drugs that cause drug interactions. The P&P indicated, Verify that you're administering the medication at the proper time by the correct route .errors. Administer the medication to the patient .as needed, to aid in swallowing, minimize adverse effects and promote absorption.

Based on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 95) received appropriate services to meet resident's behavioral health care needs by failing to: 1.Ensure the psychiatric services( type of mental health care that focuses on diagnosing and treating mental illness) were provided to Resident 95 who was prescribed Ativan (Lorazepam- drug used to treat anxiety) and Seroquel ( Quetiapine- drug to treat depression) after manifesting confusion, anxiety and climbing out of bed. Resident 95 had diagnoses of anxiety and depression and was on Prozac(Fluoxetine- drug used to treat depression), Ambien ( drug used treat insomnia) and Valium ( medicine used to treat anxiety disorder). 2. Ensure Interdisciplinary Team (IDT group of healthcare professionals from different disciplines who collaborate to provide comprehensive and coordinated care for a patient) addressed resident's behavioral problems and the use of psychotropic medicines (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). These failures had the potential to put Resident 95 at risk for increased pharmacological treatment for resident's behavioral symptoms and lack or inappropriate treatment or management of Resident 95 's mental and psychosocial needs. Findings: 1.During a review of Resident 95's Admission Record, the Admission Record indicated the resident was admitted on [DATE] to the facility. During a review of Resident 95's History and Physical (H&P) dated 3/6/2025, the H &P indicated the resident had a history of multiple sclerosis ( disorder in which body's immune system attacks the protective covering of the nerve cells in the brain and spinal cord ), possible status epilepticus (a prolonged or continuous seizure activity that can be life threatening) and femur fracture ( a break in the thigh bone)surgery after a fall in the hospital. During a review of Resident 95's Minimum Data Set (MDS- a resident assessment tool) dated 3/12/2025, the MDS indicated the resident had an intact cognition(thought process) and had no potential indicators of psychosis( a severe mental condition in which thought, emotions are so affected that contact is lost with reality) such as hallucinations(perceptual experiences in the absence of real external sensory stimuli) and delusions (having false or unrealistic beliefs). The MDS indicated the resident required partial/moderate assistance (helper does less than half the effort) with bed mobility, oral hygiene and personal hygiene. The MDS indicated the resident had diagnoses that included anxiety disorder, seizure disorder or epilepsy( disorder of the brain characterized by repeated seizures) and hip fracture. During a review of Resident 95's Medication Administration Record (MAR-MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) 3/2025, the MAR indicated the resident was on Valium ( a medicine of the benzodiazepine family that acts as an anxiolytic) 10 milligrams( mgs.- unit of measurement) every 8 hours as needed for anxiety. The MAR indicated the Valium was ordered 3/8/2025 and was reordered on 3/29/2025. During a review of Resident 95's MAR, the MAR indicated Prozac (can treat depression, obsessive-compulsive disorder (OCD), bulimia nervosa, and panic disorder)60 mgs. daily was ordered 3/6/2025. During a review of Resident 95's MAR, the MAR indicated Seroquel 25 mgs. every 12 hours as needed for agitation was ordered on 3/5/29025. The MAR indicated Seroquel's physician order was changed to 25 mgs. nightly on 3/13/2025. During a review of Resident 95's MAR, the MAR indicated Zolpidem (Ambien) 5 mgs. nightly prn (as needed) for insomnia was ordered on 3/5/2025 and was reordered on 3/19/2025. During a review of Resident 95's Nursing Progress Note dated 3/17/2025 timed at 6:22 p.m., the Nursing Progress Note indicated the resident was confused, restless, agitated and had a feeling of sadness. The Nursing Progress Note indicated the resident was confused and forgetful to situation and time and the resident tend to say, help me, help me. During a review of Resident 95's Nursing Progress Note dated 3/17/2025, timed at 3:36 a.m., the Progress Notes indicated the resident was anxious, confused, and was climbing out of bed. The Nursing Progress Notes indicated the resident was awake, with episode of inability to relax manifested by calling out from time to time and received pain medication for the complaint of right forearm pain. The Progress Notes indicated on 3/17/2025, at 3:40 a.m. the resident woke up and requesting for anti- anxiety medicine again and medication was provided. During a review of Resident 95's Informed Consent (voluntary agreement to accept treatment after receiving education regarding risks, benefits and alternatives offered) dated 3/16/2025 timed at 7:30 p.m., the Informed Consent indicated a signed consent for the use of Ativan 1 mg. twice a day for anxiety. During a review of Resident 95's Informed Consent dated 3/17/2025 timed at 7:30 p.m., the Informed Consent indicated a signed consent for the use of Seroquel 50 mgs. nightly for psychosis. During a concurrent observation and interview on 3/27/2025, at 8:39 a.m. with Resident 95, Resident 95 was lying in bed. Resident 95 stated she was sleepy and not that awake yet. Resident 95 stated she could not remember the names of her medications that help her relax and there was no psychiatrist seeing her with her anxiety. During a concurrent interview and record review of Resident 95's electronic chart on 3/27/2025, at 10:43 a.m. with Registered Nurse (RN 2), RN 2 stated the psychotropic medicines were given to Resident 95 's anxiety. RN 2 stated the resident had psychosis, depression and anxiety and confirmed there was no psychiatrist evaluating resident's behavioral problems and psychotropic medicines RN 2 stated the resident should be seen by a psychiatrist so his behavioral needs and mental health will be addressed and reassessed. RN 2 stated Resident 95 could get sleepier, and her mental health could get worse if resident's psychotropic medicines were not reassessed for appropriateness of use. During a concurrent interview and record review of Resident 95's electronic chart on 3/27/2025, at 3:25 p.m. with RN 3, RN 3 confirmed the resident had no diagnosis for psychosis .RN 3 stated Resident 95 could be at risk for unnecessary medicines and could be at risk for adverse effects (undesired and unwanted harmful effects that can occur after taking a medication) of the psychotropic medicines if the medications are not properly monitored for its use. During a concurrent interview and record review of Resident 95's electronic chart on 3/28/2025, at 9:07 a.m. with Assistant Nurse Manager(ANM), ANM verified the resident was on Valium, Prozac, Ativan, Seroquel and Ambien. ANM stated on 3/17/2025, the resident had a change in condition (COC-significant change in someone's health, functioning, or circumstances that requires attention or intervention) when the resident was manifesting more anxiety. ANM stated the neurologist( medical doctor who specializes in the diagnosis, treatment, and management of disorders affecting the brain, spinal cord, and nervous system) ordered Ativan 1 mg. twice a day and increased the dose of Seroquel to 50 mgs. due to resident's agitation. ANM stated there was no psychiatrist involved in the resident's case. ANM stated the facility should have consulted a psychiatrist because the resident was manifesting more anxiety. ANM stated the resident's behavioral change should have been addressed properly so the resident can have a better quality of life. ASM stated using Seroquel and Ativan could act as a chemical restraint and could be also an unnecessary medicine. 2. During a review of Resident 95's IDT Care Conference( structured meeting where the care team , resident, and family members discuss the resident's care plan, progress, and any concerns to ensure a collaborative approach to care) dated 3/20/2025, the IDT Care Conference indicated psychotropic medicines usage and change in condition of the resident were not addressed during the meeting. During a concurrent interview and record review of Resident 95's electronic chart on 3/28/2025, at 9:07 a.m. with ANM, ANM confirmed the IDT Care Conference conducted on 3/20/2025 did not address the resident's change in condition regarding her increased anxiety on 3/17/2025. ANM stated the IDT Care Conference is performed twice a week and the facility should have addressed the behavior during IDT meeting. During an interview on 3/28/20245, at 11:45 a.m. with Director of Nursing (DON), DON stated the facility conducted IDT Meeting on all residents to ensure residents' goals are met, plan of care and residents' progress are discussed. DON stated psychiatric consultation should be expected to ensure Resident 95's behavior was addressed. DON stated Resident 95's increased anxiety was a change in condition with two psychotropic medicines added and should be discussed during IDT Care Meeting to reach resident's goals. During a review of facility's policy and procedure (P&P) titled Transitional Care Center: Interdisciplinary Team Conference, revised 11/2024, the P&P indicated resident's needs are assessed and the plan of care is established from admission through discharge by utilizing an interdisciplinary team approach composed of Physicians, Director of Nursing or designee, Activity Coordinator, Physical therapist, Speech Therapist, Social Services, and other members as is appropriate in caring for the resident. During a review of facility's P&P titled Psychotropic Drug Management for Long Term Care Facilities, revised 3/2022, the P&P indicated psychoactive medications (anti-psychotics, anti-depressants, anti-anxiety, hypnotics) must only be prescribed by a person authorize to prescribe medications, when a medication is necessary to treat a specific condition as diagnosed and documented in the medical record. The P&P indicated it is the responsibility of the physician or provider who prescribes psychoactive medications to include the specific condition and target behavior documented in the medical record. The P&P indicated if the physician wishes to write a new order for a prn antipsychotic, the physician should evaluate the patient to determine appropriateness of the order, evaluation and rationale must be documented in the medical order.

Based on observation, interview, and record review, the facility failed to ensure two of four sampled Residents (Resident 95 and Resident 293) were free of unnecessary psychotropic medications (any drug that affects the brain activities associated with mental processes and behavior) by failing to: A. Assess appropriateness of Resident 95's psychotropic medications and reevaluated when Resident 95's had increased anxiety (emotion characterized by feelings of tension, worried thoughts) on 3/17/2025. B. Document indication for the use of Seroquel (medication that treats several kinds of mental health conditions including schizophrenia [a mental illness that is characterized by disturbances in thought]) and Ativan (medication to treat anxiety) for Resident 95 and Resident 293. These failures had the potential to put Resident 95 and Resident 293 at risk for unnecessary psychotropic medicines and increased adverse effects (unwanted and harmful result that can occur after taking a medication) associated with the prescribed medications. A. During a review of Resident 95's admission Record, the admission Record indicated Resident 95 was admitted to the facility on [DATE]. During a review of Resident 95's History and Physical (H&P) dated 3/6/2025, the H&P indicated Resident 95 had a history of multiple sclerosis ( disorder in which body's immune system attacks the protective covering of the nerve cells in the brain and spinal cord ), possible status epilepticus (a prolonged or continuous seizure activity that can be life threatening) and femur fracture ( a break in the thigh bone)surgery after a fall in the hospital and anxiety (emotion characterized by feelings of tension, worried thoughts ). During a review of Resident 95's Minimum Data Set (MDS- a resident assessment tool) dated 3/12/2025, the MDS indicated Resident 95 had an intact cognition (ability to think, understand, learn, and remember) and had no potential indicators of psychosis( a severe mental condition in which thought, emotions are so affected that contact is lost with reality) such as hallucinations(perceptual experiences in the absence of real external sensory stimuli) and delusions (having false or unrealistic beliefs). The MDS indicated Resident 95 required partial/moderate assistance (helper does less than half the effort) with bed mobility, oral hygiene and personal hygiene. The MDS indicated the resident had diagnoses that included anxiety disorder, seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) or epilepsy (disorder of the brain characterized by repeated seizures) and hip fracture. During a review of Resident 95's Medication Administration Record (MAR), the MAR indicated Prozac (medication used to treat depression [ a mood disorder that causes a persistent feeling of sadness and loss of interest]) 60 milligrams (mgs. - unit of measurement) daily by mouth ordered on 3/6/2025.The MAR indicated Prozac had no indication for its use. During a review of Resident 95's MAR, the MAR indicated Seroquel (medication used to treat depression) 25 mgs. every 12 hours as needed for agitation ordered on 3/5/2025. The MAR indicated Seroquel's physician order was changed to 25 mgs. nightly on 3/13/2025. During a review of Resident 95's Physician Order Report, dated 3/17/2025 timed at 5:14 p.m. the Physician Order Report indicated an order of Seroquel 50 mgs. by mouth nightly and was started on 3/17/2025, at 11:15 p.m. During a review of Resident 95's MAR, the MAR indicated Zolpidem (Ambien) 5 mgs. nightly as needed (prn) for insomnia (difficulty falling asleep) was ordered on 3/5/2025 and was reordered on 3/19/2025. During a review of Resident 95's Nursing Progress Note dated 3/17/2025 timed at 6:22 p.m., the Nursing Progress Note indicated Resident 95 was confused, restless, agitated and had a feeling of sadness. The Nursing Progress Note indicated Resident 95 was confused and forgetful to situation and time and the resident tend to say, help me, help me. During a review of Resident 95's Nursing Progress Note dated 3/17/2025, timed at 3:36 a.m., the Nursing Progress Notes indicated Resident 95 was anxious, confused, and was climbing out of bed. The Nursing Progress Notes indicated Resident 95 was awake, with episode of inability to relax manifested by calling out from time to time. The Nursing Progress Notes indicated Resident 95 received pain medication for complaint of right forearm pain. The Nursing Progress Notes indicated on 3/17/2025, at 3:40 a.m. Resident 95 woke up requested anti- anxiety medication and was provided to Resident 95. During a review of Resident 95's Physician Order Report, dated 3/16/2025, timed at 7:30 p.m. an order of Ativan 1 milligram (mg.- unit of measurement) by mouth 2 times a day without indication and was started on 3/17/2025 at 8:00 a.m. During a review of Resident 95's Informed Consent (voluntary agreement to accept treatment after receiving education regarding risks, benefits and alternatives offered) dated 3/16/2025 timed at 7:30 p.m., the Informed Consent indicated a signed consent for the use of Ativan 1 mg. twice a day for anxiety. During a review of Resident 95's Informed Consent dated 3/17/2025 timed at 7:30 p.m., the Informed Consent indicated a signed consent for the use of Seroquel 50 mgs. nightly for psychosis. During a review of Resident 95' Neurology Transitional Care Unit Follow up Note dated 3/17/2025, the Neurology Transitional Care Follow Up Note indicated Resident 95 was still having depression and aphasia (disorder that makes it difficult to speak) was improving. The Neurology Transitional Care Unit Follow Up Note indicated Resident 95 continued to have mood changes and would treat depression/anxiety aggressively, reevaluate, increased the dose of Seroquel to 50 mgs. nightly for rage episodes as described by the resident's family member and would start Ativan (medicine to treat anxiety) 1 mg. twice a day. During a review of Resident 95's Care Plan titled Psychotropic Drug Use and Risk for related side effects initiated 3/6/2025, the Care Plan indicated Resident 9. were on psychotropic medicines such as Seroquel for psychosis manifested by hallucinations (sensory experiences that occur without external stimulus), Ambien for hypnotics manifested by insomnia, Fluoxetine for depression manifested by worthlessness/helpless/hopeless and Diazepam for anxiety manifested by inability to relax. The Care Plan's goals indicated the resident will have than less than two episodes of hallucinations, inability to relax, inability to sleep and feeling of worthlessness. The Care Plan's interventions included administration of medication as ordered and monitoring of resident's behavior. During a concurrent observation and interview on 3/27/2025, at 8:39 a.m. with Resident 95, Resident 95 was lying in bed. Resident 95 stated she was sleepy. Observed Resident 95 not fully awake. Resident 95 stated she could not remember the names of her medications that help her relax. During a concurrent interview and record review of Resident 95's electronic chart on 3/27/2025, at 10:43 a.m. with Registered Nurse (RN 2), RN 2 stated the psychotropic medicines were given to Resident 95 's anxiety. RN 2 stated Resident 95 had psychosis, depression and anxiety and confirmed there was no psychiatrist evaluating resident's behavioral problems and psychotropic medication. RN 2 stated the Valium, Prozac and Ambien were resident home medications that were continued in the facility and no documented diagnosis of psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) was found in the electronic health record. RN 2 stated Resident 95 might become sleepier due to the use if these psychotropic medications. RN 2 stated Resident 95's mental health could get worse if resident's psychotropic medications were not reevaluated or monitored for appropriateness of use. During a concurrent interview and record review on 3/27/2025, at 12:22 p.m. with RN 3, reviewed Resident 95's electronic health record. RN3 stated there was no diagnosis of psychosis in Resident 95's electronic health the chart. RN 3 stated psychotropic medicines from home will be verified by licensed nurse with the physician who will reconcile the medications from home. RN 3 stated not reassessing the appropriateness of psychotropic medicines could put Resident 95 at risk for unnecessary medication and adverse effects. During a concurrent interview and record review on 3/28/2025, at 10:37 a.m. with RPH1 reviewed Resident 95's electronic health record. RPH 1 stated the physician's order for Ativan had no indication for its use and Seroquel was ordered for agitation. RPH 1 stated if he had seen the order for Ativan without indication, he would have clarified the order with Resident 95's physician. RPH 1 stated Resident 95 could be at risk for side effects like sedation (stated of calmness, relaxation, or sleepiness caused by a drug) and would not be able to participate in activities of daily living. RPH 1 stated psychotropic medication could act as a chemical restraint (medication given primarily to control a person's behavior, used for discipline or convenience and not required to treat medical symptoms) and could cause adverse effects if they are given without proper indication and monitoring for their appropriateness. During a concurrent interview and record review on 3/28/2025, at 9:07 a.m. with Assistant Nurse Manager (ANM), reviewed Resident 95's electronic health record. ANM stated Resident 95 took Valium, Prozac, Ambien at home prior to admission to the facility. ANM stated Seroquel and Ativan were started in the facility. ANM stated the physician order of Ativan 1 mg. twice a day had no indication for its use. ANM stated there should be an indication when ordering a psychotropic medication like Ativan. ANM stated Resident 95 had a change in condition (COC- any significant alteration in a patient's physical, mental, or emotional stays that requires attention and intervention) on 3/17/2025 for increased anxiety. ANM stated the neurologist (medical doctor who specializes in diagnosing and treating diseases of the brain, spinal cord, and nerves) ordered the Ativan and increased the dose of Seroquel 50 mgs nightly for psychosis. ANM stated the facility should have ordered psychiatric consultation, to ensure the use of psychotropic medication was addressed and Resident 95's increased anxiety. ANM stated the use of too many psychotropic medications could lead to unnecessary medication and could affect resident's activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily). During an interview on 3/28/2025, at 11:45 a.m., with the Director of Nursing (DON), the DON stated the facility should know why the psychotropic medications were prescribed and why the resident would need the medications. The DON stated Resident 95 should have gotten a psychiatric consult to address the change in condition of increased anxiety on 3/7/2025 and Seroquel and Ativan were ordered for the increased anxiety. B. During a review of Resident 293's admission Record, the admission Record indicated Resident 293 was admitted on [DATE]. During a review of Resident 293's Hospitalist Progress Note dated 3/24/2025, the Hospitalist Progress Note indicated Resident 293 was oriented to person. During a review of Resident 293's History & Physical (H&P) dated 3/22/2025, the H&P indicated Resident 293 had diagnoses of anxiety (intense, excessive, and persistent worry and fear about everyday situations), cirrhosis (chronic liver damage from a variety of causes leading to scarring and liver failure), and rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood). During a review of Resident 293's Active Medication Orders dated 3/28/2025 indicated Resident 293 was prescribed lorazepam (medication to treat anxiety) 0.5 mg every eight hours as needed for anxiety, insomnia (trouble falling asleep or staying asleep). The active medication orders also indicated that Resident 293 was taking Seroquel 25 mg nightly with no indication of its use. During a review of Resident 293's Completed Medication Administration Record (MAR) dated 3/28/25, the MAR indicated Resident 293 was given lorazepam 0.5mg on 3/24/25 at 1:44 p.m., and on 3/25/25 at 6:09 p.m. The MAR also indicated Resident 293 was given Seroquel 25 mg nightly on 3/24/2025 at 8:26 p.m., 3/25/2025 at 8:56 p.m., 3/26/2025 at 8:56 p.m., and 3/27/2025 at 8:22 p.m. During a review of Resident 293's Informed Consent for Psychotropic Medications, dated 3/21/2025, the Informed Consent indicated Resident 293 was taking Ativan 0.5 mg every eight hours as needed for anxiety as manifested by impatience, inability to relax and insomnia. During a review of Resident 293's Informed Consent for Psychotropic Medications, dated 3/24/2025, the Informed Consent indicated Resident 293 was taking Seroquel 25 mg nightly for agitation as manifested by persistent crying out. During an interview on 3/28/25 at 9:55 a.m. with ANM, the ANM stated agitation was not a diagnosis for giving Seroquel it was a manifestation of a behavior. The ANM stated that insomnia was not an appropriate manifestation to give lorazepam during the day. The ANM stated lorazepam should be given for insomnia at night. The ANM stated facility pharmacist should have caught this. The AMN stated that the use of too much psychotropic medication would be deemed unnecessary. During an interview on 3/28/25 at 11:45 a.m. with the DON, the DON stated we need to know the reasons why psychotropic medications were prescribed and if they were appropriate for Resident 293 to take. The DON stated to much psychotropic medication can cause respiratory depression, constipation and depression. During a review of facility's policy and procedure (P&P) titled Psychotropic Drug Management for Long Term Care Facilities, revised 3/2022, the P&P indicated Psychoactive medications (anti-psychotics, anti-depressants, anti-anxiety, hypnotics) must only be prescribed by a person authorized to prescribe medications, when a medication is necessary to treat a specific condition as diagnosed and documented in the medical record and to use the lowest effective dose to optimize treatment and reduce adverse effects. The P&P indicated it is the responsibility of the physician or provider who prescribes psychoactive medications to include the specific condition and target behavior documented in the medical record. The P&P indicated if the physician wishes to write a new order for a prn antipsychotic, the physician should evaluate the patient to determine appropriateness of the order, evaluation and rationale must be documented in the medical order.

Based on observation, interview, and record review, the facility failed to ensure safe, secured, and limited access to Resident 20's, Resident 94's and Resident 296's prepared medication that was left at the bedside and Resident 95's gabapentin (a medication used to treat nerve pain), affecting four of five residents sampled during medication administration. This deficient practice increased the risk of unintended access to medications, potential for misuse and medication errors for Residents 20, 94, 95 and 296. Findings: a. During a concurrent observation and interview on 3/26/2025 at 8:46 a.m. with Registered Nurse (RN) 2, RN 2 prepared five medications to be administered for Resident 20. RN 2 stepped away, stating she needed to find a pill-cutter and left the following medications unattended at her mobile computer station. 1. One tablet of losartan 50 milligram ([mg] a unit of measurement for mass) 2. Two tablets of vitamin D 25 microgram ([mcg] a unit of measurement for mass) 3. One tablet of vitamin C 500 mg 4. One-half tablet of hydrochlorothiazide 25 mg 5. One tablet of Thera-vite (multivitamin with iron) RN 2 performed blood pressure check for Resident 20 and based on blood pressure reading, RN 2 stated she would administer medications except for losartan 50 mg and hydrochlorothiazide 25 mg. RN 2 left Resident 20's room to ask a question to Certified Nurse Assistant (CNA), leaving behind the losartan 20 mg and hydrochlorothiazide 25 mg unattended in Resident 20's room. b. During a concurrent observation and interview on 3/26/2025 at 9:20 a.m. with RN 2, RN 2 prepared five medications to be administered for Resident 94. RN 2 crushed the tablet form of following medications to be administered with apple sauce. RN 2 stated she needed to find a spoon and left the mixture of medications and docusate oral liquid on the bedside table unattended when she left Resident 94's room. 1. One tablet of amlodipine 5 mg 2. One tablet of ferrous gluconate 324 mg 3. One tablet of bisoprolol 5 mg 4. One tablet of multivitamin with iron 5. 10 milliliters ([mL] a unit of measurement for volume) of docusate sodium oral liquid 50 mg per 5 mL c. During a concurrent observation and interview on 3/26/2025 at 10:22 a.m. with RN 4, RN 4 initially prepared five medications to be administered for Resident 296 and then returned them to automated dispensing storage when Resident 296 was not found to be in his room. On 3/26/2025 at 10:59 a.m., RN 4 stated she saw Resident 296 returned from therapy and so she was ready to retrieve medications and administer them. RN 4 stated she needed to bring the blood pressure monitor and left the following medications unattended on mobile computer station in resident's room. 1. One tablet of furosemide 20 mg 2. One tablet of amlodipine 2.5 mg 3. One tablet of aspirin 81 mg chewable 4. One-half tablet of metoprolol tartrate 25 mg 5. One tablet of amiodarone 200 mg d. During a concurrent observation and interview on 3/26/2025 at 2:07 p.m. with RN 2, RN 2 prepared one capsule of gabapentin 300 mg to be administered for Resident 95. RN 2 stated she needed to get apple sauce from the kitchen and left the gabapentin at Resident 95's bedside unattended. RN 2 stated she forgot the meds on the cart unattended. RN 2 stated medications should not be left unattended because that would increase the risk that residents could grab the medication and take them without supervision. During an interview on 3/27/2025 at 4:58 p.m. with the Director of Nursing (DON), DON stated no medications should be left unattended. DON stated if there was a reason for a facility nurses to step away, they should move the medications to medication room to prevent medication errors, prevent medications storage at unsafe temperatures, and to prevent unintended access to medications. During a review of the facility's policy and procedure (P&P) titled, Pyxis MedStation Nursing Use of Policy - So Bay Community, applicability includes TCC, dated 3/2023, the P&P indicated, Custody of the medication is the responsibility of the nurse removing the medication (e.g., the nurse removing the medication must be the one administering the medication - except .above). During a review of the facility's P&P titled, Labeling of Medications, applicability includes TCC, dated 5/2024, the P&P indicated, Drugs dispensed from Pyxis or floorstock and immediately administered to the patient do not require additional labeling. This includes unit dose administration. An immediately administered medication is one that an authorized staff member prepares or obtains, takes directly to a patient, and administers to that patient without any break in the process. During a review of the facility's P&P titled, Medication Management, applicability includes TCC dated 7/2023, the P&P indicated, Medication Administration Procedures .Note: Do not leave the medication at the bedside. Facility did not provide any specific policy focused only on medication storage.

Based on observation, interview and record review, the facility failed to observe infection control measures by not ensuring staff perform hand hygiene when food server (FSW) failed to wash her hands when entering leaving the kitchen area. This failure had the potential to result in cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) and place the residents at risk for the spread of infection. Findings: During tray line observation on 03/26/2025 at 11:03 a.m., in the kitchen, FSW walk in the kitchen, from outside holding a used surgical mask on her right hand. FSW walked towards her co-worker who was preparing food in the kitchen. FSW left the kitchen again without washing her hands. During a concurrent observation and interview on 03/26/2025 at 11::46 a.m., with FSW, FSW stated she should wash her hands when entering and leaving the kitchen area. FSW stated she was in a hurry to ask another kitchen staff about something and don't want to forget. FS 1 stated that not washing her hands can cause cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) and infection control issues. During an interview on 3/28/25 at 09:07 am, with the Kitchen Director Manager (KDM), KDM stated he does in-service once a month about handwashing and different area, and daily huddles, for all shift, KDM stated staff should wash their hands prior to entering the kitchen area and prior to leaving the kitchen area. During an interview on 03/28/25 at 09:14 a.m., with Kitchen Assistants Director (KAD), KAD stated it was important for staff to wash their hands prevent to cross contamination. KAD stated all kitchen staff including the cook, should wash their hands when entering the kitchen area and prior to leaving the kitchen area and must wear a hair net. During a review of the facility's policy and procedure (P&P) revised 10/22, titled Hand Hygiene, the P&P indicated, In the food &Nutrition Services Department: Hands are washed with soap and water at the following Times: After taking a break/when returning to kitchen, After touching hair, skin, beard or clothing.

Based on interview and record review, the facility failed to ensure one of 3 sampled residents (Resident 1) received care and services necessary to avoid physical harm and mental anguish by not allowing 2 security guards to threatened Resident 1 and physically escort the resident out of the facility. This deficient practice resulted in Resident 1 being upset and causing him to have symptoms of anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome) leading to an elevated blood pressure and exacerbating his illness symptoms which led to a transfer to an acute care hospital. Findings: During a telephone interview with Resident 1 on 5/19/17 at 1:21 p.m., Resident 1 stated that on 5/17/17 morning, he was provided with bus tokens and was being discharged against his will to a homeless shelter. Resident 1 stated he had never felt so threatened in his life because he could not even wipe his backside. Resident 1 stated security was called to his room to physically throw him out on the street which gave him an anxiety attack that led to his transfer to the Emergency Department. According to the admission record, Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the review of facility's Interdisciplinary Team (IDT) care conference note, dated 5/15/17, on the day of admission to the facility, Resident 1 was assessed as oriented to person, place, time, and situation, was assessed as being a high risk for falls, required set up and stand by assistance for feeding, dressing and toileting, independent in bed mobility and transfer between bed to chair with independent gait with ability to walk the distance of 50 feet. In the IDT note was documented Resident 1 was living in a foreign country and currently was visiting a friend in Los Angeles and was staying at the friend's house. According to the Occupational Therapist's (OT) note, dated 5/16/17 at 3:59 p.m., Resident 1 required set up assistance during feeding and stand by assistance with grooming, and when conducting upper and body dressing. A review of a physician's orders [REDACTED]. According to a phone interview with the Ombudsman on 5/19/17 at 2:41 p.m., and an e-mailed letter, on 5/26/17 at 1:47 p.m., from the Ombudsman, on 5/17/17, the Ombudsman saw the facility's licensed clinical social worker 1 (LCSW 1) with sweat pants in her hand and two security guards in Resident 1's room at the facility. In the interview, the Ombudsman stated the situation appeared to her as if the security guards were physically going to remove Resident 1 out of the facility's property. The Ombudsman informed the medical social worker 1 (MSW 1) and security guards that Resident 1 had rights and that he should not be removed from the facility. Resident 1 must be given a 30 days discharge/transfer notice which would contain information about his rights to appeal the facility's decision with Office of Administrative Hearing and Appeals (OAHA), before he can be discharged . In addition, the Ombudsman informed the licensed clinical social worker 1 (LCSW 1) and Administrator (ADM) about Resident 1's right for appeal and about new notification process regarding the discharge notice requirement sent to the Ombudsman when a resident was being discharged and a discharge notice had not been provided to Resident 1. A review of MSW 1 progress note dated 5/17/17, at 12:01 p.m., the day the facility was attempting to discharge Resident 1 to a shelter, indicated that MSW 1 had told Resident 1 that since he had the discharge order and was not willing to discuss the discharge, she was going to contact the facility's security. In this note it was documented that MSW 1's contacted the facility's Risk Management, who agreed to have security staff escort Resident 1 out of the facility. During Resident 1's stay at the facility he shared a room with another resident, who had a family member (FM 1) present in Resident 1's room on 5/17/17 during his discharge. According to the e-mailed FM 1's letter, dated 5/21/17, at 7:45 p.m., on the day of Resident 1 discharge, MSW 1 entered his room and informed Resident 1 that she had worked with Resident 1 by calling shelters on his behalf, arranged transportation, and that Resident 1 simply had to go. Resident 1 informed MSW 1 he would not be leaving and in turn MSW 1 told Resident 1 that she would have to call the security. According to FM 1's letter, a nurse, three security guards, and someone from administration entered Resident 1's room sometime later that day. According to the interview with facility's security guard 1 (SG 1) on 5/19/17 at 4:36 p.m., SG 1 received a call from MSW 1 and was instructed to escort Resident 1 out of the facility. SG 1 stated that the physician had discharged Resident 1 and Resident 1 was giving them a hard time about leaving the facility. SG 1 indicated that Resident 1 was only dressed in a gown with no other form of clothing. SG 1 stated that she and another security guard showed up to remove Resident 1 from the facility. A review of the licensed nurses notes, written by the registered nurse 1 (RN 1) and dated 5/17/17, at 11 a.m., indicated during Resident 1's discharge the resident complained to RN 1 that he was feeling hot and was diaphoretic (sweating heavily). At 3 p.m. on the same day, Resident 1 had stated that his arms became more contracted, painful, and he was unable to hold the phone during a call, so RN 1 had to assist him. In the note was documented RN 1 received an order from the physician to transfer Resident 1 to the Emergency Department. A review of a physician's discharge summary dated 5/17/17 at 3:38 p.m., indicated Resident 1 was having increased stiffness and pain to his upper extremities. According to the emergency medical technician (EMT) note, dated 5/17/17, Resident 1's blood pressure was 140/101 when the ambulance arrived at the facility to transport Resident 1 to the Emergency Department (ED). A review of Resident 1's History and Physical (H & P) from the general acute care hospital (GACH), dated 5/18/17 at 7:54 a.m., indicated on 5/17/17, Resident 1 experienced increased anxiety due to the plan to be discharged to a shelter instead of to his friend's home, which Resident 1 felt exacerbated his baseline paresthesia (a pricking, burning, tingling, or numbing sensation that is usually felt in the arms, legs, hands, and feet). The H & P further indicated that Resident 1 reported intermittent (not continuous or steady) right-sided chest tightness without associated shortness of breath, nausea, or vomiting over the past three days when he was informed at the facility of his discharge. A review of a physician's progress note from the GACH dated 5/19/17 at 1:45 p.m., indicated Resident 1 presented from the facility to the ED with progressively worsening bilateral upper and lower extremity paresthesia as evidenced by stiffness and tightness and contractures (a permanent shortening of a muscle or joint) as well as vibratory sensation of the left upper extremity for approximately three days in setting of anxiety over pending discharge. A review of the facility's policy and procedure titled, Coordinating Care for Patients Who are Without a Residence, dated 10/1/09, indicated in keeping with the philosophy and mission of the facility, the policy provides care and discharge planning for patients who are without a residence in a manner that respects their rights and needs. The designated health care provider will make every attempt to assist a resident in understanding and accepting his/her current medical condition, the impact of not having a residence on health, and available residence options. Any patient with decision-making capacity retains the right to determine what resources and living arrangements he/she will accept. This includes the right to refuse going to a shelter following discharge. At the time of discharge to a non-healthcare related location, the health care provider will complete the Community Shelter Discharge Referral form and request patient to sign either acceptance or refusal of referrals.

Based on interview and record review, the facility failed to notify Resident 1 in writing of the discharge to a shelter and the reasons for the 30 day before the anticipated discharge day. The facility also failed to provide the notice of the proposed transfer and discharge to the Office of the State Long-Term Care Ombudsman (advocate for the rights of all residents of long-term care facilities). Resident 1 was discharged to a shelter that he refused to go to when he was unable to physically take care of himself. This deficient practice resulted in Resident 1 being upset and causing him to have symptoms of anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome) leading to an elevated blood pressure to go up to 140/101 (normal blood pressure is at or below 120/80) and exacerbating his illness symptoms which led to a transfer to an acute care hospital. Resident 1 felt threatened by the security guards that showed up to his room to physically escort him out of the facility. Findings: During a telephone interview with Resident 1 on 5/19/17 at 1:21 p.m., Resident 1 stated that on 5/17/17 morning, he was provided with bus tokens and was being discharged against his will to a homeless shelter. Resident 1 stated he had never felt so threatened in his life because he could not even wipe his backside. Resident 1 stated security was called to his room to physically throw him out on the street which gave him an anxiety attack that led to his transfer to the Emergency Department. According to the admission record, Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the review of facility's Interdisciplinary Team (IDT) care conference note, dated 5/15/17, on the day of admission to the facility, Resident 1 was assessed as oriented to person, place, time, and situation, was assessed as being a high risk for falls, required set up and stand by assistance for feeding, dressing and toileting, independent in bed mobility and transfer between bed to chair with independent gait with ability to walk the distance of 50 feet. In the IDT note was documented Resident 1 was living in a foreign country and currently was visiting a friend in Los Angeles and was staying at the friend's house. According to the Occupational Therapist's (OT) note, dated 5/16/17 at 3:59 p.m., Resident 1 required set up assistance during feeding and stand by assistance with grooming, and when conducting upper and body dressing. A review of a physician's orders [REDACTED]. According to a phone interview with the Ombudsman on 5/19/17 at 2:41 p.m., and an e-mailed letter, on 5/26/17 at 1:47 p.m., from the Ombudsman, on 5/17/17, the Ombudsman saw the facility's licensed clinical social worker 1 (LCSW 1) with sweat pants in her hand and two security guards in Resident 1's room at the facility. In the interview, the Ombudsman stated the situation appeared to her as if the security guards were physically going to remove Resident 1 out of the facility's property. The Ombudsman informed the medical social worker 1 (MSW 1) and security guards that Resident 1 had rights and that he should not be removed from the facility. Resident 1 must be given a 30 days discharge/transfer notice which would contain information about his rights to appeal the facility's decision with Office of Administrative Hearing and Appeals (OAHA), before he can be discharged . In addition, the Ombudsman informed the licensed clinical social worker 1 (LCSW 1) and Administrator (ADM) about Resident 1's right for appeal and about new notification process regarding the discharge notice requirement sent to the Ombudsman when a resident was being discharged and a discharge notice had not been provided to Resident 1. During an interview with MSW 1 on 5/20/17, at 4:13 p.m., confirmed there was no written notice given to Resident 1 prior to his discharge. MSW 1 stated that the only notice that was similar to a discharge summary was given to residents after being discharged . During an interview with LCSW 1 on 5/21/17, at 12:15 p.m., LCSW 1 acknowledged that Resident 1 was not provided any written documentation about discharge. During an interview with the medical director (MD) on 5/21/17 at 2:15 p.m., acknowledged that Resident 1 was not given any paperwork regarding his discharge. A review of MSW 1 progress note dated 5/17/17, at 12:01 p.m., the day the facility was attempting to discharge Resident 1 to a shelter, indicated that MSW 1 had told Resident 1 that since he had the discharge order and was not willing to discuss the discharge, she was going to contact the facility's security. In this note it was documented that MSW 1's contacted the facility's Risk Management, who agreed to have security staff escort Resident 1 out of the facility. During Resident 1's stay at the facility he shared a room with another resident, who had a family member (FM 1) present in Resident 1's room on 5/17/17 during his discharge. According to the e-mailed FM 1's letter, dated 5/21/17, at 7:45 p.m., on the day of Resident 1 discharge, MSW 1 entered his room and informed Resident 1 that she had worked with Resident 1 by calling shelters on his behalf, arranged transportation, and that Resident 1 simply had to go. Resident 1 informed MSW 1 he would not be leaving and in turn MSW 1 told Resident 1 that she would have to call the security. According to FM 1's letter, a nurse, three security guards, and someone from administration entered Resident 1's room sometime later that day. According to the interview with the facility's security guard 1 (SG 1) on 5/19/17 at 4:36 p.m., SG 1 received a call from MSW 1 and was instructed to escort Resident 1 out of the facility. SG 1 stated that the physician had discharged Resident 1 and Resident 1 was giving them a hard time about leaving the facility. SG 1 indicated that Resident 1 was only dressed in a gown with no other form of clothing. SG 1 stated that she and another security guard showed up to remove Resident 1 from the facility. A review of the licensed nurses notes, written by the registered nurse 1 (RN 1) and dated 5/17/17, at 11 a.m., indicated during Resident 1's discharge the resident complained to RN 1 that he was feeling hot and was diaphoretic (sweating heavily). At 3 p.m. on the same day, Resident 1 had stated that his arms became more contracted, painful, and he was unable to hold the phone during a call, so RN 1 had to assist him. In the note was documented RN 1 received an order from the physician to transfer Resident 1 to the Emergency Department. A review of a physician's discharge summary dated 5/17/17 at 3:38 p.m., indicated Resident 1 was having increased stiffness and pain to his upper extremities. According to the emergency medical technician (EMT) note, dated 5/17/17, Resident 1's blood pressure was 140/101 when the ambulance arrived at the facility to transport Resident 1 to the Emergency Department (ED). A review of LCSW's Discharge Planing note, dated 5/15/17, at 4:40 p.m., indicated the goal for Resident 1 was to have a safe discharge, with durable medical equipment (DME), and home health agency to be arranged and provided if indicated. LCSW 1's note indicated LCSW 1 met with Resident 1 to review discharge planning and that discharge may be as soon as two to three days. Resident 1 indicated to LCSW 1 that he will most likely go home with his friend and then work on his plane ticket to get home from there. The note indicated that LCSW 1 encouraged Resident 1 to reach out to his friend and make an alternate plan in case the plan did not work. A review of LCSW 1's Discharge Planning note, dated 5/16/17 at 3:12 p.m., once again, indicated the discharge planning goal for Resident 1 was to have a safe discharge, with DME, and home health agency to be arranged and provided if indicated. LCSW 1's note indicated that she had offered resources such as shelter information. A review of MSW 1's Plan of Care note, dated 5/17/17, at 10:09 a.m., indicated that MSW 1 informed Resident 1 he was being discharged the same day and that there were several options/resources available to him upon discharge. MSW 1 discussed options of providing the resident with bus tokens or to provide patient with shelter placement/resource. According to the licensed vocational nurse case manager (CM) a progress note, dated 5/17/17, at 10:50 a.m., the facility offered Resident 1 to be discharged to a shelter and Resident 1 had refused to go. A review of MSW 1's Plan of Care note, dated 5/17/17 at 2:30 p.m., indicated MSW 1 met with Resident 1 again and attempted to discuss discharge plan. MSW 1 indicated Resident 1 was alert and oriented. Per MSW 1's note, she attempted to discuss the following options again: providing bus tokens, clothing, and resources (clinic, shelter, etc.) versus shelter placement with clothing. A review of Resident 1's History and Physical (H & P) from the general acute care hospital (GACH), dated 5/18/17 at 7:54 a.m., indicated on 5/17/17, Resident 1 experienced increased anxiety due to the plan to be discharged to a shelter instead of to his friend's home, which Resident 1 felt exacerbated his baseline paresthesia (a pricking, burning, tingling, or numbing sensation that is usually felt in the arms, legs, hands, and feet). The H & P further indicated that Resident 1 reported intermittent (not continuous or steady) right-sided chest tightness without associated shortness of breath, nausea, or vomiting over the past three days when he was informed at the facility of his discharge. A review of a physician's progress note from the GACH dated 5/19/17 at 1:45 p.m., indicated Resident 1 presented from the facility to the ED with progressively worsening bilateral upper and lower extremity paresthesia as evidenced by stiffness and tightness and contractures (a permanent shortening of a muscle or joint) as well as vibratory sensation of the left upper extremity for approximately three days in setting of anxiety over pending discharge. A review of the facility's policy and procedure titled, Coordinating Care for Patients Who are Without a Residence, dated 10/1/09, indicated in keeping with the philosophy and mission of the facility, the policy provides care and discharge planning for patients who are without a residence in a manner that respects their rights and needs. The designated health care provider will make every attempt to assist a resident in understanding and accepting his/her current medical condition, the impact of not having a residence on health, and available residence options. Any patient with decision-making capacity retains the right to determine what resources and living arrangements he/she will accept. This includes the right to refuse going to a shelter following discharge. At the time of discharge to a non-healthcare related location, the health care provider will complete the Community Shelter Discharge Referral form and request patient to sign either acceptance or refusal of referrals.