Every finding on record at Ramona Rehabilitation and Post Acute Care Center

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices were followed in accordance with professional standards of practice, when:1. The convection oven had splattered, solidified greasy residue on the glass doors and black crusted residue at the bottom of the oven; and2. One opened package of white loaf bread with a date of January 30, 2026, was found stored on the shelf, readily available for use. The opened package of the white loaf bread did not have an open date and a use-by date.These failures had the potential to cause foodborne illnesses (stomach illness resulting from ingestion of contaminated food) in a medically vulnerable population.Findings:1. On February 9, 2026, at 9:05 am, an initial tour of the kitchen was conducted with the Dietary Supervisor (DS). The convection oven had solidified greasy residue on the glass doors and black crusted residue at the bottom of the oven. In a concurrent interview with the DS, he stated the convection oven was cleaned once a week with a degreaser.On February 13, 2026, at 12:07 p.m., the Registered Dietician (RD) was interviewed. The RD stated the expectation was for the kitchen staff to follow the cleaning schedule. The RD stated the kitchen equipment should be kept clean and in sanitary condition.A review of the facility policy and procedure titled, RANGES AND OVENS, dated, 2023, indicated, .OVENS.CLEANING PROCEDURE.Weekly, and as often as necessary.According to the Food and Drug Administration (FDA - agency responsible for protecting public health by ensuring the safety of the food supply) Food Code 2022, Section 4-601.11, titled, Equipment, Food-Contact Surfaces, Non-Food-Contact Surfaces, and Utensils, indicated, .NONFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris , and Section 4-602.13, titled, Nonfood-Contact Surfaces, indicated, NONFOOD-CONTACT SURFACES OF EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues.2. On February 9, 2026, at 9:05 am, an initial tour of the kitchen was conducted with the DS. One opened package of white loaf bread with a date of January 30, 2026, was found stored on the shelf, readily available for use. The opened package of the white loaf bread did not have an open date and a use-by date. In a concurrent interview with the DS, he stated the opened package of white loaf bread did not have an open date and a use-by date. The DS stated bread is for good seven days after the package had been opened. The DS stated the kitchen staff should place a label with an open date and a use-by date for food that was already open.On February 13, 2026, at 12:07 p.m., the RD was interviewed. The RD stated the kitchen staff were expected to label all opened foods with an open date and a use-by date.A review of the facility document titled, DRY GOODS STORAGE GUIDELINES, dated 2023, indicated bread shelf life when opened is between five to seven days.A review of the facility policy and procedure titled, LABELING AND DATING FOODS, dated 2023, indicated, .All food items in the storeroom, refrigerator, and the freezer need to be labeled and dated.Newly opened food items will need to be closed and labeled with an open date and used by the date.

Based on observation, interview, and record review, the facility failed to ensure proper infection control practices were implemented for seven out of 97 residents reviewed for infection control practices when:1. For Residents 47 and 108, nursing staff did not clean and disinfect shared medical equipment, including a blood pressure (BP) cuff and stethoscope (medical instrument for listening to the action of someone's heart or breathing, typically having a small disk-shaped resonator that is placed against the chest, and two tubes connected to earpieces), before and after use, in accordance with the facility's infection control policy;2. Certified Nursing Assistant (CNA) 2 did not perform hand hygiene in between serving food trays to four residents in Station 2 during the lunch meal service on February 9, 2026; and3. For Resident 30, CNA 3 did not perform handwashing before and after entering Resident 30's room who required contact isolation precautions for Clostridium Difficile (C - diff - a highly contagious bacteria causing severe diarrhea, fever, and abdominal pain).These failures had the potential to result in the transmission of infectious organisms between residents and compromise residents' health and safety.Findings: 1a. On February 9, 2026, at 9:15 a.m., during a medication administration observation for Resident 108, Licensed Vocational Nurse (LVN) 3 was observed retrieving a BP cuff from the bottom drawer of her medication cart, and entering the resident's room with a stethoscope draped around her neck. LVN 3 was observed not to disinfect the BP cuff and stethoscope before entering Resident 108's room. On February 9, 2026, at 9:18 a.m., LVN 3 was observed using the BP cuff and stethoscope, which had not been cleaned or disinfected, to obtain Resident 108's blood pressure. On February 9, 2026, at 9:22 a.m., after obtaining blood pressure reading, LVN 3 was observed draping the used stethoscope around her neck and placed the used BP cuff into the bottom drawer of the medication cart and keeping the used stethoscope draped around her neck without cleaning or disinfecting the equipment. 1b. On February 9, 2026, at 9:53 a.m., during a medication administration observation for Resident 47, LVN 3 was observed retrieving the same BP cuff from the bottom drawer of her medication cart and entering the resident's room with the same stethoscope draped around her neck. LVN 3 was observed using the same BP cuff and stethoscope, which had not been cleaned or disinfected after prior use, to obtain Resident 47's blood pressure. On February 9, 2026, at 9:57 a.m., after obtaining blood pressure reading, LVN 3 was observed draping the used stethoscope around her neck and placing the used BP cuff back into the bottom drawer of the medication cart without cleaning or disinfecting the equipment. On February 9, 2025, at 3:11 p.m., during an interview with LVN 3, LVN 3 acknowledged the BP cuff and stethoscope were not cleaned or disinfected before and after use between residents. LVN 3 stated the BP cuff and stethoscope are shared equipment and should have been cleaned and disinfected using Sani-Cloth germicidal disposable wipes (disinfectant wipes used to kill bacteria and viruses) available in the medication cart. On February 11, 2026, at 10:44 a.m., during an interview with the Director of Nursing (DON), the DON stated the BP cuff, and stethoscopes are considered shared medical equipment and required to be cleaned and disinfected with disinfectant wipes before and after each use for infection control prevention. A review of the facility's policies and procedures titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated October 2018, indicated, .Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard.Non-critical items are those that come in contact with intact skin.Non-critical resident-care items include.blood pressure cuffs.Reusable items are cleaned disinfected.between residents (e.g., stethoscope, durable medical equipment).Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. 2. On February 9, 2026, at 12:17 p.m., during the lunch meal service at Station 2, CNA 2 was observed dropping off a meal tray in room [ROOM NUMBER], who required Enhanced Barrier Precaution (EBP- an infection control strategy for nursing homes to reduce the spread of multidrug-resistant organisms [MDROs] by requiring the use of gowns and gloves during high-contact resident care), and leaving the room holding a desert bowl, spoon and cup with her bare hands. CNA 2 proceeded to the food cart and placed the desert bowl, spoon and cup on top of food cart. CNA 2 proceeded to pick up one meal tray from inside the food cart and brought the food tray to room [ROOM NUMBER]-B. CNA 2 came out of room with another meal tray and placed the meal tray on top of the food cart. CNA 2 took one meal tray from inside the food cart and proceeded to serve it to room [ROOM NUMBER]-B, an EBP room, and came out of the room holding a plate cover. CNA 2 went to the food cart and placed the plate cover on top of the food cart. CNA 2 took one meal tray from inside the food cart and proceeded to RM [ROOM NUMBER], an EBP room, and came out of room holding a plate cover. CNA 2 was observed to not perform hand hygiene throughout and in between serving the residents. CNA 2 was stopped in the hallway and was interviewed. CNA 2 confirmed she did not perform hand hygiene in between serving the food trays to the residents. CNA 2 stated the staff should observe hand hygiene between provision of care to residents. CNA 2 stated, I guess in between every patient. CNA 2 further stated she should have performed hand hygiene in between passing trays to the residents. On February 9, 2026, at 3:26 p.m., the Infection Preventionist (IP) was interviewed. The IP stated her expectation was for staff to perform hand hygiene before and after patient care and between patients. The IP stated passing trays were part of patient care, and staff should wash hands or perform hand hygiene with ABHR (alcohol-based hand rub) in between passing trays. The IP stated CNA 2 should have performed hand hygiene in between serving meals trays. A review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, revised August 2019, indicated, .This facility considers hand hygiene the primary means to prevent the spread of infections .All personnel shall follow the handwashing/hand hygiene procedures to prevent the spread of infections to other personnel, residents, and visitors .Use an alcohol based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .before and after direct contact with residents .After contact with objects .within the immediate vicinity of the resident .Before and after entering isolation precaution settings .Before and after assisting a resident with meals . 3. On February 9, 2026, at 3:14 p.m., a contact isolation sign for C-diff was observed posted by the door for Resident 30. Resident 30 was observed lying in bed and stated he was doing alright. On February 9, 2026, at 3:30 p.m., Certified Nursing Assistant (CNA) 3 was observed to don (to put on) personal protective equipment (PPE – equipment worn to minimize exposure to hazards and/or illnesses. Examples: gloves, gown and mask) and entered Resident 30's room. On February 9, 2026, at 3:38 p.m., CNA 3 was observed doff (to remove) the PPEs, went out of Resident 30's room and used the hand sanitizer. CNA 3 was observed to get a diaper from the linen cart, don PPEs and went back inside Resident 30's room. On February 9, 2026, at 4:11 p.m., during an interview with CNA 3, she stated she used the hand sanitizer when she came out of Resident 30's room. CNA 3She also stated she did not wash her hands with soap and water when she took a clean diaper from the linen cart and re-entered Resident 30's room. On February 13, 2026, at 12:45 p.m., during an interview with the Infection Preventionist (IP), she stated she expected the staff to follow the C-diff contact precaution, which was to wash hands with soap and water before entering and after leaving the resident's room who was on C-diff isolation. The IP stated CNA 3 should have washed her hands with soap and water before and after she entered Resident 30's room. Resident 30's record was reviewed. Resident 30 was admitted to the facility on [DATE], with diagnoses which included enterocolitis (inflammation of both the small intestine and colon [large intestine]). A review of Resident 30's laboratory examination for stool culture on January 19, 2026, indicated a positive result for Clostridium Difficile toxins (poisonous, typically protein-based substances that cause disease upon contact or absorption). A review of the facility policy and procedure titled, Clostridium Difficile, revised October 2018, indicated, .Measures are taken to prevent the occurrence of Clostridium difficile infections (CDI) among residents. Precautions are taken while caring for residents with C. difficile to prevent transmission to others.Spores can persist on resident-0care items and surfaces for several months an are resistant to some common cleaning and disinfection methods.Steps toward prevention and early intervention include.frequent hand washing with soap and water by staff and residents.When caring for residents with CDI, staff is to maintain vigilant hand hygiene. Handwashing with soap and water is superior to ABHR (alcohol- based hand rub) for the mechanical removal of C. difficile spores from hands.

Based on observation, interview, and record review, the facility failed to ensure care and treatment was provided, for four of 97 residents reviewed, when:1.For Resident 51, the facility did not provide ongoing assessment and monitoring for bilateral (both) lower extremities edema (swelling caused by too much fluid trapping in the body's tissues);2. For Resident 104, the facility did not provide ongoing assessment and monitoring for bilateral upper and lower extremities, and low blood pressure;3. For Resident 112, the facility did not notify the physician of the resident's change in level of consciousness; and4. For Resident 55, the facility did not identify, address, and notify the physician of the left elbow skin discoloration on February 10, 2026. These failures had the potential for a delay in treatment and placed the residents at risk of complications.Findings: 1.On February 10, 2026, at 10:25 a.m., Resident 51 was observed sitting at bedside, upright with legs dangling off the bed. Resident 51's bilateral lower extremities (both legs, ankles and feet) were observed with edema. In a concurrent interview with Resident 51, she stated she has a history of bilateral lower extremity edema and a recent blood clot to her right leg. Resident 51 stated she usually takes Lasix (a diuretic prescribed to remove excess water and salt from the body through increased urination) 80 milligrams (mg – unit of measurement). Resident 51 stated her left leg edema had worsened and developed new pain behind the knee/calf of her right leg. Resident 51 stated the nurses would check her lower extremities edema once in a while. On February 12, 2026, at 3:16 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated Resident 51 reported right calf pain approximately 3 days ago. CNA 1 stated she reported it to the charge nurse. On February 13, 2026, at 3:16 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated Resident 51 had worsening edema to the right lower extremity. LVN 1 stated she notified the physician and received an order to change Lasix 40 mg to two times a day. LVN 1 stated Resident 51 did not report right lower extremity calf pain. On February 13, 2026, Resident 51's medical record was reviewed. Resident 51 was admitted to the facility on [DATE], with diagnoses which included congestive heart failure (CHF - a chronic, progressive condition where the heart muscle is too weak or stiff to pump blood efficiently, causing blood to back up and fluid to congest in the lungs, legs, and abdomen) and acute embolism and thrombosis (the formation of a blood clot (thrombus) inside a vessel, while an embolism occurs when that clot—or another object like fat or air—breaks off, travels through the bloodstream, and lodges elsewhere) of the right lower extremity. A review of Resident 51's Minimum Data Set (MDS - a resident assessment tool), dated January 28, 2026, indicated Resident 51 had a BIMS (Brief Interview of Mental Status) score of 15 (cognitively intact). A review of Resident 51's care plan, date initiated on January 23, 2026, indicated, risk for injury and skin breakdown r/t (related to) edema.site(s): edema to bilateral lower extremities .monitor edema daily.as needed .call MD (medical doctor) if worsening.monitor for acute changes in condition.notify physician if these occur. A review of Resident 51's medical records indicated the following physician orders: -Monitor Both Lower extremities +2 pitting edema to increasing pitting, skin tear, signs of infection, every shift for 14 days, date ordered January 23, 2026, with stop date on February 6, 2026; -Furosemide Oral Tablet 40 MG (Furosemide – generic for Lasix) Give 1 tablet by mouth one time a day for CHF, date ordered January 26, 2026; administered until February 4, 2026; and -Furosemide Oral Tablet 40 MG (Furosemide) Give 1 tablet by mouth two times a day for CHF, date ordered February 4, 2026; administered until February 12, 2026. A review of Resident 51's daily skilled charting indicated the nursing staff did not document status of Resident 51's edema on the following dates: - January 24, 2026; - January 25, 2026; - January 26, 2026; - January 27, 2026; - January 28, 2026; - January 29, 2026; - January 30, 2026; - January 31, 2026; - February 1, 2026; - February 2, 2026; - February 3, 2026; - February 8, 2026; - February 9, 2026; and - February 10, 2026 On February 13, 2026, at 12:21 p.m., a concurrent interview and record review was conducted with the Assistant Director of Nursing (ADON). The ADON reviewed Resident 51's care plan and daily skilled charting. The ADON stated Resident 51's edema should have been monitored daily and the expectation was for the nursing staff to follow interventions according to the resident's care plan and physician orders. A review of the facility policy and procedure titled, Skin Assessment, revised December 11, 2022, indicated, .It is the policy of this facility to monitor the resident's skin condition daily.implement interventions when needed to prevent complications.provide documented licensed nurse assessments on an as-needed basis.the licensed nurse shall notify the physician for orders and follow-up treatment. the licensed nurse progress notes as to findings and doctor's orders . A review of the facility policy and procedure titled, Resident Examination and Assessment, revised February 2014, indicated, .physical exam.skin.presence of edema.documentation.all assessment data obtained during procedure.reporting.notify physician of any abnormalities . 2. On February 12, 2026, at 8:55 a.m., Resident 104's medical record was reviewed. Resident 104 was admitted to the facility on [DATE], with diagnoses which included severe sepsis (a life-threatening medical emergency caused by the body's overwhelming response to an infection) with septic shock (the most severe, life-threatening stage of sepsis, when a body-wide infection causes extremely low blood pressure and cellular abnormalities). A review of Resident 104's Minimum Data Set (MDS-a resident assessment tool), dated December 9, 2025, indicated Resident 104 had a BIMS (Brief Interview of Mental Status) score of 13 (cognitively intact). A review of Resident 104's Nursing admission Screening/History, dated December 2, 2025, indicated, BLE (bilateral lower extremities - both legs), bilateral arms (both arms) +1 (mild swelling caused by a small amount of extra fluid trapped in the body's tissues). A review of Resident 104's daily skilled charting indicated there was no documentation of the status of Resident 104's edema on both lower extremities and arms on December 5 to 15, 2025. A review of Resident 104's daily skilled charting, dated December 16, 2025, indicated, .edema present.BUE (bilateral upper extremities-both arms)/BLE, 4+ very deep pitting, indentation lasts a long time, leg is very swollen. A review of Resident 104's medical records indicated the following physician orders: - Lasix (diuretic prescribed to remove excess water and salt from the body through increased urination) Oral Tablet 40 milligrams (mg – unit of measurement). (Furosemide) Give 40 mg by mouth two times a day for edema (swelling caused by too much fluid trapping in the body's tissues), date ordered December 16, 2025; and - MD (medical doctor) order to send resident to ER (emergency room) for abnormal laboratory results, date ordered December 17, 2025. A review of Resident 104's blood pressure exceptions, indicated Resident 104 had low blood pressures on the following dates: -December 9, 2025: 75/54 mmHg (millimeters of Mercury – unit of measurement); and -December 15, 2025: 72/51 mmHg. Further review of Resident 104's record indicated there was no documented evidence the low blood pressure readings were addressed including notification to the physician for further evaluation and management. A review of Resident 104's care plan, did not include a plan of care to address the edema on both upper and lower extremities which were present on admission. On February 12, 2026, at 3:09 p.m., an interview was conducted with CNA 1. CNA 1 stated when a CNA identified a systolic blood pressure is less than 120 or diastolic (pressure in your arteries when your heart is resting between beats) blood pressure is less than 80, the CNA should report it to the charge nurse, and the charge nurse would notify the physician. CNA 1 stated Resident 104 had BLE edema since admission and throughout her stay in the facility. CNA 1 stated Resident 104 did not suddenly develop BLE edema. On February 13, 2026, at 9:49 a.m., an interview was conducted with LVN 1. LVN 1 stated some risks for hospitalization would include: if a resident has wounds, long term lung disease or worsening edema. LVN 1 stated to prevent hospitalization the licensed nurse was expected to assess the resident every shift, review the resident's medical record and vital signs (essential measurements of how the body is functioning), then the licensed nurse will notify the physician of any changes in the resident's status. LVN 1 stated the licensed nurse would assess and monitor edema by weekly weights, urine output and increased size of the extremity. LVN 1 stated if edema worsens it is considered a change of condition and the licensed nurse should notify the physician. On February 13, 2026, at 11:30 a.m., a concurrent interview and record review was conducted with the ADON. The ADON reviewed Resident 104's blood pressure, weights and daily skilled charting as listed above. The ADON acknowledged the nursing staff did not follow the facility policy for acute condition changes. The ADON stated Resident 104's blood pressure 72/51 mmHg on December 15, 2025, was considered too low and the licensed nurse should have notified the physician. The ADON stated edema assessment was part of the nursing head to toe assessment. The ADON stated the nursing staff was expected to assess and monitor edema every shift. A review of the facility policy and procedure titled, Resident Examination and Assessment, revised February 2014, indicated, .physical exam.skin.presence of edema.documentation.all assessment data obtained during procedure.reporting.notify physician of any abnormalities.abnormal vital signs. A review of the facility policy and procedure titled, Acute Condition Changes, revised March 2018, indicated, .the physician will help identify individuals.with a significant risk for having acute changes of condition.in addition.the nurses shall assess.document/report.the following baseline information.vitals signs.the staff will monitor and document the resident/patient's progress and responses to treatment.the physician will adjust treatment accordingly. 3. On February 10, 2026, at 10:10 a.m., Resident 112 was observed well groomed, sleeping in bed, calm with head of the bed elevated. On February 10, 2026, at 2:25 p.m., Resident 112 was observed sleeping in bed. Resident 112 was not easily arousable with knocking on the door or calling resident's name while standing next to resident bedside. On February 10, 2026, at 3:05 p.m., Resident 112 was observed sleeping in bed. Resident 112 did not awaken with speaking to the resident. On February 10, 2026, at 3:35 p.m., a concurrent observation and interview was conducted with Speech Therapist (ST) at Resident 112 bedside. The ST was attempting to arouse Resident 112 with calling resident's name and gentle touch. Resident 112 was observed opening eyes then falling back asleep. The ST stated she was working with Resident 112 every day for 30 minutes on her swallowing. The ST stated Resident 112 has been sleepy the last couple of days. The ST stated Resident 112 was unable to tolerate thin liquids water. The ST was observed giving Resident 112 nectar thick water. Resident 112 was observed coughing. Resident 112 was observed unable to answer simple questions. On February 11, 2026, at 11:11 a.m., Resident 112's medical record was reviewed. Resident 112 was admitted to the facility on [DATE], with diagnoses which included cognitive functions following cerebral infarction (a person's thinking, memory and reasoning abilities are affected after blockage of blood flow to the brain). A review of Resident 112's Minimum Data Set (MDS - a resident assessment tool), dated October 19, 2025, indicated Resident 112 had a BIMS (Brief Interview of Mental Status) score of 11 (moderate cognitive impairment). A review of Resident 112's, Nursing admission Screening/History, dated January 28, 2026, indicated, .Unarousable/Coma/Persistent Vegetative State.No. The MDS, Section B: Hearing, Speech, and Vision, dated February 4, 2026, indicated Resident 112 was not comatose, persistent vegetative state. A review of Resident 112's Daily Skilled Note indicated Resident 112's level of consciousness as follows: -February 10, 2026: alert, person, place, time, situation; -February 11, 2026: alert person: short term memory impairment, impaired decision-making ability; and -February 12, 2026: alert person place time situation. A review of Resident 112's ST (Speech Therapy) Treatment Encounter Note dated February 11, 2026, at 12:42 p.m., indicated, .with her medication nurse.attempting to arouse her.when therapist came.to work with her today.continues with congestion and coughing.daughter stated may be having a relapse of pneumonia or influenza infection.may need to see the doctor for antibiotics. On February 11, 2026, at 11:54 a.m., Resident 112 was observed sleeping in bed with head of bed elevated. Resident 112 did not awaken to voice. On February 12, 2026, at 3:09 p.m., Resident 112 was observed sleeping in bed. A concurrent observation and interview were conducted with CNA 1. CNA 1 stated Resident 112 baseline level of consciousness was alert and would answer appropriately. CNA 1 stated Resident 112 had been lethargic and confused. CNA 1 stated that she reported to the licensed nurse. On February 13, 2026, at 9:49 a.m., an interview was conducted with LVN 1. LVN 1 stated when a resident was identified with a change in mental status or a resident was observed lethargic or sleepy, the licensed nurse would notify the physician with the change of condition findings. On February 13, 2026, at 12:16 p.m., Resident 112 was observed sleeping in bed, with head of the bed elevated. Resident 2 did not awaken to voice or knocking on resident's room door. On February 13, 2026, at 2:32 p.m., a concurrent interview and record review was conducted with the ADON. The ADON reviewed Resident 112's medical record. The ADON stated Resident 112 had dementia (decline in mental ability). The ADON stated Resident 112 had a chest x-ray (imaging test to take pictures inside the body) on February 12, 2026, with conclusion: no acute cardiopulmonary (heart and lungs) process. The ADON reviewed the nursing admission screening. The ADON stated Resident 112's baseline was alert. The ADON stated the expectation was the licensed nurse will assess and monitor the resident mental status and behavior, document on the daily skilled note every shift and report any change in condition from baseline to the physician. A review of the facility policy and procedure titled, Resident Examination and Assessment, revised February 2014, indicated, .physical exam.neurological.alertness and orientation .documentation.all assessment data obtained during procedure.reporting.notify physician of any abnormalities.abnormal change in cognitive, behavioral or neurological status from baseline. A review of the facility policy and procedure titled, Acute Condition Changes, revised March 2018, indicated, .the physician will help identify individuals.with a significant risk for having acute changes of condition.in addition.the nurses shall assess.document/report.the following baseline information.level of consciousness.cognitive status.the staff will monitor and document the resident/patient's progress and responses to treatment.the physician will adjust treatment accordingly. 4. On February 10, 2026, at 11:18 a.m., Resident 55 was observed lying in bed, awake and alert. Resident 55's left elbow was observed with purplish discoloration. In a concurrent interview with Resident 55, she stated she kept bumping her left arm on the side rail. On February 13, 2026, at 10:47 a.m., Resident 55 was observed with Licensed Vocational Nurse (LVN) 2. LVN 2 assessed Resident 55 and stated Resident 55 had a discoloration on the left elbow that was fading. Resident 55 stated she would always bump her elbow on the side rails, and she informed a staff member about it. In a concurrent interview and record review with LVN 2, she stated the nurse would assess, notify the physician, monitor, and document the new skin condition. LVN 2 stated there was no documented evidence Resident 55's left elbow discoloration was identified, assessed, monitored and reported to the physician. On February 13, 2026, at 11:32 a.m., during a concurrent interview and record review with the Treatment Nurse (TN), she stated the CNA should report it to the charge nurse when a new identified skin condition, and the charge nurse would notify the physician. The TN stated the skin discoloration should be monitored as a change of condition. The TN further stated there was no documentation Resident 55's left elbow skin discoloration was identified, assessed, monitored and reported to the physician. Resident 55's medical record was reviewed. Resident 55 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (a severe form of one-sided paralysis) and hemiparesis (a neurological condition characterized by weakness on one side of the body, affecting the arms, legs, and face). A review of the physician's history and physical, dated December 22, 2025, indicated Resident 55 was alert. A review of Resident 55's Minimum Data Set (MDS – an assessment tool), dated December 28, 2025, indicated a Brief Interview of Mental Status (BIMS – a cognitive assessment tool) score of 15 (cognitively intact). The MDS also indicated Resident 55 did not have any skin conditions. A review of the facility policy and procedure titled, SKIN ASSESSMENT, revised December 11, 2022, indicated, .It is the policy of this facility to monitor the resident's skin condition daily, implement interventions when needed to prevent complications, and provide documented licensed nurse assessments on an as-needed basis .Nursing assistants will check resident's skin every shift and shall report any skin integrity impairment to the licensed nurse for follow-up. The licensed nurse will observe the reported impairment .The licensed nurse shall perform a weekly skin check according to the weekly summary schedule .The licensed nurse shall notify the physician for orders and follow-up treatment. The resident or family will be notified of changes in the resident's skin status .The licensed nurse will make an entry on the resident's care plan as well as the licensed nurse progress notes as to findings and doctor's orders .

Based on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with physician orders and the facility's policies and procedures, when a medication error rate of 11.9% was identified, with five medication errors out of 42 medication administration opportunities, during medication pass observations for two of five residents observed (Residents 32 and 47).These failures included administration of incorrect medication, incorrect dosage form, and omissions of ordered medication while documenting them as administered, which had the potential to compromise residents' medication therapy and safety. Findings:1. On February 9, 2026, at 9:53 a.m., during a medication administration observation, Licensed Vocational Nurse (LVN) 3 was observed preparing and administering seven medications to Resident 47, including:- Vitamin C (supplement) 500 mg (milligram - unit of measurement) tablet;- Docusate sodium (stool softener) 100 mg softgel capsule;- Multivitamin with minerals (supplement) tablet;- Vitamin D (supplement) 25 mcg (microgram - unit of measurement) tablet;- Jardiance (used to treat Type II Diabetes) 25 mg;- Xarelto (blood thinner used to prevent blood clots) 15 mg tablet; and- Acidophilus lactobacillus (probiotic supplement) capsule.On February 9, 2026, at 12:57 p.m., a review of Resident 47's physician orders indicated:- There was no physician order for vitamin C 500 mg; and- There was a physician order for cyanocobalamin (vitamin B12 - supplement) 500 mcg, one tablet by mouth daily for supplement, dated [DATE].The ordered cyanocobalamin 500 mcg was not administered to Resident 47 during the observed 9 a.m. medication pass with LVN 3.A review of Resident 47's Medication Administration Record (MAR), dated February 2026, indicated the following:- There was no documentation of vitamin C 500 mg being administered; and- Cyanocobalamin 500 mcg was documented as administered at 9 a.m. on February 9, 2026.On February 9, 2026, at 3:11 p.m., during a concurrent interview and record review with LVN 3, LVN 3 confirmed Resident 47 did not have a physician order for Vitamin C 500 mg but had an order for vitamin B12 500 mcg. LVN 3 acknowledged administering vitamin C 500 mg instead of vitamin B12 500 mcg and stated the error may have occurred because the bottles were similar in size and appearance, both beginning with Vitamin and containing 500 in the strength.2. On February 10, 2026, at 9:23 a.m., during a medication administration observation, LVN 5 was observed preparing and administering 16 medications to Resident 32, including:- Aspirin (used to prevent blood clots) enteric coated (EC - a coating on the drug tablet to protect the stomach and to allow aspirin to pass through the stomach to the small intestine before dissolving) 81 mg tablet;- Carvedilol (used to treat high blood pressure) 6.25 mg tablet;- Divalproex (mood stabilizer) 500 mg delayed-release (DR - designed with a special coating that prevents the medication from dissolving in the stomach and allow it to be released in the intestine) tablet;- Duloxetine (used to treat depression) 20 mg DR capsule;- Hydroxychloroquine sulfate (used to treat autoimmune conditions such as lupus, causing inflammation and pain) 200 mg tablet;- Losartan potassium (used to treat high blood pressure) 50 mg tablet;- Prednisone (steroid used to reduce inflammation) 10 mg tablet;- Quetiapine (antipsychotic medication used to treat mental illness) 50 mg tablet;- Ropinirole (used to treat tremors) 0.5 mg tablet;- Conjugated estrogen (hormone therapy, used to treat hot flashes, menopausal symptoms) 0.3 mg tablet;- CertaVite (vitamins and minerals) tablet;- Docusate sodium 100 mg;- Oxycodone-acetaminophen (narcotic pain medication)10-325 mg tablet;- Levofloxacin (antibiotic used to treat bacterial infection) 500 mg;- Lorazepam (used to treat anxiety) 1 mg; and- Pregabalin (used to treat nerve pain) 150 mg.On February 10, 2026, at 10:04 a.m., a review of Resident 32's physician orders indicated:- Aspirin 81 mg chewable tablet, give one tablet by mouth one time a day for MI/CVA (myocardial infarction [heart attack] and cerebrovascular accident [stroke]), dated [DATE];- Calcium Carbonate (supplement) 500 mg chewable tablet, give one tablet by mouth three times a day for Supplement, dated [DATE]; and- Glycolax (brand name for polyethylene glycol 3350 - used to treat constipation) 17 gm (gram - unit of measurement) / scoop, give 1.5 scoop by mouth one time a day for bowel management. Mix 1.5 capfuls with 8 oz (ounce - unit of measurement) of water or juice (25.5 g), dated [DATE].A review of Resident 32's MAR, dated February 2026, indicated the following medications were documented as administered at 9 a.m. on February 9, 2026:- Aspirin 81 mg chewable tablet;- Calcium carbonate 500 mg chewable tablet; and- GlycoLax 17 gm/scoop, 1.5 scoop.On February 10, 2026, at 10:29 a.m., during a concurrent interview and record review with LVN 5, LVN 5 reviewed Resident 32's physician orders and MAR. LVN 5 confirmed:- She had administered aspirin 81 mg enteric-coated tablet instead of the ordered aspirin 81 mg chewable tablet;- Calcium Carbonate 500 mg and GlycoLax were documented as administered at the 9 a.m. medication pass but were not administered; and- There were no medication bottles for Aspirin 81 mg chewable tablet, Calcium Carbonate 500 mg, and GlycoLax available in her medication cart at the time of administration. - She had discarded an expired bottle of GlycoLax earlier that morning and had not replaced it with a new bottle prior to the medication pass.- She acknowledged she should have verified the medication label and the dosage form against the physician's order prior to administration and should not have documented medications as administered when they were not given.- Further stated she may have selected Yes in the electronic MAR for medications scheduled 9 a.m. without verifying each medication prior to documentation.On February 11, 2026, at 10:44 a.m., during an interview with the Director of Nursing (DON), the DON stated the nursing staff are required to follow the Rights of medication administration, including right medication and right dosage form, and must verify the medication label against the MAR during three preparation checks according to the facility's policy and procedures. The DON stated the nursing staff should carefully read medication labels, confirm correct dosage form, and accurately document medications administered in the electronic MAR.A review of the facility's policies and procedures titled, Preparation and General Guidelines, IIA2: Medication Administration - General Guidelines, dated February 2020, indicated, .FIVE RIGHTS.right drug, right dose.are applied for each medication being administered. A triple check of these 4 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away.Check #1: Select the Medication - label, container and contents are check for integrity and compared against the medication administration record (MAR) by reviewing the 5 Rights.Check #2: Prepare the dose - the dose is removed from the container and verified against the label and the MAR by reviewing the 5 Rights.Check #3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the 5 Rights.Administration.2) Medications are administered in accordance with written orders of the prescriber.Documentation (including electronic) .At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented.

Based on observation, interview, and record review, the facility failed to ensure medications were stored in accordance with the facility's policies and procedures and manufacturer's specifications, when:1. An insulin (medication to treat diabetes mellitus [abnormal blood sugar]) pen was stored in the Medication Cart at Nursing Station 3 without documentation of the date removed from refrigeration;2. Two discontinued controlled substances (CS - those with high potential for abuse and addiction) were stored in the Medication Cart at Nursing Station 4 with other active medications; and3. A single-use plastic vial of Levalbuterol inhalation solution was stored without a prescription label, without light protection, and without documentation of the date removed from its protective foil pouch.These failures had the potential to result in residents receiving ineffective, deteriorated, or discontinued medications, leading to medication errors and compromised treatment outcomes. Additionally, the improper storage of discontinued controlled substances had the potential to increase the risk of diversion (medication taken by someone other than the person for whom it was prescribed) or misuse.Findings:1. On February 10, 2026, at 11:31 a.m., during an inspection of Medication Cart at Nursing Station 3 with Licensed Vocational Nurse (LVN) 4, a HumaLOG KwikPen (brand of insulin pen used to treat diabetes) 100 units/3mL (units/mL - unit of measurement) was observed labeled for Resident 19. The insulin pen was stored at room temperature in an opened manufacturer's box (originally containing five pens; one pen remained). There was no date written on the pen to indicate when it had been removed from refrigeration. On February 10, 2026, at 11:31 a.m., during a concurrent interview, LVN 4 stated she was unsure when the insulin pen had been removed from the refrigerator and acknowledged the date of removal should have been written on the insulin pen. On February 11, 2026, at 10:44 a.m., during an interview and record review with the Director of Nursing (DON), the manufacturer's package insert for HumaLOG KwikPen was reviewed. The DON acknowledged that without documentation of the date removed from refrigeration, the 28-day room-temperature stability period could not be accurately determined and stated the unopened insulin pen stored at room temperature without the date should have been discarded. A review of the manufacturer's package inserts for HumaLOG KwikPEN, dated January 2026, indicated: .When stored at room temperature, HUMALOG U-100 .can only be used for a total of 28 days, including both not in-use (unopened) and in-use (opened) storage time. A review of the facility's policies and procedures titled, Medication Storage in the Facility, ID1: Storage of Medications, dated February 2020, indicated, .Medications requiring refrigeration UNTIL OPENED: .Insulin - Once opened should be kept outside of refrigerator.2. On February 10, 2026, at 2:24 p.m., during an inspection of the Medication Cart at Nursing Station 4 with LVN 5, the following discontinued medications were observed stored in the medication cart together with active medications:- A blister card of Ambien (brand name for zolpidem, used to treat insomnia) 5 mg (milligram - unit of measurement), labeled for Resident 79; and - A blister card of Tramadol (narcotic pain medication) 50 mg, labeled for Resident 3.On February 10, 2026, at 2:24 p.m., a review of physician orders indicated:- Resident 79's Ambien 5 mg was discontinued on January 27, 2026, at 12:58 p.m., with the reason documented as ineffective; and- Resident 3's Tramadol 50 mg was discontinued on January 9, 2026, at 6:30 p.m.On February 10, 2026, at 2:24 p.m., during a concurrent observation, interview, and record review with LVN 5, LVN 5 confirmed the medications were discontinued and remained stored in the medication cart. LVN 5 stated the discontinued medications should be marked D/C, removed from the medication cart, and provided to the DON for proper disposal if a controlled substance.On February 11, 2026, at 10:44 a.m., during an interview with the DON, the DON acknowledged discontinued controlled medications should have been removed from the medication cart and secured separately pending destruction. The DON stated it was not acceptable for the Ambien to remain in the cart for approximately two weeks and Tramadol for approximately four and a half weeks after discontinuation and confirmed the facility's policy and procedure had not been followed. A review of the facility's policy and procedure titled, Disposal of Medications and Medication-Related Supplies, IE3: Discontinued Medications, dated October 2012, indicated, .When medications are discontinued by the prescriber., the medications are marked as discontinued and stored in a secure and separate area from the active medications.Medications are removed from the medication cart.immediately upon receipt of an order to discontinue (to avoid inadvertent administration). Medication awaiting disposal.are stored in a locked secure area designated for that purpose until destroyed.A review of the facility's policy and procedure titled, Medication Storage in the Facility, ID2: Controlled Substance Storage, dated October 2012, indicated, .Controlled substances remaining in the facility after the order has been discontinued.retained in the facility in a securely locked area with restricted access until destroyed. A review of the facility's policy and procedure titled, Disposal of Medications and Medication-Related Supplies, IE5: Medication Destruction, dated October 2012, indicated, .Discontinued medications.which do not qualify for return to the pharmacy for credit, are destroyed.Unused.non-returnable medications should be removed from their storage area and secured until destroyed.3. On February 10, 2026, at 3:41 p.m., during an inspection of Medication Cart at the Split Nursing Station (between Nursing Station 1 and 2) with LVN 6, one unit-dose plastic vial of levalbuterol (medication used to treat breathing problems such as bronchospasm) 1.25 mg/3 mL (mg/mL - unit of measurement) inhalation solution was observed stored in the top drawer of the medication cart. The vial was outside of its protective foil pouch, had no prescription label, and had no documentation indicating the date it was removed from the foil pouch. On February 10, 2026, at 3:41 p.m., during a concurrent observation and interview, LVN 6 confirmed the vial was stored outside of its foil pouch and acknowledged there was no prescription label to identify which resident it belonged to. LVN 6 also acknowledged that without documentation of the date removed from the pouch, it was unknown how long the vial had been stored outside of light protection and stated it should have been removed from the medication cart and discarded.On February 11, 2026, at 10:44 a.m., during an interview and record review of the manufacturer's package insert for levalbuterol with the DON, the DON acknowledged the medication should have been discarded due to lack of labeling, lack of light protection, and absence of a documented removal date from foil pouch. A review of the manufacturer's package inserts for levalbuterol inhalation solution, dated February 2020, indicated, .Store Levalbuterol Inhalation Solution.in the protective foil pouch at 20 - 25 C (68 - 77 F) .Protect from light and excessive heat. Keep unopened vials in the foil pouch. Once the foil pouch is opened, the vials should be used within 2 weeks. Vials removed from the pouch, if not used immediately, should be protected from light and used within 1 week.A review of the facility's policy and procedure titled, Medication Storage in the Facility, ID1: Storage of Medications dated February 2020, indicated, .Medications.are stored safely, securely, and properly, following manufacturer's recommendations.Outdated, contaminated, or deteriorated medications.are immediately removed from inventory, disposed of according to procedures for medication disposal.Medication storage conditions are monitored on a monthly basis by the consultant pharmacist or pharmacy nurse consultant and corrective action taken if problems are identified.All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining .

Based on interview and record review, the facility failed to ensure the consultant pharmacist's (CP) December 2025 Medication Regiment Review (MRR) recommendations were reviewed and acted upon in a timely manner, for two of five sampled residents (Residents 28 and 79).This failure had the potential to result in unresolved medication-related issues due to delayed evaluation of medication therapy and compromised resident care. Findings:1.On February 13, 2026, Resident 28's record was reviewed. Resident 28's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included Alzheimer's (memory loss).A review of Resident 28's physician orders indicated an active order for omeprazole (a medication used to reduce stomach acid, to treat frequent heartburn, acid reflux, and stomach ulcers) 20 mg (milligram - unit of measurement) delayed-release capsule (designed to release the medication in the intestine to prevent breakdown of the medication by stomach acids), one capsule by mouth daily for acid indigestion, dated December 13, 2025.A review of Resident 28's Consultant Pharmacist MRR, dated December 31, 2025, indicated a recommendation related to omeprazole. However, the recommendation was incomplete and partially unreadable, with missing or illegible portions, and the full content of the CP's recommendation could not be determined from the document provided.A review of Resident 28's Medication Administration Records (MAR), for December 2025, January 2026, and February 2026 indicated omeprazole was administered from December 14, 2025, through February 13, 2026.There was no documented evidence the facility sought clarification from the consultant pharmacist regarding the incomplete recommendation. There was also no documentation indicating the recommendation was endorsed to the physician or the physician reviewed and accepted or rejected the recommendation.On February 13, 2026, at 3:22 p.m., during a concurrent interview and record review with the Director of Nursing (DON), the DON reprinted the original MRR document received via email from the CP and confirmed the recommendation remained incomplete, partially unreadable and missing contents. The DON stated she should have clarified the recommendation with consultant pharmacist and endorsed it to the physician for review. The DON acknowledged there was no documented evidence of physician review or action regarding the December 2025 MRR recommendation related to omeprazole. The DON stated physician review of CP's recommendations should occur within three to seven days. 2. On February 13, 2026, Resident 79's record was reviewed. Resident 79's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included fracture of the vertebra (spine).A review of Resident 79's physician orders indicated omeprazole 20 mg, one tablet by mouth in the morning for gastrointestinal (GI - stomach and intestine) prophylaxis (used to prevent stomach irritation), dated November 7, 2025.A review of Resident 79's Consultant Pharmacist MRR, dated December 2025, indicated the CP recommended changing the administration time of omeprazole 20 mg from 9 a.m. to 6:30 a.m. to allow administration on an empty stomach prior to breakfast.A review of Resident 79's MAR for November 2025, December 2025, January 2026, and February 2026 indicated omeprazole remained scheduled at 9 a.m. and was administered at 9 a.m. from November 8, 2025, through February 13, 2026, except for December 20, 2025, when the dose was held.There was no documentation on the CP's MRR report, no physician progress notes, and no other medical record documentation indicating physician review, response or acceptance, or rejection of the CP's December 2025 recommendation.On February 13, 2026, at 2:39 p.m., during an interview and record review, the DON confirmed the December 2025 CP recommendation for Resident 79 was not reviewed by the physician in a timely manner. The DON acknowledged there was no documented physician review or action regarding the recommendation. The DON stated physician review of CP recommendations should occur within three to seven days. A review of the facility's Policy and Procedures titled, Consultant Pharmacist Reports, IIIA1: Medication Regimen Review, dated October 2012, indicated, .The consultant pharmacist reviews the medication regimen of each resident at least monthly.Resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented in the resident's (active record) and reported to the Director of Nursing, and/or prescriber as appropriate.Recommendations are acted upon and documented by the facility staff and or the prescriber.Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing.A review of Micromedex (a clinical drug reference used by healthcare professionals), Omeprazole - Administration, dated January 28, 2026, Indicated, .Swallow capsule whole 30 minutes prior to the first meal of the day.

Based on interview and record review, the facility failed to ensure the physician evaluated and documented the clinical rationale supporting the continued use of the as-needed (PRN) lorazepam (a psychotropic medication used to treat anxiety) beyond 14 days, for one of five residents reviewed for unnecessary psychotropic (drug that affects brain activities associated with mental processes and behaviors) medications (Resident 28).This failure had the potential to result in unnecessary use of psychotropic medications and increased risk for adverse effects, including sedation, confusion, and falls. Findings:On February 12, 2026, a review of Resident 28's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses including anxiety disorder, Alzheimer's disease (progressive memory loss, a type of dementia), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), psychosis (a psychotic disorder characterized by a loss of contact with reality), and insomnia (difficulty sleeping).A review of Resident 28's Care Plan Report, initially dated September 24, 2025, and revised February 13, 2026, indicated: . (Resident name) at Risk for adverse side effects and for mood concerns related to dx (diagnosis) anxiety and r/t (related to) antianxiety medication usage: Lorazepam as ordered. IDT (interdisciplinary team - a group of healthcare professionals) will continue to assess ongoing alternative or need for this medication and monitor for any adverse side effects or any concerns related to moods/behaviors. She has episodes of crying when confused and anxious.A review of Resident 28's Physician orders indicated the following PRN lorazepam orders:- On March 7, 2025, lorazepam 0.5 mg (milligram - unit of measurement), one tablet by mouth every 6 hours as needed for anxiety/restless or agitation, was ordered and remained active until May 27, 2025;- On July 17, 2025, lorazepam 0.5mg, one tablet by mouth every six hours as needed for anxiety, was ordered and remained active until September 26, 2025;- On September 26, 2025, the PRN order was renewed at the same dose and frequency, with the indication revised to anxiety manifested by crying out, and remained active until December 17, 2025;- On December 17, 2025, the PRN lorazepam order was renewed at the same dose and frequency with a specified duration of 14 days for anxiety manifested by crying out, and remained active until December 31, 2025; and- On January 8, 2026, the PRN lorazepam order was reordered at the same dose and frequency, with the indication revised to anxiety manifested by restlessness, and remained active at the time of survey.A review of Resident 28's Medication Administration Records (MAR), indicated the PRN lorazepam was administered as follows:- March 2025 - 19 times;- April 2025 - 14 times;- May 2025 - 4 times;- July 2025 - 3 times;- August 2025 - 13 times;- September 2025 - 26 times;- October 2025 - 41 times;- November 2025 - 34 times;- December 2025 - 21 times;- January 2026 - 9 times; and- February 2026 - 5 times (through February 13, 2026).A review of Resident 28's MAR from March 2025 to February 13, 2026, for PRN administration of lorazepam indicated ongoing use of lorazepam beyond 14 days.A review of Resident 28's Psychotropic IDT note - V 2, dated January 30, 2026, indicated a quarterly review of psychotropic medications, including PRN lorazepam. The form indicated the PRN lorazepam was marked as effective, and the frequency of PRN administration was documented as no change. The IDT recommended continuation of the current regimen. However, the record did not include physician-documented clinical rationale or a specified duration supporting continuation of PRN lorazepam beyond 14 days. No additional psychotropic IDT team notes were identified for the time periods reviewed during which PRN lorazepam orders extended beyond 14 days.On February 13, 2026, the facility provided a hospice Physician Order for Change in Plan of Care note signed and dated February 13, 2026. The document indicated it was a late entry for March 8, 2025, to May 27, 2025, for hospice order and included an order for PRN lorazepam. However, the documentation did not include physician-documented clinical rationale supporting continuation of PRN lorazepam beyond 14 days during the time period reviewed. A review of Resident 28's Physician's Progress Notes, dated April 20, 2025, June 20, 2025, and July 30, 2025, did not indicate the physician documented a clinical rationale supporting continuation of PRN lorazepam beyond 14 days or specified duration of PRN lorazepam orders. Further review of Resident 28's record indicated there was no documented evidence the physician evaluated the use of PRN lorazepam beyond 14 days and there was no rationale for the continued use of the PRN lorazepam.On February 13, 2026, at 4:01 p.m., during a concurrent interview and record review with the Director of Nursing (DON), the DON confirmed the hospice note did not include physician-documented clinical rationale supporting continuation of PRN lorazepam beyond 14 days. A review of the medical record with the DON, including progress notes and IDT psychotropic review notes for March through May 2025, and July 2025 through February 2026, did not identify physician-documented clinical rationale supporting continuation of PRN lorazepam beyond 14 days. The DON stated it was the facility's responsibility to clarify the duration and obtain physician-documented rationale when PRN psychotropic medications are continued beyond 14 days, even when the medication is ordered by a hospice physician. The DON further stated PRN psychotropic medications should be used judiciously due to potential adverse effects, including sedation and falls.A review of the facility's policies and procedures titled, Psychotropic PRN Medication Management, dated November 12 ,2025, indicated, .PRN psychotropic medications shall be prescribed and administered in accordance with applicable federal and state regulations. PRN orders will be reviewed periodically and managed consistent with regulatory requirements. When a PRN order reaches its designated duration of 14 days, the prescribing practitioner will determine whether continuation is clinically indicated. Documentation shall reflect clinical rationale, ongoing need when available, and monitoring consistent with resident condition. Renewal or discontinuation of PRN psychotropic medications shall be determined by the prescribing practitioner based on clinical judgment and resident status.

Based on observation, interview, and record review, the facility failed to ensure medications were administered and documented in accordance with the physician orders and the facility policy when the nursing staff administered an as-needed (PRN) medication but failed to document the administration in the Medication Administration Record (MAR), for one of six residents observed during medication administration (Resident 108).This failure resulted had the potential to compromise pain management, delayed evaluation of medication effectiveness, and increased the risk of duplicate dosing. Findings:On February 9, 2026, at 9:25 a.m., during a medication administration observation for Resident 108, Licensed Vocational Nurse (LVN) 3 was observed asking the resident if she was experiencing pain. Resident 108 stated she had no pain but felt uncomfortable in the abdominal area due to recent surgery. LVN 3 asked if Tylenol (brand name for acetaminophen, medication used to relieve pain and fever) would be acceptable, and the resident agreed.On February 9, 2026, at 9:31 a.m., LVN 3 asked Resident 108 her current pain level. Resident 108 stated her pain level was 3 (mild pain on a 0-10 pain scale, where 0 means no pain and 10 means severe pain). LVN 3 was observed administering nine prepared medications, including two tablets of acetaminophen 325 mg (milligram - unit of measurement) to Resident 108.On February 9, 2026, a review of Resident 108's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses, including small bowel obstruction (a blockage in the intestine), hernia status post exploratory laparotomy (hernia repaired through open abdominal surgery).A review of Resident 108's physician order, dated February 8, 2026, indicated:- Tylenol 325 mg (Acetaminophen), give two tablets by mouth every six hours as needed for mild pain.On February 9, 2026, at 11:57 a.m., a review of Resident 108's Medication Administration Record (MAR), dated February 2026, indicated there was no documentation for the 9 a.m. PRN acetaminophen dose administered. The MAR did not contain LVN 3's initials, time of administration, or documentation of medication effectiveness.A review of Resident 108's Care Plan Report, dated February 9, 2026, indicated the resident was at risk for abdominal pain related to recent surgery and required administration of analgesic medication as ordered. The care plan further indicated that staff were to evaluate and document the severity of pain and the resident's response to interventions.On February 9, 2026, 3:02 p.m., during a concurrent interview and record review of Resident 108's MAR with LVN 3, LVN 3 confirmed she had administered acetaminophen 325mg, two tablets, during the 9 a.m. medication pass but had not documented the administration in the electronic MAR. LVN 3 stated she forgot to select Yes in the MAR in PointClickCare (PCC, a cloud-based electronic health record and care coordination platform designed specifically for the long-term and post-acute care settings) to indicate the administration of acetaminophen. LVN 3 acknowledged approximately 5.5 hours had elapsed since the medication was administered and stated the documentation should occur after the medication was given.On February 11, 2026, at 10:44 a.m., during an interview with the Director of Nursing (DON), the DON stated medication administration must be documented in the MAR immediately after administration. The DON stated that without documentation, there is no record confirming the medication was given. The DON acknowledged the PRN acetaminophen was administered at 9:31 a.m. on February 9, 2026, was not documented in the MAR until approximately 5.5 hours later, at the time the omission was brought to the facility's attention and confirmed this was not in accordance with facility policy. The DON further stated documentation of PRN pain medication administration is essential to monitor the resident's pain status, evaluate effectiveness of treatment, and guide further clinical assessment.A review of the facility's policy and procedure titled, Preparation and General Guidelines, IIA2: Medication Administration - General Guidelines, dated February 2020, indicated, .Documentation (including electronic) .The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the mediation repot off-duty without first recording the administration of any medications.When PRN (as-needed) medications are administered, the following documentation is provided.a. Date and time of administration.c. Results achieved from giving the dose and the time results were noted. d. Signature or initials of person recording administration and signature or initials of person recording effects, if different from the person administering the medication.

Based on observation, interview, and record review, the facility failed to ensure food served met the individual needs. for one of three residents (Resident 109), when the kitchen staff did not follow the diet spreadsheet during the tray line observation on February 11, 2026, for residents on renal diet (diet for patients with kidney disease by limiting potassium, phosphorus, and protein to reduce waste in the blood).This failure had the potential to compromise Resident 109's nutritional and health status.Findings:On February 11, 2026, at 11:55 a.m., tray line observation for lunch was conducted in the presence of the Dietary Supervisor (DS). The meal tray for Resident 109 was observed to contain one three-ounce of barbeque pork with one three-ounce piece of barbeque sauce, one piece of bread roll, one half-cup brussels sprout, and one half-cup of polenta, ready to be delivered. The DS was asked to check the meal tray prepared for Resident 109. The DS inspected the prepared meal tray for Resident 109 and stated the meal tray had barbeque sauce. The DS stated Resident 109 was on renal diet and should not have the barbeque sauce.On February 12, 2026, at 2:36 p.m., during an interview with the Registered Dietician (RD), she stated the kitchen staff should follow the spreadsheet when serving foods to the residents. She stated Resident 109 could not have the barbeque sauce in his diet. The RD stated the kitchen staff did not follow the spreadsheet for Resident 109 who was on renal diet.On February 11, 2026, Resident 109's record was reviewed. Resident 109 was admitted to the facility on [DATE], with diagnosis which included end stage renal disease (ESRD - final, irreversible stage of kidney failure requiring dialysis [a life sustaining treatment for kidney failure, filtering wastes and excess fluid from the blood when kidneys can no longer perform this function] or a transplant for survival) and diabetes (a chronic condition causing high blood sugar).A review of Resident 109's physician order dated February 4, 2026, indicated, .CCHO (Consistent or Controlled Carbohydrate - a meal plan for managing diabetes and blood sugar by consuming a similar, set amount of carbohydrates at each meal) Renal diet.Regular texture.Regular consistency.A review of the facility document titled, WINTER MENUS, for February 11, 2026, indicated, .RENAL DIETS.Pork.Gravy (no BBQ Sauce).

Based on interview and record review, the facility failed to evaluate and develop new interventions for one of three sampled residents (Resident 1), who has poor decision making, high risk for fall, and had fall incidents on June 16 and June 22, 2025. This failure placed Resident 1 at risk for further falls which could result in serious injury while at the facility. On July 10, 2025, at 9:05 a.m., an unannounced visit was conducted at the facility to investigate a complaint on quality-of-care issues. On July 10, 2025, Resident 1's record was reviewed. Resident 1's admission Record, indicated Resident 1 was admitted on [DATE], with diagnoses which included prosthetic aortic valve replacement (surgery to restore proper blood flow through the heart), acute kidney disease (a condition the kidneys cannot filter waste from the blood) and dementia (impaired thinking abilities, forgetfulness).A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated June 13, 2025, indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 13 (cognition intact).A review of Resident 1's Progress Notes, indicated the following:- June 13, 2025, at 4:10 p.m., indicated, .Pt (patient) showing S/S (signs and symptoms) of increased confusion .Pt stating that ‘The air conditioner man is coming to pick me up.' ‘I need to go to the front of the building so the truck can take me to buy things.;-June 14, 2025, at 10:01 p.m., indicated, .CNA (Certified Nursing Assistant) Entered room and found patient kneeling . Patient stated she was Trying to turn off her call light .;-June 15, 2025, at 10:16 p.m., indicated, .Resident Continues with increase Confusion and stating I'm being Held hostage and nobody wants to release me .-June 17, 2025, at 2:17 p.m., indicated, .Alert and responsive .Able to let needs known with confusion and forgetfulness .-June 22, 2025, at 10:24 a.m., indicated, .pt found sitting next to bed with back against bed, states she was coming from the restroom to go back to bed, resident states she was attempting to sit down on the bed when she slid down onto the floor, wheels locked, footwear on .neurochecks initiated .;-June 23, 2025, at 12:57 p.m., indicated, Fall IDT Meeting .Pt found sitting next to bed with back against bed .no bruising, redness, or swelling noted .IDT recommends to continue current intervention .;During further review of the IDT notes, the recommendations on June 23, 2025, were the same recommendations on June 16, 2025. There were no additional interventions recommended by the IDT after the second fall on June 22, 2025.-June 23, 2025, at 11:21 p.m., indicated, .Black eye to bilateral eye and discoloration to fore head .Resident had an unwitnessed fall on 06/22/25 (June 22, 2025) and was noted with [NAME] (sic) eye to bilateral eye and discoloration to forehead .date and time of MD (physician) notification: 06/24/2025 (June 24, 2025) 10:52 PM (p.m.) .Per MD to Observe and if Symptoms changes to send patient to ER .;-June 24, 2025, at 7:52 a.m., indicated, .pt do tried to get up x 3 (times three) on shift, pt always re direct to get some rest .;-June 26, 2025, at 2:26 a.m., indicated, .Resident alert with confusion. Resident noted to be taking brief and non-skid socks off and attempting self-transfer to BR (bathroom) .;-June 26, 2025, at 2:52 p.m., indicated, .Resident Had (sic) an unwitness (sic) Fall .If this has occurred before: Yes, resident had a fall on 6/14/25 & 6/22/25 . Resident found on floor on buttocks.resident no complaint of pain.MD notified 8:02 a.m no new orders.;-June 27, 2025, at 2:01 a.m., indicated, .increased confusion and bruising eyes and forehead. Physician notified and sent resident to ER via 911 ambulance. (family member) was notified on June 27, 2025, at 2 a.m .On July 10, 2025, at 10:30 a.m., an interview with Licensed Vocational Nurse (LVN)/charge nurse was conducted; and stated the following: a. The resident was found in the room at the side of the bed leaning against the bed with legs on to the side. b. The resident was alert and responded appropriately and stated she had not hit her head.c. There was no redness or bruise that she noticed during her shift. d. The resident explained she was trying to go to the rest room and did not use the call bell.e. She reported the resident's fall to the supervisor and did not recall a registered nurse assessing the resident after the fall.On July 10, 2025, at 10:40 a.m., during an interview with CNA 1, CNA 1 stated a resident is on close monitoring if considered high risk for fall. CNA 1 stated the staff would have to conduct rounds on the residents every 10-15 minutes to make sure the residents are safe, would offer drinks, and aid the bathroom.On July 11, 2025, at 11:02 a.m., during an interview, the Director of Nursing (DON) stated the process in managing falls follows the facility policy and procedure. The DON stated when a resident falls, the Administrator or the DON would be notified. She stated the IDT team would meet and review the incident usually a day after the fall. The IDT would look at the contributing factors resulting in a fall, which could be staffing issues, poor lighting, medications and diagnoses of the residents. The DON stated Resident 1's fall incident on June 14, 2025, was related to the resident's dementia and the resident underestimated her abilities. The DON stated the supervisor should be notified when a resident falls, and the supervisor would only go and assess the resident for a serious fall with injury. The DON stated her expectation is for the CNAs to conduct rounding every 15 minutes and if unable to do rounds, the CNAs should notify the charge nurse. The DON stated a 1:1 observation is used for residents with frequent falls and stated the DON should have considered this intervention when the intervention for Resident 1 was not working. A review of the facility's policy and procedure titled, Fall Prevention, dated May 2025, indicated, .to implement and maintain a comprehensive fall program.the goal to minimize the risk of falls and fall-related injuries.through consistent assessment, intervention.monitoring.some individuals fall repeatedly.Interventions need to be evaluated for effectiveness.

Based on interview and record review, the facility failed to ensure intravenous (IV - fluids/medication given directly into the bloodstream) antibiotic medications was provided according to the physician's orders upon discharge from the General Acute Hospital (GACH), for one of five residents (Resident A). This failure resulted in Resident A not receiving the IV antibiotics as prescribed, and needed to extend the IV medication to address Resident A's infection. Findings: On March 6, 2025, at 10:30 a.m., an unannounced visit was conducted for the investigation of a complaint for quality of care. On March 6, 2025, at 11:15 a.m., a review of Resident A's medical record was conducted. Resident A's Admission Record, indicated Resident A was admitted to the facility on [DATE], with diagnoses which included sepsis (a life-threatening blood infection), bacteremia (bacteria in the blood stream), and xenogenic heart valve (a type of tissue from another species - a pig or a cow). A review of Resident A's Extended Care Facility Admission Orders and Transfer (Discharge) Summary, dated December 8, 2024, at 1:20 p.m., indicated, .will continue with prolonged IV ampicillin (medication to treat infection) 2 G (gram - a unit of measurement) q (every) 6 (six) hours and IV Ceftriaxone (medication to treat infection) 2 g (gram) q (every)12 hours until 1/11/25 (January 11, 2025) via PICC (peripherally inserted central catheter - a thin flexible tube inserted into a vein in the upper arm and threaded into a larger vein near the heart). Close follow up with infectious disease . A review of Resident A's Physician's Progress Notes, dated December 20, 2024, by [name of physician], indicated, .continue Ampicillin 2G (gram) IV q (every) 4 hrs (hours) .Continue Ceftriaxone 2G (gram) IV q(every)12 hrs (hours)-Continue both for 6 (six) weeks from 11/30/24 (November 30, 2024) . A review of Resident A's Order Summary Report, included the following physician's orders: - .Ampicillin Sodium Injection Solution Reconstituted 1 GM .Use 2 gram intravenously every 6 (six) hours for BACTEREMIA until 1/13/2025 (January 13, 2025) ., date ordered December 8, 2024; - .Ampicillin Sodium Injection Solution Reconstituted 1 GM .Use 2 gram intravenously every 6 (six) hours for BACTEREMIA for 4 (four) days ., date ordered December 9, 2024; - .Ampicillin Sodium Injection Solution Reconstituted 1 GM .Use 2 gram intravenously every 6 (six) hours for Bacteremia until 01/11/2025 (January 11, 2025) ., date ordered December 30, 2024; - .Ampicillin Sodium Injection Solution Reconstituted 1 GM .Use 2 gram intravenously every 6 (six) hours for Bacteremia until 01/31/2025 (January 31, 2025) ., date ordered January 14, 2025; - .Ampicillin Sodium Injection Solution Reconstituted 1 GM .Use 2 gram intravenously every 6 (six) hours for Bacteremia until 02/01/2025 (February 1, 2025) ., date ordered January 19, 2025; and - .Ceftriaxone Sodium Intravenous Solution Reconstituted 2 GM .Use 2 gram intravenously every 12 hours for bacteremia unitl January 13, 2025 .for 34 days , date ordered December 8, 2024. A review of Resident A's Medication Administration Record (MAR), for the month of December 2024 and January 2025, indicated Ceftriaxone IV was not documented as administered on the following dates and times: - December 11, 2024, at 9:00 p.m.; - December 16, 2024, at 9:00 p.m.; - December 31, 2024, at 9:00 p.m.; - January 9, 2024, at 9 a.m. A review of Resident A's MAR, for the month of December 2024, and January 2025, indicated Ampicillin IV was not documented as administered on the following dates and times: - December 14, 2024, starting 6 p.m. to December 30, 2024, at 6 a.m. (total of 64 doses); - December 30, 2024, at 6 p.m.; - January 9, 2025, at 12 p.m.; - January 19, 2025, at 12 p.m.; and - January 22, 2025, at 12 p.m. A review of Resident A's care plans indicated the following: - IV therapy for severe sepsis, dated December 10, 2024, Interventions: Ampicillin as ordered, Ceftriaxone as ordered, monitor the site for edema, redness-report abnormal to medical doctor; and - Risk for infection related to Diagnosis, severe sepsis, dated December 10, 2024, Interventions: administer antibiotics therapy as ordered. A review of Resident A's Progress Notes/ Discharge Summary, dated February 1, 2025 (by primary provider) indicated, .pt (patient) finished 6 (six) weeks if IV Rocephin (Ceftriaxone) as recommended. Her IV Ampicillin was cut short prematurely but restarted so that she completed 6 weeks of IV Ampicillin .significant development that occurred during SNF (skilled nursing facility) stay: Interruption of IV Ampicillin before the end of 6 weeks of treatment so restarted . On March 6, 2025, at 2:05 p.m., an interview and concurrent record review was conducted with the Assistant Director of Nursing (ADON). The ADON stated IV orders were given to the Registered Nurse (RN) and placed on a white board at station one with the times the medication was due and stop dates. The ADON stated to keep the IV antibiotics on time, when a resident is admitted , the hospital records were reviewed to ensure IV therapy would be continued. The ADON stated the RN supervisor was responsible for adding new residents to the board if admissions or new orders were received. The ADON reviewed Resident A's IV antibiotic orders and stated, a registry night shift RN reviewed Resident A's orders upon admission and did not know why the Ampicillin was changed from 34 days to 4 days the following day. The ADON stated the progress notes from Resident A's doctor, written on December 20, 2024, indicated to continue Ampicillin 2 gm (gram) and the Ceftriaxone 2gm (gram) for 6 (six) weeks, but did not know why the Ampicillin was not restarted until December 30, 2024, and for every 6 hours. On March 6, 2025, at 4:55 p.m., an interview and record review were conducted with the Director of Nursing (DON). The DON stated she reviewed Resident A's notes and did not understand why the Ampicillin was stopped and restarted multiple times; it should have been given consistently for the 34 days it was originally ordered. A review of the undated facility ' s policy and procedure titled, Administering IV Antibiotics, indicated, .safe and effective administration of intravenous (IV) antibiotics in compliance with state and federal regulations .only licensed nurses may administer IV antibiotics .before administration .verify the physician's order in the resident's medical record .document all administration details, including date, time, medication name, dosage, route, infusion rate, and any observed reactions. Assess IV site regularly for signs of infection, extravasation, or complications .report medication errors immediately to the supervisor and physician, document the incident .

Based on interview and record review, the facility failed to ensure an allegation of physical abuse was reported to California Department of Public Health (CDPH) immediately, but not later than two (2) hours after the allegation was made. The facility was made aware of the alleged physical abuse of a facility staff (Certified Nursing Assistant [CNA] 1) to a resident (Resident 1) on October 28, 2024. This failure had the potential to cause a delay in the investigation of the alleged abuse and to expose residents in the facility to further abuse. Findings: On November 18, 2024, at 10:15 a.m., an unannounced visit was conducted at the facility to investigate an abuse allegation. On November 18, 2024, Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which include pulmonary fibrosis (scar tissue in the lungs), chronic respiratory failure (difficulty breathing on your own), and anxiety (excessive and persistent worry). Resident 1's Minimum Data Set (MDS - an assessment tool), dated September 2, 2024, had a Brief Interview for Mental Status (BIMs - assessment to monitor cognitive status) score of 11, which indicated mild impairment. On November 18, 2024, at 12:07 p.m., during an interview with CNA 2, he stated he was at the nurse ' s station across Resident 1 ' s room, when he saw CNA 1 come out of the room with food and fluid on the front of her clothes. CNA 2 stated he heard Resident 1 screaming that CNA 1 was hitting her and choking her. CNA 2 stated she assisted another CNA to clean up Resident 1 and did not observed any scratch marks or discoloration on the resident's neck or body area, and there was little food on the resident's bed. On November 18, 2024, at 1:57 p.m., during an interview with the Administrator (ADM), the ADM stated the allegation of abuse by CNA 1 to Resident 1 was first reported to him by the Assistant Director of Nursing (ADON) on October 28, 2024, at 1:00 p.m. The ADM also stated he reported the allegation of abuse to CDPH on October 31, 2024. The ADM further stated he did not report to the state and should have reported it within the required time frame. A review of the facility ' s policy and procedure titled, Resident Abuse-Preventing, Reporting, and Investigating, dated October 2022, indicated .All alleged violations of abuse .shall be reported to the Administrator of the facility .in accordance with State and Federal law through the following procedures: Upon any allegation of abuse the facility will-WITHIN 2 HOURS OF THE ALLEGATION: *Phone call to the Dept. of Public Health/Licensing .

Based on observation, interview, and record review, the facility failed to ensure an assessment was conducted, for three of six residents (Resident 20, 30, and 33) reviewed for safe self-administration of medication when: 1. One 30 ml (milliliters - unit of measurement) cup of powder medication was found on the bedside table of Resident 20; 2. One opened tube of Desitin (brand of ointment used to prevent and treat rash) 57 GM (gram-unit of measurement) ointment was found on bedside table of Resident 30; and 3. One opened bottle of 15 ml eyedrops (medication that relieves eye irritation) was found on the overbed table of Resident 33. These failures had the potential for Residents 20, 30, and 33 to receive multiple doses of medication without proper monitoring, which could lead to harmful effects. Findings: 1. On October 21, 2024, at 9:13 a.m., during a concurrent observation and interview with Resident 20 in her room, one 30 ml cup of powder medication was observed on top of her bedside table. In a concurrent interview with Resident 20, she stated the nurse placed the medication on her bedside table this morning and then left the room. Resident 20 further stated, she put it on my bedside so I can apply it later. On October 24, 2024, Resident 20's ADMISSION RECORD, was reviewed. Resident 20 was admitted on [DATE], with diagnoses which included cerebrovascular disease (brain disease), and dysphagia (difficulty in swallowing). A review of Resident 20's Order Summary, dated August 8, 2024, indicated, Nystatin External Powder 100000 UNIT/GM (medicine used to treat skin infection), for under breast redness A review of Resident 20's Minimum Data Set (MDS - a resident assessment tool), dated August 26, 2024, indicated Resident 20 had a BIMS (Brief Interview of Mental Status) score of 14 (cognitively intact). Further review of Resident 20's medical record indicated there was no documented evidence that a self-administration assessment was conducted. On October 21, 2024, at 9:20 a.m., during a concurrent observation and interview with Licensed Vocational Nurse (LVN) 2, she stated the powder medication was Nystatin External Powder and stated, it should not be left on bed side table. LVN 2 further stated Resident 20 should have had an assessment for self-administration of Nystatin External Powder. On October 23, 2024, at 9:07 a.m., Registered Nurse (RN) 2 was interviewed. RN 2 stated there was no assessment for self-administration of medications for Resident 20. RN 2 stated there was no physician order for Resident 20 to self-administer medications. RN 2 further stated if Resident 20 will continue to self-medicate, then it could lead to further issues like skin irritation or adverse effect of the medication. 2. On October 21, 2024, at 10:22 a.m., during a concurrent observation and interview with Resident 30 in his room, one opened tube of Desitin 57 GM was on bedside table. In a concurrent interview with Resident 30, he stated he administered the medication himself when he wanted to be relieved from rash. On October 24, 2024, Resident 30's ADMISSION RECORD, was reviewed. Resident 30 was admitted on [DATE], with diagnoses which included chronic kidney disease (long -term kidney damage). A review of Resident 30's History and Physical, dated May 9, 2024, indicated Resident 30 was mentally capable of understanding. Further review of Resident 30's medical record indicated there was no documented evidence that a self-administration assessment was conducted. In addition, there was no physician order for the use of the Desitin ointment. On October 21, 2024, at 10:40 a.m., during a concurrent interview and review of Resident 30's medical records with LVN 2, she stated Resident 30 had an one open tube of Desitin 57 GM at the bedside without a physician order. LVN 2 stated medication should not be kept at the bedside. LVN 2 further stated the Desitin ointment should not be applied without a physician's order and a self-administration assessment should have been made. 3. On October 21, 2024, at 10:15 a.m., during a concurrent observation and interview with Resident 33 in her room, one opened bottle of 15 ml eyedrops was found on the overbed table. Resident 33 stated she administered the medication herself when she wanted to relief from her eye irritation and itching. On October 24, 2024, Resident 33's ADMISSION RECORD was reviewed. Resident 33 was admitted on [DATE], with diagnoses which included hypertension (elevated blood pressure). A review of Resident 33's History and Physical, dated July 23, 2024, indicated Resident 33 was mentally capable of understanding. Further review of Resident 33's medical record indicated, there was no documented evidence that a self-administration assessment was conducted. In addition, there was no physician order for the use of the eyedrops. On October 21, 2024, at 10:25 a.m., during a concurrent interview and review of Resident 33's medical records with LVN 2, she stated Resident 33 did not have a physician's order for the eyedrop solution. LVN 2 further stated the eyedrop solution should have had a physician's order, and a self-administration assessment should have been completed. On October 23, 2024, at 12:28 p.m. during an interview with the Assistant Director of Nursing (ADON), she stated her expectation for licensed nurses was to follow the policy and procedure regarding self-administration assessment and administration of medications for all residents. The ADON further stated if the policy and procedures were not followed, there was a potential for residents to not receive medications according to the physician's order, and to not be monitored for any adverse (negative) effects. A review of the facility's policy and procedure titled, Administering Medications, dated April 2019, indicated, .Residents may self-administer their own medications per Self Administration Policy and Procedure . A review of the facility's policy and procedure titled, Self Administration of Medications, dated February 2021, indicated, .Residents have the right to self-administration .The resident is able to safely and securely store the medication .Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge .The nursing staff routinely checks self-administered medications .

Based on observation, interview, and record review, the facility failed to ensure expired, discontinued, and unlabeled medications and intravenous (IV- into the vein) fluids were not readily available for use. These failures have the potential for the residents to receive wrong, contaminated, expired, or ineffective medication therapy. Findings: 1a. On October 23, 2024, beginning at 3:27 p.m., an inspection of the Station 4 Medication Cart (Med Cart) was conducted with Licensed Vocational Nurse (LVN) 9. The following medications were found expired and kept stored in the second left drawer of Med Cart 4: - One tablet ondansetron (medication for nausea/vomiting) 4 mg (milligrams- unit of measurement) tab (tablet), labeled for Resident 31, with an expiration date of March 18, 2024; - Eight tablets of Clonidine (a blood pressure medication) 0.1 mg tab, labeled for Resident 12, with an expiration date of October 2, 2024; - 25 tablets of ondansetron tab 4 mg, labeled for Resident 19, with an expiration date of October 1, 2024; - Three tablets hyoscyamine (medication that reduces secretions) 0.125 tab SL (sublingual- under the tongue), labeled for Resident 19, with an expiration date of October 10, 2024; - 29 tablets of Chest Conges Tab (medication for nasal drip) 400 mg, labeled for Resident 3, with an expiration date of April 26, 2024; and - Four tablets ondansetron tab 4 mg, labeled for Resident 1, with an expiration date of September 17, 2024. In a concurrent interview, LVN 9 stated the medications were expired and should have already been removed from the cart, to prevent the medications from being incorrectly given to residents and cause potential harm to them. LVN 9 stated expired medications have decreased efficacy after their expiration dates. LVN 9 further stated it was the nurses' responsibility to ensure all expired medications were removed from the Med Cart, and discarded in the incinerator bin following facility protocol. 1b. On October 23, 2024, beginning at 4:57 p.m., an inspection of the Station 3 Med Cart was conducted with LVN 10. The following medications were found expired and kept stored in the second left drawer of Med Cart 3: - Two capsules dicyclomine (medications for stomach cramps) 10 mg, labeled for Resident 2, with an expiration date of August 20, 2024; and - Nine tablets ondansetron tab 4 mg, labeled for Resident 2, with an expiration date of October 6, 2024. In a concurrent interview and review of Resident 2's electronic health record, LVN 10 stated she thought Resident 2 was not receiving dicyclomine anymore. LVN 10 verified the medication was expired and discontinued, and stated the medication should have been taken out of the Med Cart. LVN 10 verified ondansetron was expired, had also been discontinued, therefore the medication should not have been in the Med Cart. LVN 9 further stated expired and discontinued medications got wasted (discarded) in the medication storage room. LVN 10 stated the medication stickers are to be removed and pasted on the medication disposition form in the binders, and all these medication got popped out, and put in the incinerator box to be wasted. On October 24, 2024, the Assistant Director of Nursing (ADON) was interviewed. The ADON stated it was her expectation that anything expired should be removed from the Med Carts and the nurses were responsible for checking their own carts to make sure there were no expired medications available in the carts. The ADON stated expired and discontinued medications should not have been in the Med Carts and should have been removed from the carts and destroyed (discarded). A review of the facility's undated policy and procedure titled, FACILITY AUDITING AND REMOVAL OF EXPIRED AND DISCONTINUED MEDICATIONS, indicated, .The medication nurses will remove expired medications from the drug storage areas so that they are not administered to residents .The facility staff will remove expired medications from the medication storage areas on a regular schedule and when encountered .At least once monthly the nurse responsible for the medication cart for each station will inspect the medication cart and medication room for expiring medications . A review of the facility's policy and procedure titled, Storage of Medications, dated November 2020, indicated, .Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed . 41459 2a. On October 24, 2024, at 11:30 a.m., an inspection of the Station 1 Medication Storage Room was conducted with Registered Nurse (RN) 1. The following was found: - One bag of 1000 ml (milliliter- unit of measurement) of Dextrose (a sterile solution used to provide your body with extra water and calories from sugar)10% IV was unlabeled and readily available for use. In a concurrent interview, RN 1 stated there should be a label on the IV bag. 2b. On October 24, 2024, at 11:39 a.m., an inspection of the Station 2 Medication Storage Room was conducted with Registered Nurse (RN) 1. The following was found: - One multi-dose vial of Tubersol injection (aids in the diagnosis of tuberculosis [a bacterial infection that affects the lungs]), with an open date of September 20, 2024, was found stored in the small medication refrigerator, four days over the expiration date, readily available for use. In a concurrent interview with RN 1, RN 1 stated medication multi-dose vials were to be disposed of 30 days after opening. RN 1 further stated the medication vial of Tubersol was labeled with an open date of September 20, 2024, and should not have been in the refrigerator for continued use, since it was over the 30 day timeframe. A review of the facility's policy and procedure titled, Storage of Medication revised November 2020, indicated, .Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for prober labeling before storing . A review of the policy and procedure titled, Administering Medications, revised April 2019, indicated, .The expiration beyond use date on the medication label is checked prior to administering. When opening a mulit-dose container, the date opened is recorded on the container .the medication nurse will remove expired medications from the drug storage areas so that they are not administered to residents .the facility staff will remove expired medications from the medication storage areas on a regular schedule and when encountered . According to the webarticle published by DailyMed, indicated, .STORAGE .A vial of TUBERSOL which has been entered and in use for 30 days should be discarded .

Based on observation, interview, and record review, the facility failed to ensure safe storage practices were followed in the kitchen when: - One seven-pound (lb- unit of measurement) can of cranberry jelly was found in the dry storage area undated; - Two stalks of celery in a plastic bag were found in the walk-in refrigerator with the bag open exposing the celery to air; and - Five three-lb bars of chopped spinach were found in the freezer not dated. These failures had the potential to cause food-borne illnesses in a highly susceptible resident population. Findings: On October 21, 2024, at 9:00 a.m., an initial kitchen tour was conducted with the Dietary Manager (DM). The following were observed: - One seven-lb can of cranberry jelly was found in the dry storage area undated; - Two stalks of celery in a plastic bag were found in the walk-in refrigerator with the bag open exposing the celery to air; and - Five three-lb bars of chopped spinach were found in the freezer not dated. On October 21, 2024, at 9:22 a.m., a concurrent interview was conducted with the DM. The DM stated all food items should be dated prior to placing the items in the pantry or other storage areas. The DM stated no food should be open to air, and all food items should be dated when received. A review of the facility's policy and procedure titled, Labeling and Dating of Food, revised 2023, indicated, .food delivered to the facility needs to be marked with a received date .Newly opened food items will need to be closed and labeled with an open date and use by the date .Produce is to be dated with received date .

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Certified Nursing Assistant (CNA) 2 did not use personal protective equipment (PPE - equipment use to protect against infection or illness) when providing care to a resident requiring enhanced barrier precautions (EBP-an infection control intervention to reduce transmission of multidrug-resistant organisms [MDRO- bacteria that have become resistant to multiple antibiotics]); 2. The Laundry Staff (LS) failed to follow proper handling and storage of clean linens; 3. The Certified Occupational Therapy Assistant (COTA - healthcare provider who performs physical movement) did not conduct proper handwashing before and after providing therapy treatment to a resident; 4. The facility staff failed to ensure the nebulizer treatment tube (a plastic device that delivers air and medicine through a tube for breathing treatment) was changed according to the physician's order; and 5. Two direct care staff were observed wearing long artificial nails while providing care to the residents. These failures increased the potential for the spread of infection to an already medically compromised resident population of 95 residents. Findings: 1. On October 21, 2024, at 3:45 p.m., a resident's room was observed to have a sign by the door indicating instructions to wear appropriate PPE (gown and gloves) before entering the resident's room (Resident 76). CNA 2 was observed to enter Resident 76's room and provided care to the resident who was in the bathroom without wearing gown and gloves. In a concurrent interview with CNA 2, she stated she forgot to wear PPE. CNA 2 further stated she should have worn PPE when she provided care to Resident 76 to prevent the spread of germs and protect the residents from infection. On October 21, 2024, at 3:57 p.m., during an interview with Licensed Vocational Nurse (LVN) 1, she stated the staff should wear gown and gloves when providing direct care to Resident 76. LVN 1 stated appropriate PPE should be worn to prevent the spread of germs and protect the residents from infection. LVN 1 further stated a sign was to be posted by the wall to remind staff to wear proper PPE while doing direct care such as changing briefs, assisting in the bathroom. On October 22, 2024, at 10:07 a.m., during an interview with the Infection Prevention (IP) nurse, she stated Resident 76 had an indwelling catheter and was on enhance barrier precaution. The IP further stated CNA 2 should have worn PPE before providing care to Resident 76 to prevent the spread of infection to other residents. On October 23, 2024, Resident 76's record was reviewed. Resident 76 was admitted to the facility on [DATE], with diagnoses which included obstructive uropathy (urinary tract disorder) and pressure-induced deep tissue damage of sacral region (wound at the back area). A review of Resident 76's Order Summary, dated September 21, 2024, indicated, .Enhanced Barrier Precautions (a type of Transmission Base Precautions [TBP] - measures use to prevent the spread of infections) .staff to wear gloves and gown for high contact resident care activities . On October 24, 2024, at 12:39 p.m., during an interview with the Assistant Director of Nursing (ADON), she stated the expectation was for the staff to follow the facility infection control policy and procedure. The ADON further stated CNA 2 should have worn PPE to prevent the spread of infection to the residents. A review of the facility's undated policy and procedure titled, Enhanced Barrier Precautions, indicated, .focuses on preventing transmission of multidrug-resistant organism (MDRO) infections via staff hands and clothing .staff need to use gloves and gown with certain residents during high-contact resident care activities .when .transferring .providing hygiene .assisting with toileting . 2. On October 23, 2024, at 10:30 a.m., during a concurrent observation and interview with the Laundry Staff (LS), the LS was observed taking out clean linens from the clothes dryer and stacking them in the rolling carts, using his body without gown to prevent the linen falling out of the cart. The LS proceeded to push the cart against the wall, allowing the linen to come in contact with the wall. In a concurrent interview, the LS stated there were no extra carts to use so he stacked the rolling cart high with the linens. The LS further stated it could spread infections if the clean linens were not handled and stored properly. On October 23, 2024, at 10:55 a.m., the Housekeeping/Laundry Supervisor (HS) was interviewed. The HS stated the clean linens should not touch surfaces on the wall and should be kept in a clean storage bin. The LS further stated, it could spread infections. On October 23, 2024, at 11:41 a.m., the IP was interviewed. The IP stated laundry staff should practice proper handling and storage of clean linens. The IP further stated if laundry staff did not follow infection control policies, and practiced improper handling and storage of clean linens, it could cause cross contamination and spread of infection. On October 23, 2024, at 12:15 p.m., during an interview with the ADON, she stated clean linens should be kept in a clean environment and not touching or leaning to the walls. The ADON stated the wall was considered dirty and the contaminated linen could transmit the infection to the residents. A review of the facility's policy and procedure titled, Departmental (Environmental Services)-Laundry and Linen, dated January 2014, indicated, .the purpose of this procedure is to provide a process for the safe and aseptic handling, washing and storage of linen .clean linen will remain hygienically clean (free of pathogens [infectious agents]) .to cause human illness .designed to protect it from environmental contamination, such as covering clean linen carts . 3. On October 22, 2024, at 11:27 a.m., during a concurrent observation and interview with the Certified Occupational Therapy Assistant (COTA), the COTA was observed providing therapy to a resident and brought the resident back to the room. The COTA was then observed to assist another resident in the therapy room and did not perform hand washing or hand hygiene before and after therapy treatment in between residents. The COTA stated, I forgot to wash my hands. The COTA further stated he should have washed his hands before and after providing therapy to prevent spread of infection to other residents. On October 22, 2024, at 12:20 p.m., the Director of Rehab (DOR) was interviewed. The DOR stated the COTA should have washed his hands before touching the resident, otherwise the COTA could spread the infection to other residents. On October 22, 2024, at 2:21 p.m., the IP was interviewed. The IP stated, Staff should wash their hands before and after therapy procedures. The IP further stated if staff did not wash their hands, it could lead to the spread of infections. On September 23, 2024, at 12:04 p.m., the ADON was interviewed. The ADON stated staff members were supposed to perform hand washing before and after therapy procedures. The ADON further stated unwashed hands could transmit and spread infection to other residents. A review of the facility's policy and procedure titled, Departmental-Therapy/Rehabilitation-Prevention of Infection, dated September 2010, indicated, .Wash hands or use hand sanitizer before direct resident care .Therapist must wash their hands between residents . A review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, dated August 2019, indicated, .This facility considers hand hygiene the primary means to prevent the spread of infections .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors . 4. On October 23, 2024, at 8:27 a.m., during a concurrent observation and interview with Registered Nurse (RN) 2, the nebulizer tubing of Resident 50 was observed with white colored build up at the edge of the nebulizer mask. The nebulizer tubing was dated and labeled 10/17/24 (October 17, 2024) .CHANGED TUESDAY . In a concurrent interview with Registered Nurse (RN) 2, she stated the nebulizer tubing was soiled, and it should have been changed yesterday. A review of Resident 50's ADMISSION RECORD, indicated Resident 50 was admitted to the facility on [DATE], with diagnoses which included pneumonia (respiratory infection). A review of Resident 50's Order Summary, dated September 10, 2024, indicated, .Change and date O2 (oxygen) and nebulizer tubing .every Tue (Tuesday) . On October 23, 2024, at 11:07 a.m., during an interview with the IP, the IP stated the licensed nurses should change the soiled nebulizer tubing and should follow the schedule of the facility to change tubings every Tuesday. The IP further stated if the nebulizer tubing was not changed, it could lead to bacterial (germ) growth, the resident might inhale it and cause respiratory illness. On October 23, 2024, at 12:24 p.m., an interview was conducted with the ADON. The ADON stated her expectation for licensed nurses were to follow the standard of practice for infection control. She further stated if the nebulizer tubing was soiled, it should had been changed, and the schedule to change it every Tuesday should have been followed. A review of the facility's policy and procedure titled, Oxygen Administration, dated October 2010, indicated, .to provide guidelines for safe oxygen administration .change tubing per manufacturer guidelines . A review of the facility's policy and procedure titled, Specific Medication Administration Procedures, dated October 2012, indicated, .Rinse and disinfect the nebulizer equipment .change equipment and tubing every seven days . 5a. On October 22, 2024, at 1:57 p.m., an observation was conducted with LVN 11. LVN 11 was observed to have long artificial nails (approximately 1/2 inch from tip of fingers) when providing care to residents. On October 22, 2024, at 2:20 p.m., an interview was conducted with LVN 11. LVN 11 stated she was involved in the care of residents and I am considered as direct care staff handling residents. LVN 11 stated she was capable of helping residents in their care, passing food trays in residents' rooms, and helping to feed residents. LVN 11 stated that she had artificial nails made of gel, that was attached and extended to her natural fingernails. LVN 11 further stated she was not aware of the facility's policy for employees' nails. On October 22, 2024, at 2:27 p.m., an interview was conducted with the IP. The IP stated the facility's policy indicated nails must have appropriate length, and the nails should not be too long specially for direct care staff. The IP further stated if staff had long nails, these could potentially scratch the skin of the residents, which could lead to skin breakdown and cause infection. On October 23, 2024, at 12:07 p.m., an interview was conducted with the ADON. She stated long artificial nails could accumulate germs underneath the nails. The ADON further stated, Direct care staff should follow facility's policy regarding infection control, and staff should not have artificial long nails. 40988 5b. On October 23, 2024, beginning at 8:50 a.m., a medication administration observation was conducted with LVN 2. LVN 2 was observed wearing gel nails (a type of artificial fingernails similar to acrylic nails) while providing direct care to the residents. On October 23, 2024, at 3:20 p.m., LVN 2 was interviewed. LVN 2 stated she was wearing gel nails and the facility's policy regarding use of artificial nails was not clarified with staff, and so was not sure if it was prohibited. When asked about the length of her nails, LVN 2 stated as long as it was not too long, as she currently had it (LVN 2's nails were measured to be approximately 1/4 inch in length from the tip of the fingers), then she stated it was ok to have it. When asked what was considered too long, LVN 2 stated it was up to her judgement, since the facility had not clarified with staff what an acceptable nail length was for direct care staff to wear. On October 24, 2024, at 3:59 p.m., the IP was interviewed. The IP stated the use of gel nails was a preference, but asked to confer with the Administrator (Adm) regarding the facility's policy regarding artificial nails. After consulting with the Adm, the IP stated the facility policy indicated nails should be neat and clean, and the employee handbook indicated a length of 1/4 inch. The IP further stated neither mentioned about the use of nail polish or gel nails. On October 24, 2024, at 4:46 p.m., the Adm was interviewed. The Adm stated the facility's Hand Hygiene policy at number 11 indicated nails should be clean and tidy and strongly recommended no acrylic for direct care staff. The Adm further stated in the employee handbook there is a mention of 1/4 inch length for the nails. The Adm stated he expected direct care staff to adhere to facility policy. According to the web article titled, Guideline for Hand Hygiene in Health-care Settings (MMWR 2002, volume 51) published by the Centers for Disease Control and Prevention (CDC - a leading national public health institute in the United States), .even after careful handwashing, HCWs (health care workers) often harbor substantial numbers of potential pathogens (disease causing viruses, fungi, and bacteria) in the subungual (under the nails) spaces .HCWs who wear artificial nails are more likely to harbor gram-negative pathogens on their fingertips than those who have natural nails, both before and after handwashing . According to the web article titled, WHO (World Health Organization) Guidelines on Hand Hygiene in Health Care, published by the World Health Organization, .Long, sharp fingernails, either natural or artificial, can puncture gloves easily .Each health-care facility should develop policies on the wearing of .artificial fingernails or nail polish by HCWs. These policies should take into account the risks of transmission of infection to patients .recommendations are that HCWs do not wear artificial fingernails or extenders when having direct contact with patients . A review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, dated August 2019, indicated, .Wearing artificial fingernails is strongly discouraged among staff members with direct resident-care responsibilities, and is prohibited among those caring for severely ill or immunocompromised residents .The infection preventionist maintains the right to request the removal of artificial fingernails at any time if he or she determines that they present an unusual infection control risk . A review of the facility's employee handbook titled, Personal Appearance, dated 2024, indicated, .natural nail tips should be kept to 1/4 inch in length .A growing body of evidence suggests that wearing artificial nails may contribute to transmission of certain healthcare-associated pathogens (germs that cause disease) .

Based on observation, interview, and record review, the facility failed to treat resident with respect and dignity when the staff failed to cover the urinary bag, for one of one resident reviewed for dignity (Resident 53). This failure increased the potential to negatively affect Resident 53's psychosocial wellbeing. Findings: On October 21, 2024, at 3:30 p.m., Resident 53 was observed with Licensed Vocational Nurse (LVN) 1. Resident 53's urinary bag was observed attached to the resident and was filled with 300 ml (millimeter-unit of measurement) yellow liquid. The urinary bag was observed hanging below the level of Resident 53's bed. In a concurrent interview with LVN 1, she stated the staff did not cover the urinary bag with a dignity bag (used to cover urine collection bag) and was exposed. She further stated, it should have been covered, I will feel embarrassed if that bag was mine and not covered. On October 23, 2024, Resident 53's record was reviewed. Resident 53 was admitted to the facility on [DATE], with diagnoses which included obstructive uropathy (blockage in urinary tract). A review of Resident 53's History and Physical, dated March 15, 2024, indicated Resident 53 had no capacity to understand and make decisions. A review of Resident 53's Order Summary, dated July 31, 2024, indicated, .Foley catheter (tube that drains urine) 16fr/10ml (french-unit of measurement), to closed drainage system for Obstructive uropathy . On October 24, 2024, at 12:20 p.m., during an interview with the Assistant Director of Nursing (ADON), she stated residents should be treated with respect and dignity all the time. The ADON further stated leaving the urinary bag uncovered will cause psychosocial effect to resident. She stated, it should have been covered with dignity bag. A review of the facility's policy and procedure titled, Dignity, dated February 2021, indicated, .Residents are treated with dignity and respect at all times .The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs .Staff are expected to promote dignity and assists residents .keep urinary catheter bags covered . A review of the facility's policy and procedure titled, Resident [NAME] Of Rights, dated December 2012, indicated, .Dignity .The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality .

Based on observation, interview, and medical record review, the facility failed to manage the pain, for one of three residents reviewed for pain (Resident 137), when the pain medication was not administered according to the physician's order. This failure resulted in Resident 137 not receiving the pain medication as ordered by the physician and had the potential for Resident 137 to experience pain not to be managed appropriately and affect overall health condition. Findings: On October 21, 2024, at 9:22 a.m., a concurrent observation and interview was conducted with Resident 137. Resident 137 was observed wearing a neck brace sitting at bedside and grimacing while repositioning himself. Resident 137 stated he arrived at the facility on October 16, 2024, around 5 p.m., and did not receive pain medication until the next day around 7 a.m. Resident 137 further stated he asked for pain medicine at 2 a.m., in the morning of October 17, 2024, and the nurse replied, We don't have your doctor's orders and the pain medication was not available. On October 22, 2024, at 6 p.m., during a follow up interview with Resident 137, he stated he had a pain level of nine out of 10 the previous night and was given Norco (medicine to relieve pain) 7.5-325 mg (milligram - unit of measurement) instead of Norco 10-325 mg. Resident 137 further stated the nurse told him Norco 10-325 mg was not yet delivered to the facility, and he could not get any more from the Cubix (smart cabinet holds and dispense medication) reserve. Resident 137 stated he felt his needs were not being met. On October 23, 2024, at 8:45 a.m., in a follow up interview with Resident 137, he stated his pain was not managed through the night. Resident 137 stated his order for Norco 10-325 mg for severe pain was not available to him. Resident 137 stated the night nurse told him the doctor would sign the order today. A review of Resident 137's electronic record indicated Resident 137 was admitted to the facility on [DATE], with diagnoses which included displaced fracture of second cervical vertebra (a break in the bones of the neck), contusion (injury to the skin and underlying tissue of an area of the body) left hand, fibromyalgia (widespread musculoskeletal pain), and pain in the left shoulder and left upper arm. A review of Resident 137's physician's order indicated the following orders dated October 17, 2024: - Norco 7.5-325 mg one tab by mouth every four hours as needed for moderate pain (rate of 4 to 6); and - Norco 10-325 mg one tab by mouth every four hours as needed for severe pain (rate of 7 to 10). A review of Resident 137's care plan, dated October 17, 2024, indicated, .at risk for pain and discomfort r/t (related to) DX (diagnosis) .cervical fracture .fibromyalgia .Evaluate and document severity of pain and response to interventions .Medications per MD (physician) order . A review of Resident 137's Medication Administration Record, for the month of October 2024, indicated Norco 7.5-325 mg was administered to Resident 137 with a pain rating of severe pain on the following dates and times: - October 20, 2024, at 2:05 p.m.; pain rate of 8; - October 20, 2024, at 11:53 p.m.; pain rate of 9; - October 21, 2024, at 4:25 p.m.; pain rate of 7; - October 21, 2024, at 8:25 p.m.; pain rate of 7; - October 22, 2024, at 9:57 a.m.; pain rate of 9; and - October 22, 2024, at 10:20 p.m.; pain rate of 10. A review of the pharmacy document indicating the times Norco 10-325 mg was pulled out from the Cubix reserve for Resident 137 did not indicate Norco 10-325 mg was taken from the Cubix on the above dates when the resident's pain level was severe (7 to 10 pain rate). On October 23, 2024, at 8:37 a.m., LVN 2 was interviewed. LVN 2 stated Resident 137 had stated to her that his pain was not being managed effectively in the facility, and he did want to experience severe pain while in the facility. LVN 2 stated she did not offer any alternative pain management measures and was not able to administer any Norco 10-325 mg to the resident throughout her shift on October 22, 2024, since the resident's medication supply had not yet been delivered. LVN 2 stated the medication should have been available, and the resident not having his pain medication could prevent him from resting and being comfortable. On October 23, 2024, at 3:35 p.m., an interview with Licensed Vocational Nurse (LVN) 3 was conducted. LVN 3 stated she cared for Resident 137 since October 21, 2024. After assessing Resident 137, she gave him Norco 10-325 mg around 8:30 a.m. LVN 3 stated at the end of the shift, she endorsed to the oncoming night nurse that there was one Norco 10-325 mg available for the resident, and she had submitted an electronic refill order to the pharmacy for the medication. LVN 3 stated she returned to work on the morning of October 22, 2024, and at the change of shift, the outgoing night nurse endorsed to her that there was no more Norco 10-325 mg available for Resident 137. LVN 3 stated Registered Nurse (RN) 1 was able to request a code from the pharmacy to pull the Norco 10-325 mg from the Cubix at the end of the shift, which LVN 3 used to remove the medication and administer to Resident 137. LVN 3 stated she passed on the code to the next shift because there was still one dose available for the resident. When asked about the facility's process for pain management, LVN 3 stated staff would assess the resident's pain level and offer medication according to the physician's order, then re-assess within the hour to see if the medication was effective. LVN 3 stated she would contact the physician if the pain medication was ineffective. LVN 3 stated Resident 137 had mentioned to her that the Norco 7.5-325 mg was ineffective and required the Norco 10-325 mg dose instead for better pain control. LVN 3 stated Resident 137's pain should be managed, but it was not currently being managed appropriately. On October 23, 2024, at 4:19 p.m., a concurrent review of Resident 137's MAR was conducted with RN 1. RN 1 stated Norco 7.5-325 mg (moderate pain) was administered to Resident 137 for severe pain instead of administering Norco 10-325 mg. RN 1 stated Resident 137 should have received Norco 10-325 mg for severe pain. RN 1 stated residents with orders for narcotics were entered into the electronic system and the orders faxed to the pharmacy. RN 1 stated the pharmacy would then verify with the physician and obtain the physician's signature to authorize the pharmacy to dispense the narcotic medication. RN 1 stated medications were usually filled within six to eight hours and if the medication was not delivered within 24 hours, the licensed staff would follow up with the pharmacy. RN1 stated further stated the pharmacy could also provide a code for the licensed staff to access the Cubix and remove the narcotic medication from the reserve storage when the medication is still not available. RN 1 stated she did not know why Resident 137 was not medicated with the Norco 10-325 mg when it was available in the Cubix. RN 1 further stated Resident 137's pain should have been managed. A review of the facility's policy and procedure titled, Administering Medications, revised April 2019, indicated, .Medications are administered in accordance with the prescriber orders, including any required time frames . A review of facility's policy and procedure titled, Pain Assessment and Management, revised dated March 2020 indicated, . the pain management program is based on a facility-wide commitment to appropriate assessment and treatment of plan, based on professional standards of practice, the comprehensive care plan and the resident's choices related to pain management .Implementing Pain Management Strategies .Implement the medication regimen as ordered, carefully documenting the results of the interventions

Based on observation, concurrent interview, and record review, the facility failed to monitor for anticoagulant (medication that treats blood clots) use, for one of two residents reviewed (Resident 138), when Resident 138 was observed to have multiple bruises on both arms. This failure resulted in Resident 138 not being monitored for potential harmful side effects of anticoagulants. Findings: On October 22, 2024, at 2:45 p.m., a concurrent observation and interview with Resident 138 was conducted. Resident 138 was observed with multiple scattered purple and red discolorations on both arms. Resident 138 stated he was on blood thinner and was not given instructions or teaching on monitoring for signs and symptoms of bleeding. On October 22, 2024, a review of Resident 138 electronic medical record indicated Resident 138 was admitted to the facility on [DATE], with diagnoses which included acute embolism and thrombosis of deep veins (condition blocking blood flow in veins and arteries) of the left lower extremity, and history of long term use of anticoagulants. A record review of Resident 138's Order Summary Report, included a physician's order, dated October 17, 2024, which indicated Resident 138 was on apixaban (blood thinner) 5 (five) mg (milligram - unit of measurement) 1 (one) tablet by mouth 2 (two) times a day. A record review of Resident 138's Nursing Admission Screening/History, dated October 17, 2024, indicated no skin issues. A record review of Resident 138's care plan, initiated on October 18, 2024, indicated Resident 138's skin integrity was at risk related to anticoagulant use. A record review of Resident 138's Progress Notes, dated October 18, 2024, indicated Licensed Vocational Nurse (LVN) 7 did a follow up skin assessment. LVN 1 documented Resident 138 had purple discoloration to left inner arm, right elbow, redness to the abdominal fold and both wrist. On October 24, 2024, at 8:45 a.m. an observation, concurrent interview, and record review with LVN 8 was conducted. LVN 8 stated Resident 138 was on apixaban 5mg. Stated she did not notice the bruising on Resident 138's arms. LVN 8 further stated there was no monitoring of Resident 138 for anticoagulant use. LVN 8 stated there should be monitoring for adverse affects from anticoagulant use. October 24, 2024, at 9:05 a.m., an observation, concurrent interview, and record review with Registered Nurse (RN) 1 was conducted. Observed Resident 138's right upper arm with purple and red discolorations on both lower arms. RN 1 stated Resident 138 did not have an order to monitor for signs and symptoms of bleeding nor was baseline labs ordered. RN 1 further stated Resident 138 should be monitored for signs and symptoms of bleeding or bruising. Stated nursing should monitor residents on anticoagulants because they need to know if they were experiencing any signs or symptoms of bleeding such as nose bleeds or bruising. RN 1 stated the licensed nurse who identifies the change in skin condition would be responsible for initiating a change of condition and notifying the physician. RN 1 stated there was no change of condition documented. RN 1 stated the Certified Nursing Assistant (CNAs) and licensed nurses are responsible for daily assessing the residents. On October 24, 2024, at 12:01 p.m. an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated the facility's process was to identify patient with anticoagulant therapy and verify the order. The ADON stated licensed nurses make sure there is a care plan regarding the order and the importance and reason for the care plan was if a patient is at risk; skin discoloration could be from bleeding if on anticoagulants. The ADON further stated the CNA was responsible for monitoring all patient for change in skin condition when doing Activities of Daily Living (ADL) and showers by looking for skin discolorations, any breakdown, or any tears. The CNA must notify the licensed nurse of any skin changes. The ADON stated the licensed nurse must assess and do an SBAR if it was a new issue. The ADON stated the licensed nurse must notify the doctor for further orders. On October 24, 2024, at 12:18 p.m. a follow up interview with Resident 138 was conducted. Resident 138 stated no one has reassessed his skin. On October 24, 2024, at 12:18 p.m. a follow up interview with the ADON was conducted. The ADON stated there was no new skin changes documented on shower days since October 18, 2024 for Resident 138. The ADON stated there was no documented information of new bruising was noted for Resident 138. The ADON stated no prior labs was ordered and there were no current orders. The ADON stated Resident 138 should have been monitored for any adverse effects of anticoagulant use. A review of the facility's policy and procedure titled, Anticoagulation - Clinical Protocol, revised and dated November 2018, indicated, .As a part of the initial assessment, the physician and staff will identify individuals who are currently anticoagulant; for example, those with recent history of deep vein thrombosis (DVT), .Assess for any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications .The staff .will monitor for possible complications in individuals who are being anticoagulated and will manage related problems .If an individual on anticoagulant therapy shows signs of excessive bruising, hematuria, hemoptysis (blood mixed with sputum), or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next schedule dose of anticoagulant .

Based on interview and facility policy review the facility failed to answer the call light within a reasonable time, for one of 95 residents (Resident 34). This failure had the potential to not meet the resident's needs. Findings: On October 21, 2024, at 10:05 a.m., an interview with Resident 34 was conducted. Resident 34 stated on the he could not get help for up to an hour usually during the morning shift. A review of Resident 34's electronic medical record indicated Resident 34 was admitted to the facility on [DATE], with diagnoses which include fusion of the spine (surgical process that joins vertebrae in the spine), wedge compression fracture (fracture when the front of a vertebrae collapses) of T7-T8 vertebrae, and ankylosing spondylitis (inflammatory arthritis) of thoracic region. A review of Resident 34's History and Physical, dated September 28, 2024, indicated Resident 34 was mentally capable of understanding. On October 24, 2024, 12:40 p.m., an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated everyone was responsible for answering the call lights and they should not be ignored. The ADON further stated the resident could fall if basic needs such as bowel movement, transferring, or reaching out for something were not met if call light was not answered in a timely manner. On October 23, 2024, at 12:50 p.m., an interview with the family representative (FR) was conducted. The FR stated Resident 34 was transferred to the facility on [DATE], with a fractured back, a punctured lung and was there for rehab. The FR stated Resident 34 called her and complained that the nurses do not come when he would call. The FR stated the only time the staff responded to Resident 34 was when she would call the nurse's station from home. The FR stated the husband calls for assistance with using the restroom and repositioning. The FR stated this had frustrated him. On October 24, 2024, at 3:10 p.m. observed call light in room [ROOM NUMBER] on while several staff were talking at the nurse station and Certified Nursing Assistant (CNA) 1 was walking from room to room looking in and out and did not answer the call light in room [ROOM NUMBER]. On October 24, 2024, at 3:17 p.m., an interview with CNA 1 was conducted. CNA 1 stated call lights should be answered as soon as possible, and it was everyone's responsibility to answer the call lights. CNA 1 further stated it is important to answer the call lights as soon as possible to prevent accidents. The CNA stated she heard the call light going off and she should have answered it. A review of the facility's policy and procedure titled, Call System, dated December 2016, indicated, .It is the policy of this facility to provide each resident with a call system to enable them to request assistance .Answer all call bells promptly .

Based on interview and record review, the facility failed to notify the physician for one of four sampled residents (Resident A), when the resident who had diabetes (a condition that impairs the body's ability to process blood sugar) and was taking multiple diabetic medications, consumed 40% of breakfast and had refused to eat lunch on October 21, 2019. In addition, the facility failed to monitor the resident's vital signs, blood sugar level after the resident had a change of condition on October 21, 2019. These failures had resulted in Resident A's blood sugar to drop dangerously low without prompt intervention, thereby causing the resident to be transferred to the acute care hospital. Findings: On November 6, 2019, at 10:26 a.m., an unannounced visit to the facility was conducted to investigate a complaint related to a quality of care issues. Resident A's record was reviewed. The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's Medication Administration Record [REDACTED] a.Liraglutide Solution ( medication used to control high blood sugar) Pen-injector 18 MG/3 ML (milligrams per milliliter) Inject 1.2 milligram subcutaneously (under the skin) one time a day for diabetes . A review of Lexicomp, a nationally recognized drug reference, indicated Liraglutide's peak time (highest concentration of a drug in the bloodstream) is at 8 to 12 hours. (If the medication was given at 9 am, peak will be at 4 pm - 8 pm) b.SitaGLIPtine [MEDICATION NAME] (medication to lower blood sugar) tablet 100 MG (milligrams) Give 1 tablet by mouth one time a day for diabetes . According to Lexicomp, the Sitagliptine's effect peaks at 1 to 4 hours (If medication was given at 9 am, peak will be at 12 noon); c.[MEDICATION NAME] Hcl (medication to lower blood sugar) Tablet 500 MG Give 1 tablet by mouth two times a day for Diabetic give with food . According to Lexicomp, [MEDICATION NAME]'s effect peaks at 2 to 3 hours. (If the medication was given at 9 am, peak will be at 12 noon) A review of the facility's meal times indicated breakfast was delivered at 8:30 a.m., and lunch at 12:30 p.m. at the station where Resident A was located. A review of the facility records titled, ADL (activities of daily living) Flow Record, on October 21, 2019, indicated the following: a. Resident A ate 40% of her breakfast meal, and had refused the food substitute; and b. Resident A refused lunch, and food substitute. The ADL review record on October 21, 2019, indicated the charge nurse was not notified of the resident's food intake. On November 12, 2019, at 12:03 p.m., a concurrent interview and record review was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated if a resident refused to eat her meals, the CNA should offer a substitute. In addition, she stated the CNA should inform the charge nurse and document the food refusal in the ADL flow record when a resident continued to refuse the meal and the substitute. A review of the facility document titled, .SBAR (Situation Background Assessment Recommendation- a communication tool for changes of condition between the nurses and the physician) dated October 21, 2019, at 11:30 a.m., indicated, .Resident appears pale, cold and clammy .Nursing Notes .New orders STAT (to be done immediately) CBC (Complete Blood Count- test that screens for certain disorders that can affect health), CMP (Comprehensive metabolic panel-blood test that helps evaluate kidney and liver function) d/t (due to) resident appears pale, cold and clammy .Blood sugar at 96 (normal range 70 - 110) . There was no documented evidence the physician was notified of the resident's (Resident A) poor intake during breakfast and lunch food refusal on October 21, 2019. On November 6, 2019, at 2:37 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated on October 21, 2019, at 11:30 a.m., while doing medication pass, she noticed Resident A was cold and clammy; however, the resident's blood sugar was at 96. She stated she did not check the resident's blood sugar after 11:30 a.m. There was no documented evidence indicating a reassessment of the resident was conducted after the change of condition at 11:30 a.m. On November 6, 2019, at 3:21 p.m., LVN 2 was interviewed. She stated that on October 21, 2019, at the start of the evening shift (3 p.m.-11 p.m.), she received a report regarding the resident's change of condition during the a.m. shift (7 a.m.-3 p.m.). LVN 2 stated she started passing medication to the other residents and when she got to the resident's (Resident A) room, the resident was unresponsive. A concurrent review of the resident's progress notes with LVN 2 was conducted. She verified that on October 21, 2019, at 4:54 p.m., the resident was found unresponsive, with a low BP 80/50 (normal 120/80). The record indicated that the resident was cold and clammy, with a weak pulse. The progress notes indicated the physician gave an order to send the resident to the acute care hospital for evaluation. On November 12, 2019, at 1:01 p.m., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated for a resident with a blood sugar of 96, the licensed nurse was expected to check the resident at least every 30 minutes and to obtain a physician order [REDACTED]. In a concurrent record review with the ADON, she verified that there was no documentation indicating that Resident A's vital signs, blood sugar level and change of condition were monitored from 11:30 a.m., to the time the resident (Resident A) was found unresponsive at 4:54 p.m. A review of the STAT CMP dated October 21, 2019, collected at 4 p.m., prior to the resident being found unresponsive, indicated that the resident's blood glucose (sugar) level was CL (critically low) at 26. A review of the EMS (emergency medical services) notes titled, .Patient Care Report . dated October 21, 2019, indicated EMS was at the facility at 5:20 p.m. The narrative report indicated, .on scene assessing an [AGE] year-old female lying in bed in an altered state .upon their arrival the patient had a BGL (blood glucose level) of 26, GCS of 9 (Glasgow Coma Scale - score of 9-12 means moderate [MEDICAL CONDITION]) .established a 20G IV in the RAC (right antecubital - forearm) and administered [MEDICATION NAME] 10% . Prior to transport the patient daughter arrived on scene and stated that this is not a normal presentation of the patient . The acute care hospital ED (Emergency Department) Provider notes dated October 21, 2019 at 1851 (6:51 p.m.) indicated, .Given the patient's history and physical exam findings .SUSPECT: [MEDICAL CONDITION] (brain damage) 2/2 (secondary to) [DIAGNOSES REDACTED] (low blood sugar) vs (versus) .cardiac (heart) etiology . .Impression: 1. Acute [MEDICAL CONDITION] 2. [DIAGNOSES REDACTED] 3. [MEDICAL CONDITION] (high potassium) 4. Lactic acidosis (lactic acid build up in the blood stream) . The acute care hospital record titled, Physician Discharge Summary, written on October 23, 2019, indicated, .admitted : October 21, 2019 .discharge date : October 22, 2019 .Principal Diagnosis: [REDACTED]. Patient passed away at 8:56 a.m . A review of Lexicomp, indicated [MEDICATION NAME] had the following US (United States) boxed warning: Post marketing cases of [MEDICATION NAME]-associated lactic acidosis have resulted in death .The onset is often subtle, accompanied by nonspecific symptoms (e.g., malaise .respiratory distress .abdominal pain) .Temporarily discontinue therapy in patients with restricted food and fluid intake . A review of the facility's policy titled, Food Intakes: Recording Percentage/Nutritional Assessment, revised January 2012, indicated, Any resident meal percentage less than 75% will be reported to the licensed nurse .If more than 75% of the entire meal is refused by the resident on a consistent basis, the licensed charge nurse will interview the resident to try to determine ways to improve meal intake. If follow through is required, the charge nurse will request a dietary evaluation and/or notify the physician, if appropriate . A review of the facility's undated policy titled, Diabetes Management, indicated, .Management of [DIAGNOSES REDACTED] (low blood sugar) .Severity of [DIAGNOSES REDACTED] is determined by a combination of blood sugar results and clinical symptoms .Symptoms of [DIAGNOSES REDACTED] may include .drowsiness, weakness .[MEDICAL CONDITION](increased heart rate) .pale/cool/moist skin .unconsciousness .For symptomatic but responsive (conscious) residents with [DIAGNOSES REDACTED]: If he/she is able to swallow .give resident 4 ounces of orange juice .Recheck blood sugar in approx. 15 minutes .repeat juice if indicated and recheck blood sugar in approx. 15 minutes .If no improvement, call the doctor .Stay with the resident .Monitor vital signs .Hold all diabetic medications .

Based on observation, interview, and record review, the facility failed to ensure one of five residents (Resident 279) did not develop a pressure ulcer (bedsores) when he was positioned on a bedpan for forty-five minutes. This failure resulted in Resident 279 developing pressure ulcers on both buttocks. Findings: On (MONTH) 22, 2019, at 11:03 a.m., Resident 279 was observed lying in bed and alert. During a concurrent interview with Resident 279, Resident 279 was able to state his full name, the time, the place, and the reason why he was admitted to the facility. Resident 279 stated he was admitted to the facility for rehabilitation after a [MEDICAL CONDITION] (broken bone). Resident 279 stated he was given the wrong bedpan and he developed a bedsore on his tailbone. On (MONTH) 22, 2019, starting at 11:50 a.m., wound care observation was conducted in Resident 279's room with Licensed Vocational Nurse (LVN) 1. Resident 279's right buttocks was observed to have an area which was purplish in color and had no open skin area. Resident 279's left buttocks was observed to be purplish in color with a partially open area which was reddish in color. During a concurrent interview with LVN 1, she stated, it's facility acquired wounds on both buttocks and staged as unstageable ulcers (skin loss with slough (product of dead tissue) and/or eschar (scab) at the base of the wound; the color of the surrounding area may be different from the wound bed). On (MONTH) 23, 2019, at 3:09 p.m., Resident 279 was interviewed. Resident 279 stated he was given a fleets enema (liquid laxative (medication for constipation) administered through the anus) last week after lunch at approximately between 12 p.m. to 3 p.m. Resident 279 stated he was given a fracture bedpan (a bedpan smaller than a regular bedpan and used for someone with [MEDICAL CONDITION]). Resident 279 stated he was told by the facility staff he was given the fracture bedpan just in case I have bowel movement. Resident 279 stated he was on the bedpan for approximately 45 minutes. Resident 279 stated he felt uncomfortable when he was on the bedpan so he turned his call light button on. Resident 279 stated nobody checked on him while he was on the bedpan until he put his call light on. Resident 279 stated when the facility staff went into his room to remove the fracture bedpan, he was told by the facility staff he had red marks on his buttocks. Resident 279 stated he was not happy that he got the wounds. On (MONTH) 23, 2019, at 4 p.m., Certified Nursing Assistant (CNA)1 was interviewed. CNA 1 stated he would check the resident every five to ten minutes if the resident was put on a bedpan. On (MONTH) 23, 2019, at 4:01 p.m., CNA 2 was interviewed. CNA 2 stated she would check the resident every 30 to 45 minutes if the resident was put on a bedpan. On (MONTH) 24, 2019, CNA 3 was interviewed. CNA 3 stated she would check the resident five minutes after she put the resident on a bedpan. On (MONTH) 24, 2019, at 10:15 a.m., LVN 2 was interviewed. LVN 2 stated the CNA assigned on the afternoon shift (3 p.m. to 11 p.m.) on (MONTH) 18, 2019, placed Resident 279 on a fracture bedpan. LVN 2 stated she did not know how long Resident 279 was on the bedpan. LVN 2 stated Resident 279's pressure ulcers should have been prevented if the CNA went to check the resident sooner. On (MONTH) 24, 2019, at 10:25 a.m., CNA 2 was interviewed. CNA 2 stated on (MONTH) 18, 2019, she worked the afternoon shift. CNA 2 stated at approximately 3:30 p.m. on (MONTH) 18, 2019, she went to answer the call light of Resident 279. CNA 2 stated Resident 279 told her, he was on the bedpan, he was given a laxative, and he felt uncomfortable on the bedpan. CNA 2 stated she checked Resident 279 and she noticed he was leaning towards his side and she saw the fracture bedpan was placed crooked so she repositioned the fracture bedpan. CNA 2 stated the fracture bedpan was too small for Resident 279 so she told Resident 279 she would get him a bigger bedpan. CNA 2 stated she returned to Resident 279 and replaced the fracture bedpan with a regular bedpan. CNA 2 stated she went to check Resident 279 ten minutes after she placed him on the regular bedpan. CNA 2 stated she did not check Resident 279's buttocks before she replaced the fracture bedpan with a regular bedpan. CNA 2 stated when she removed the regular bedpan, she noticed red marks on Resident 279's buttocks. On (MONTH) 24, 2019, at 12:09 p.m., the Director of Nursing (DON) was interviewed. The DON stated she was aware of Resident 279's pressure ulcers caused by the extended use of a bedpan. The DON stated Resident 279's pressure ulcers could have been prevented if the CNA checked Resident 279's skin when she replaced the fracture bedpan and if the resident was not left on the bedpan for an extended time. On (MONTH) 24, 2019, at 4:44 p.m., Resident 279 was interviewed. Resident 279 stated he could not recall which facility staff put him on the bedpan. Resident 279 stated that he was almost positive he was put on the bed pan by the first shift (7 a.m. to 3 p.m.). Resident 279 stated the shift ended and nobody went back to check him or they forgot about him. Resident 279 stated he was in excrutiating pain from the skin contact with the bedpan. On (MONTH) 24, 2019, at 5:13 p.m., a follow up interview was conducted with LVN 2. LVN 2 stated she worked the morning shift on (MONTH) 18, 2019. She stated she administered a fleets enema to Resident 279 on (MONTH) 18, 2019, at 2:45 p.m. LVN 2 stated she put Resident 279 on a fracture bedpan at approximately 2:55 p.m. on (MONTH) 18, 2019 (inconsistent with her own statement during the interview on (MONTH) 24, 2019, at 10:15 a.m.). LVN 2 stated she reported she administered a fleets enema and put Resident 279 on the bedpan to LVN 4. LVN 2 stated she did not report to a CNA that Resident 279 was on the bedpan. LVN 2 stated Resident 279 did not have any skin condition before she administered the fleets enema to him. On (MONTH) 24, 2019, at 5:37 p.m., a follow up interview was conducted with CNA 2. CNA 2 stated she could not recall if there were red marks on Resident 279's buttocks when she replaced the fracture bedpan with a regular bedpan on (MONTH) 18, 2019. On (MONTH) 24, 2019, at 6:40 p.m., LVN 3 was interviewed. LVN 3 stated she worked double shifts (7 a.m. to 11 p.m.) on (MONTH) 18, 2019. LVN 3 stated the report she received from LVN 4 did not include Resident 279 was on a bedpan. LVN 3 further stated she did not receive a change of shift report from LVN 2. LVN 3 stated CNA 2 notified her Resident 279 had red marks on his buttocks. LVN 3 stated she went to assess Resident 279's buttocks and noticed red and burgundy discoloration which appeared to be bedpan marks on Resident 279's buttocks. On (MONTH) 25, 2019, at 9:38 a.m., LVN 4 was interviewed. LVN 4 stated she worked the 3 p.m. to 11 p.m. shift on (MONTH) 18, 2019. LVN 4 stated she received report from LVN 2 (outgoing nurse) on (MONTH) 18, 2019. LVN 4 stated she received report a fleets enema was administered on Resident 279 by LVN 2. LVN 4 stated she did not receive report Resident 279 was placed on a bedpan. On (MONTH) 25, 2019, at 10:30 a.m., wound care observation was conducted with LVN 1 in Resident 279's room. Resident 279's left and right buttocks wounds were observed to have open areas. The wound on the left buttock measured approximately nine centimeter (cm- a unit of measurement)) by one cm, with the open area measuring approximately six cm by one cm. The wound on the right buttock measured approximately five cm by one cm, with an open area measuring three cm by one cm. During a concurrent interview, LVN 1 described both left and right buttocks wounds as deep tissue injury (DTI- purple or maroon localized area of intact skin or blister due to pressure on the underlying tissue). Resident 279's record was reviewed. Resident 279's ADMISSION RECORD, indicated Resident 279 was admitted to the facility on (MONTH) 12, 2019, with [DIAGNOSES REDACTED]. Resident 279's Nursing Admission Screening/History, dated (MONTH) 12, 2019, indicated Resident 279 did not have pressure ulcers upon admission. Resident 279's HISTORY AND PHYSICAL, dated (MONTH) 16, 2019, indicated .PATIENT MENTALLY CAPABLE OF UNDERSTANDING? YES . Resident 279's Medication Administration Record [REDACTED] The facility document, SBAR (Situation, Background, Assessment, Request) Communication Form and progress note, dated (MONTH) 18, 2019, at 6:27 p.m. was reviewed. The document indicated, (Resident 279's name) .discoloration to bilateral (both) buttock (sic) . Resident 279's Minimum Data Set (MDS- an assessment tool), dated (MONTH) 19, 2019, indicated Resident 279 had a Brief Interview for Mental Status score of 15 (a score of 13- 15 meant Resident 279's cognition (thinking) was intact). The facility document titled, Weekly Wound Report, dated (MONTH) 19, 2019, was reviewed. The document indicated, (Resident 279's name) .Location: right buttock .Indicate whether this site was acquired during the residents stay .Acquired .Date acquired: 07/18/2019 (July 18, 2019) .Comments 100% (percent) intact maroon discolored skin .COMMENTS DTI pressure ulcer/injury caused by patient laying on a fractured (sic) bedpan for an extensive period of time . The facility document, Weekly Wound Report, dated (MONTH) 19, 2019, was reviewed. The document indicated, .(Resident 279's name) .Location: left buttock .Indicate whether this site was acquired during the residents stay .Acquired .Date acquired: 07/18/2019 (July 18, 2019) .Comments: 100% intact maroon discolored skin .COMMENTS DTI pressure ulcer/injury caused by patient laying a fractured (sic) on a bedpan for an extensive period of time . The facility policy titled, CHANGE OF SHIFT REPORT, revised (MONTH) 1998, was reviewed. The policy indicated, .It is the policy of this facility that a verbal report on resident status will be given by the on-duty nurses to the on-coming nurses at each change of shift, in order to provide communication and continuity of resident care regarding .change of condition .any unusual occurence or event . The facility policy titled, PRESSURE ULCER MANAGEMENT PROGRAM, revised (MONTH) 11, 2011, was reviewed. The policy indicated, .It is the policy of this facility to have a system of evaluation, assessment and monitoring of residents for pressure sore management and/or prevention .