Every finding on record at Rio Hondo Subacute & Nursing Center

Based on observation, interview, and record review, the facility failed to provide services with reasonable accommodation of resident needs and preferences by failing to ensure the call lights for six (6) of 6 sampled residents (Residents 8, 140, 9, 34, 142 and 24) reviewed for environment were accessible to residents. This failure had the potential for Residents 8, 140, 9, 34, 142 and 24 to receive delayed or no assistance from facility staff which could lead to a fall or accident and decline in the resident's wellbeing. Findings During a review of the facility's policy and procedure (P&P) titled, Accommodation of Needs, revised January 2020, the P&P indicated , Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. During a review of the facility's P&P titled, Answering the Call Light, revised 10/24/2024, the P&P indicated, Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. 1. During a review of Resident 8's admission Record (AR), the AR indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following but not limited to diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), acute kidney failure (AKF - a sudden loss of kidney function that happens over a few hours or days), muscle weakness, need for assistance with personal care, and aphasia (a brain disorder that affects how you talk, read, write, and understand what people say). During a review of Resident 8's Care Plan with focus risk for falls, dated 2/9/2022, the care plan indicated to place call light within reach while in bed. During a review of Resident 8's Care Plan with focus impaired verbal communication, dated 1/10/2024, the care plan indicated to keep call light in reach. During a review of Resident 8's Minimum Data Set (MDS - a resident assessment tool), dated 7/25/2026, the MDS indicated the resident has modified independence (some difficulty in new situations only) in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 8 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with oral hygiene, upper body dressing and personal hygiene but was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting hygiene, shower/bathe self, lower body dressing and putting on/ taking off footwear. During an observation on 8/3/2026 at 8:34 AM in Resident 8's room, Resident 8 was observed lying in bed while call light was observed tucked in to the bed rail and hanging from the bed rail. During a concurrent observation and interview on 8/5/2026 at 10:11 AM, the Infection Preventionist Nurse (IPN) stated the call light is not within reach, and it should be within reach so that Resident 8 could call for assistance when needed. During a concurrent observation and interview on 8/5/2026 at 11:14 AM, the Director of Nursing (DON) stated the call light is not within reach, and it is important to have the call light within reach so the resident can call facility staff when assistance was needed. 2. During a review of Resident 140's admission Record (AR), the AR indicated the resident was initially admitted to the facility on [DATE] with diagnoses of hemiplegia (a medical condition that cause total or partial paralysis on one side of the body affecting the face, arm and leg) and hemiparesis (muscle weakness or reduced control on just one side of the body) following cerebral infarction (ischemic stroke - when a blood vessel that take blood to the brain gets blocked) affecting the left non-dominant side and epilepsy (a brain disorder that causes repeated, unprovoked seizures [a sudden uncontrollable [NAME] of electric activity in the brain that temporarily changes how a person acts, moves, feels or holds awareness]). During a review of Resident 140'S MDS, dated [DATE], the MDS indicated the resident was severely impaired with cognitive (ability to think, remember, and reason) skills for daily decision making. Resident 140 was dependent (helper does all of the effort) with chair/bed-to-chair transfers, going from lying to sitting on side of the bed, rolling left and right in bed, upper and lower body dressing (the ability to dress and undress above and below the waist), putting on/taking off footwear, personal hygiene and toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). During a review of Resident 140's care plan dated 8/3/2022, Resident 140's care plan indicated Resident 140 was at risk for falls related to impaired mobility and indicated an intervention to place call light within reach while in bed. During a review of Resident 140's Care Plan dated 3/12/2026, Resident 140's Care Plan indicated Resident 140 used a pad-style call light (soft touch call light - a specialized patient-assistance button designed for individuals with limited mobility, poor dexterity, or weak grip strength and only requires minimal, gentle pressure to activate) to be positioned at the side of her head due to functional mobility and indicated interventions to position call light at side of resident's head, to ensure device remained within reach and functional at all times and to reposition the call light after care, repositioning or bed mobility. During a review of Resident 140's Care Plan dated 7/22/2026, Resident 140's Care Plan indicated Resident 140 used bilateral quarter side rails to assist with bed mobility and positioning and indicated an intervention to keep the call light and frequently used personal items within reach. During a concurrent observation and interview on 8/3/2026 at 8:37 AM with Resident 140 in her room, Resident 140 was observed lying in bed attempting to pull the cord of her soft touch call light which was wrapped around the right upper quarter side rail and wedged between the side rail and the mattress. Resident 140 was unable to retrieve the call light. Resident 140 stated she had a headache and needed help. During a concurrent observation and interview on 8/3/2026 at 8:50 AM with Certified Nursing Assistant (CNA) 2 inside Resident 140's room, Resident 140 was observed lying in bed attempting to pull the cord of the soft touch call light which was wrapped around her quarter side rail and wedged between the side rail and the mattress. Resident 140 was unable to retrieve the call light out and stated she had a headache and needed help. CNA 2 stated Resident 140's call light was not easily accessible to Resident 140 and out of her reach. During an interview on 8/5/2026 at 1:54 PM with Licensed Vocational Nurse (LVN) 11, LVN 11 stated Resident 140 has left sided weakness, is able to verbalize her needs when she wants to and is able to use her call light to call for help. LVN 11 stated the purpose of a call light is for residents to ask for help and since Resident 140 is unable to get up, it is important to ensure her call light is within reach. LVN 11 further stated if Resident 140's call light was wrapped around the side rail and the soft touch pad was stuck between the side rail and mattress Resident 140 would not be able to retrieve it to ask for staff help. 3. During a review of Resident 9's admission Record (AR), the AR indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 9's diagnoses included hemiplegia (total or severe loss of movement on one side of the body) affecting left dominant side and contracture (a permanent or hard-to-change tightening of muscles, tendons, skin, or other soft tissues that causes joints to become stiff) right hand, and contracture left hand. During a review of Resident 9's Minimum Data Set (MDS, resident assessment tool), dated 5/4/2026, the MDS indicated Resident 9 was severely impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 9 was dependent (helper does all of the effort) with oral hygiene, toileting hygiene, shower/bath self, upper and lower body dressing, putting on/ taking off footwear, roll left and right, sitting to lying and personal hygiene. During observations on 8/3/2026 at 8:58 AM, in Resident 9's room, Resident 9's soft-touch pneumatic nurse call pads (a type of call pad that lights when a pressure was placed) was observed dangling on his right-side bedrail. During an observation on 8/5/2026 at 10:02 AM in Resident 9's room, Resident 9's soft-touch pneumatic nurse call pad/call light was observed on the left upper corner on his mattress, above his head. During a review of Resident 9's Care Plan initiated on 7/30/2026, indicated to promote safe transfers, bed mobility, and repositioning due to impaired mobility, weakness, decreased balance, functional limitations indicated Resident 9's call pad/light and personal belongings are kept within his reach to maintain a safe environment. During a concurrent interview and observations on 8/5/2026 at 10:08 AM in Resident 9's room with Certified Nurse Assistant 7 (CNA 7). CNA7 stated Resident 9's call pad was supposed to be near his hands and close to his chest area for easy reach, so that he can call the nurses when he needs help. During a concurrent interview and observations on 8/5/2026 at 10:12 AM in Resident 9's room with Licensed Vocational Nurse 10 (LVN 10), LVN 10 stated Resident 9's call light was not within resident's reach. LVN 10 also stated the call lights needed to remain within reach of the residents for safety, to prevent falls, and to ensure staff can promptly respond to residents' needs. During an interview on 8/5/2026 at 4:06 PM with the Director of Nursing (DON), the DON stated it was important to ensure call lights were in the reach of residents to prevent accidents, injuries, and so that residents can notify staff when they need assistance. The DON further added if call lights are not within resident's reach, staff will not be able to meet their needs. 4. During a review of Resident 34's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnoses that included hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis that affects just one side of the body) of the left dominant side, muscle weakness and abnormal gait and mobility. During a review of Resident 34's Minimum Data Set (MDS - a resident assessment tool), dated 5/5/2026, the MDS indicated the resident was independent in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, shower/bath self, upper body dressing, lower body dressing, putting on/ taking off footwear and personal hygiene but required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with oral hygiene. During a review of Resident 34's Care Plan (CP) with focus risk for falls, dated 11/10/2025, the CP indicated to place call light within reach while in bed. During a review of Resident 34's CP with focus unwitnessed fall, dated 1/7/2026, the CP indicated call light placed within reach on the right side of the bed. During a review of Resident 34's CP with focus resident uses a pad-style call light, dated 3/12/2026, the CP indicated position call light at the side of resident's head. During a concurrent observation and interview with the Resident 34 and the CNA 4 on 8/3/2026 at 3:08PM in Resident 34's room, Resident 34 was trying to remove his brief and stated he needed to be changed his brief but could not reach the call light to call for assistance. Resident 34's call light was observed tucked into the bed and hanging under the bedrail. CNA 4 stated the call light was not within reach and should not be hanging off the lower portion of the bed rail. 5. During a review of Resident 142 AR, the AR indicated the resident was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with the following but not limited to diagnoses of hemiplegia and hemiparesis on the right and left side, muscle weakness, need for assistance with personal care, and contracted (a permanent or hard-to-fix tightening of muscles, tendons, skin, or other soft tissues that stops a joint from moving normally) right and left hand. During a review of Resident 142's MDS, dated [DATE], the MDS indicated the resident was moderately impaired in cognitive skills for daily decision making. The MDS also indicated the resident was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helper is required for the resident to complete the activity) with eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 142's CP, dated 3/12/2026, the CP indicated to position call light at side of resident's head. During a review of Resident 142's CP, dated 5/21/2026, the CP indicated to ensure call light and personal items are within reach. During a concurrent observation and interview on 8/3/2026 9:49AM in Resident 142's room, Resident 142's was trying to reach his call light that was near his eyebrow. Resident 142 could not reach the call light due to left hand contractures and unable to move the right hand due to paralysis. Resident 142 stated he needed to call for assistance to change his brief, but he could not reach his call light. Resident 142 also stated he could not move his right arm. Licensed Vocational Nurse 5 (LVN 5) stated the call light should be within reach, so the resident is able to call for assistance when needed. During an interview on 8/5/2026 at 11:18AM with the Director of Nursing (DON), the DON stated Resident 142's call light was not within reach was Not ok because the resident would not be unable to call for assistance when needed. 6. During a review of Resident 24's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of generalized muscle weakness (a lack of physical strength that affects most or all of the body rather than just one specific limb or group) and Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscle rigidity, and slow, imprecise movements). During a review of Resident 24's Minimum Data Set (MDS - a resident assessment tool), dated 7/7/2026, the MDS indicated the resident was severely impaired (difficulty with or unable to make decisions, learn, remember things) with cognitive (ability to think, remember, and reason) skills for daily decision making. Resident 24 was totally dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) to requiring substantial/maximal assistance (helper does more than half the effort) for Activities of Daily Living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 24's Care Plan dated 6/16/2026, Resident 24's Care Plan indicated Resident 24 was at risk for falls/injury and included an intervention to place Resident 24's call light within reach while in bed. During a review of Resident 24's Care Plan dated 6/16/2026, Resident 24's Care Plan indicated Resident 24 utilized mechanical lift and total lift for transfer and indicated an intervention to keep light within reach at all times. During a review of Resident 24's Care Plan dated 6/23/2026, Resident 24's Care Plan indicated Resident 24 had ADLs self-care performance deficit related to impaired balance and included an intervention to encourage to use the call light for assistance. During an observation on 8/3/2026 at 9:47 AM inside Resident 24's room, Resident 24 was observed lying on her right side with a foam wedge placed behind her left side. Resident 24's call light was wrapped around the left upper quarter side rail and hanging down the side of the bed out of Resident 24's reach. During a concurrent observation and interview on 8/3/2026 at 10:00 AM with Director of Staff Development Consultant (DSDC) inside Resident 24's room, DSDC stated Resident 24's call light was out of her reach. During an interview on 8/5/2026 at 1:58 PM with Licensed Vocational Nurse (LVN) 11, LVN 11 stated Resident 24 can use her hands/arms to use her call light but if the resident was turned to her right side and the call light was placed behind her or hanging from the left upper quarter side rail, Resident 24 would not be able to reach it because she is unable to reposition herself. LVN 11 further stated that the call light must remain within the resident's reach to prevent injury, ensure her needs are met, and allow staff to respond in case of an emergency. During a concurrent observation and interview on 8/5/2026 at 4:15 PM with the DSDC in Resident 24's room, Resident 24 was observed lying on her right side with a foam wedge placed behind her left side and her call light placed on the bed behind the wedge. When DSDC asked Resident 24 if she could reach the call light, Resident 24 attempted to grab the light but was unable to do so. The DSDC stated the call light was out of her reach and handed the light to her. The DSDC then asked Resident 24 what she would do if she needed help and Resident 24 was observed pressing the call light. During an interview on 8/6/2026 at 2:58 PM with the Director of Nursing (DON), the DON stated the purpose of a call light is so a resident can inform staff when they need help. The DON further stated when a call light is out of reach, a resident will not be able to call for help which puts them at risk for their needs not being met.

Based on observations, interviews, and record reviews, the facility failed to provide appropriate services and treatments to maintain or prevent further decline in joint range of motion (ROM, full movement potential in a joint) for two of 15 sampled residents (Residents 2 and 117) by failing to: 1. Ensure Resident 2 received Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) services to apply and remove both knee extension splints after discharge from physical therapy services on 3/24/2026, resulting in more than four months without the ordered restorative intervention. 2. Ensure Resident 117 received a quarterly joint mobility screen due in April 2026. These deficient practices had the potential to contribute to further decline in joint mobility, worsen contractures (a permanent tightening or shortening of muscles, tendons, skin, or other soft tissues) and functional capacity in Residents 2 and 117. Findings: 1. During a review of the facility's policies and procedures (P&P) revised 7/2017, titled, Restorative Nursing Services, the P&P indicated residents will receive restorative nursing care as needed to help promote optimal safety and independence. During a review of the facility's admission Record (AR), the AR indicated Resident 2 originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to acute and chronic respiratory failure (any condition that affects breathing function and result in lungs not functioning properly) with hypoxia (low oxygen level in tissues) and contracture (loss of motion of a joint) right and left knee. During a review of Resident 2's Minimum Data Set (MDS, resident assessment tool), dated 6/11/2026, the MDS indicated Resident 2 had functional limitations in ROM impairments on both sides of the upper extremity (BUE, shoulder, elbow, wrist, hand) and both sides of the lower extremity (BLE, hip, knee, ankle, foot). The MDS indicated Resident 2 required dependent assistance with oral hygiene, dressing, bathing, and bed to chair transfers. During a review of Resident 2's Physical Therapy Evaluation (PTE), dated 1/11/2026, the PTE indicated Resident 2 had impaired ROM in both hips, knees, and left ankle. The PTE indicated Resident 2 had a long-term goal to safely wear a knee extension splint on the right knee and the left knee for up to four hours with minimal signs and symptoms of redness, swelling, discomfort or pain. During a review of Resident 2's PT Discharge Summary (DC), dated 3/24/2026, the PT DC indicated Resident 2 met the long-term goal to safely wear a knee extension splint on the right knee and the left knee for up to four hours with minimal signs and symptoms of redness, swelling, discomfort or pain. The PT DC indicated a discharge recommendation for a restorative nursing program. During a review of the facility's Order Summary Report (OSR), dated 8/5/2026, the OSR indicated the following physician orders dated 3/25/2026: -RNA for passive range of motion (PROM, movement at a given joint with full assistance from another person) to BLE five times a week as tolerated. -RNA to apply both Theraboots (type of boot to minimize the ankle pointing away from body) for up to four hours, once a day five times a week or as tolerated. During a review of Resident 2's Care Plan (CP), dated 3/24/26, the CP indicated Resident 2 was at risk for decline in ROM of BLE. The CP goal indicated Resident 2 will maintain current ROM of BLEs and prevent further contractures from developing. The CP interventions indicated RNA for PROM to BLE five times a week as tolerated and RNA to apply Theraboot to BLE up to four hours five times a week as tolerated. During an observation on 8/3/2026 at 11:41 AM, Resident 2 was lying in bed and wearing boots on both ankles and feet. Resident 2 had a carrot splint (device shaped like a carrot to help keep the fingers open) in the left hand and wearing a left elbow splint. Resident 2's knees were slightly bent and there were no splints on either knee. During a concurrent interview and record review on 8/4/2026 at 3:52 PM with the Director of Rehabilitation (DOR), Resident 2's PT records and active RNA orders were reviewed. The DOR stated PT discharge Resident 2 on 3/24/2026 with recommendation for RNA program to apply and remove both knee extension splints for four hours daily. The DOR stated Resident 2 currently did not have any RNA orders to apply and take off both knee extension splints. The DOR stated that PT should have ordered RNA treatment on 3/24/2026 to apply and remove both knee splints for four hours, but the order was not entered, resulting in Resident 2 not receiving RNA treatment since that date. The DOR stated without RNA treatment as recommended by PT, Resident 2 had the potential for worsening contracture, which could lead to pressure sores and skin integrity issues if contractures develop or worsen. 2. During a review of the facility's undated policies and procedures (P&P) titled, Therapy Screenings, the P&P indicated residents may receive screenings on a quarterly an annual basis. During a review of the facility's AR, the AR indicated Resident 117 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including, but not limited to chronic respiratory failure (any condition that affects breathing function and result in lungs not functioning properly), hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death) affecting right dominant side, contracture (loss of motion of a joint), and quadriplegia (partial or total loss of use of upper and lower limbs including legs, and arms). During a review of Resident 117's MDS, dated [DATE], the MDS indicated Resident 117 had intact cognition. The MDS indicated Resident 117 had functional limitations in ROM on both sides of the upper extremity (UE, shoulder, elbow, wrist, hand) and both sides of the lower extremity (LE, hip, knee, ankle, foot). The MDS indicated Resident 117 required dependent assistance with oral hygiene, dressing, bathing, and bed to chair transfers. During a review of Resident 117's CP, the CP dated 2/13/26 indicated Resident 117 was at risk for alterations in functional mobility related to quadriplegia. The CP goal indicated Resident 117 will not have a decrease in ROM for 90 days. The CP interventions indicated to monitor for pain and stiffness, monitor for redness, edema, rash around splint area and notify rehab/physician of any changes in ROM or complications. During a review of Resident 117's Joint Mobility Screen (JMS), dated 1/30/2026, the JMS indicated Resident 117 had moderate impairment in ROM in both shoulders and both hands. The JMS indicated Resident 117 had full ROM in both elbows and both wrists. The JMS indicated Resident 117 had full ROM in both hips, both knees, right ankle, and both toes. The JMS indicated Resident 117 had minimal impairment in the left ankle. During a review of Resident 117's JMS, dated 7/21/2026, the JMS indicated Resident 117 had moderate impairment in ROM in both shoulders and both hands. The JMS indicated Resident 117 had full ROM in both elbows and both wrists. The JMS indicated Resident 117 had full ROM in both hips, both knees, right ankle, and both toes. The JMS indicated Resident 117 had minimal impairment in the left ankle. During an observation on 8/3/2026 at 9:12 AM, Resident 117 was lying in bed with both elbows slightly bent and wearing resting hand splints on both wrists and hands. During a concurrent interview and record review on 8/4/2026 at 3:52 PM with the DOR, Resident 117's JMS, dated 1/30/2026 and 7/21/2026, were reviewed. The DOR stated the facility completed JMS on admission and then every quarter. The DOR stated Resident 117 did not receive a quarterly JMS in April 2026. The DOR stated the purpose of a JMS was to identify any changes in joint mobility as early as possible and to intervene as early as possible, During an interview on 8/5/2026 at 3:38 PM, the Director of Nursing (DON) stated a JMS is used to establish a baseline for a resident's joint mobility and to monitor any changes over time. The DON stated that if a resident's joint mobility changes, the facility can report those changes to the physician. The DON stated the facility completes the JMS upon admission, quarterly, and as needed. The DON also stated that if a JMS is missed, the facility may fail to recognize a decline in joint mobility and intervene when necessary.

Based on interview and record review, the facility failed to ensure three (3) of 3 sampled residents (Residents 8, 16 and 114), investigated for nutrition, were receiving the necessary services by failing to: 1. Ensure Resident 8 with renal failure (failure of the kidney to remove excess fluid and toxins in the body) was refereed to Registered Dietician and placed on a renal diet. 2. Ensure Resident 16 was referred to a Registered Dietician as ordered by physician. 3. Ensure Facility did not ensure Resident 114's weight loss was monitored by adding him to weight variance & snacks were ordered per SBAR recommendation on 6/5/26. These deficient practices have to potential to place Residents 8, 16 and 114 at risk of malnutrition (lack of proper nutrition, caused by not eating enough or not on the correct diet), unplanned weight loss, further kidney damage and electrolyte imbalance, hospitalization, and decline in the resident's overall condition. During a review of the facility's policy and procedure (P&P) titled, Weight Management, revised July 2017, the P&P indicated it's purpose, To obtain baseline weight and identify significant weight change and to determine possible causes of significant weight change. The P&P also indicated: In the event of a patterned or significant, unplanned weight loss/gain of at least 2% in a week, 5% in 30 days, 7.5% in 90 days or 10% in 180 days, the following interventions will be carried out: Notification of dietetics professional by nursing staff. The dietetics professional will assess the resident, document the assessment, and make recommendations in the resident's medical record. Orders may be obtained for nutritional supplements or other interventions. During a review of the facility's P&P titled Therapeutic Diet, dated 10/2017, the P&P indicated a therapeutic diet must be prescribed by the resident's attending physician. The attending physician may delegate this task to a registered or licensed dietitian as permitted by state law. During a review of the facility's P&P titled Physician Orders, dated 3/22/2022, the P&P indicated the licensed nurse receiving the order will be responsible for documenting and implementing the order. The P&P also indicated orders pertaining to other health care disciplines will be transcribed onto the appropriate communication system for that discipline. During a review of the facility's job description titled Registered Dietitian, dated 7/2024, the job description indicated one of the duties and responsibilities is to review the dietary requirement of each resident admitted to the facility and assist the attending physician in planning for the resident's prescribed diet plan. The job description also indicated to evaluate and implement recommendations from established committees as they may pertain to food and nutritional services. 1.During a review of Resident 8's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnoses: diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), acute kidney failure (AKF - a sudden loss of kidney function that happens over a few hours or days), disorder of kidney and ureter (medical problem that affects how your kidneys [organs that clean your blood] clean blood or how your ureters [the tubes carrying urine to the bladder] drain waste), and aphasia (a brain disorder that affects how you talk, read, write, and understand what people say). During a review of Resident 8's Care Plan with focus of abnormal labs, dated 5/26/2026, the Care Plan indicated Blood Urea Nitrogen (BUN - measures the amount of urea nitrogen [a waste product created when your body breaks down protein] level of 46 (normal range 7–20 milligrams per deciliter mg/dL for adults,) and creatinine (a waste product made by your muscles from the daily breakdown of a compound) level of 3.3 (normal range 0.7–1.2 mg/dL). The abnormal BUN and creatine high blood level indicated presence of renal failure. During a review of Resident 8's Progress Notes, dated 5/26/2026 at 3:10PM, the progress notes indicated the resident was sent to the general acute care hospital (GACH) for desaturation (reduction in the level of oxygen in the body), increase confusion and general body weakness. During a review of Resident 8's GACH History and Physical (H&P), dated 5/27/2026, the H&P indicated Resident 8 has renal failure (happens when your kidneys stop working well enough to clean waste from your blood). The H&P also indicated Resident 8's laboratory results with a BUN of 63 milligrams per deciliter (mg/dl – unit of measure) (high) and Creatinine of 3.9 mg/dl (high). During an interview on 8/6/2026 at 10:35AM, Resident 8's GACH History and Physical (H&P), dated 5/27/2026, were reviewed. The RD stated the resident has a diagnosis of AKF, and a laboratory result of high BUN and high Creatinine then the resident would be put on a renal diet. RD further stated she was not made aware. During a review of Resident 8's Physician Orders, dated 5/30/2026, the physician orders indicated a diet of carbohydrate-controlled diet (CCHO - a meal plan used for people with diabetes to keep blood sugar stable) pureed (food—like fruits, vegetables, or meat—that has been cooked, mashed, blended, or strained until it is completely smooth, soft, and creamy) texture, moderate thick consistency. During a review of Resident 8's Physician Orders, dated 6/2/2026, the physician orders indicated a diet of CCHO diet pureed texture, moderate thick consistency. During a review of Resident 8's Care Plan with focus AKF, dated 6/12/2026, the care plan indicated the resident will maintain stable renal (relating to, involving, or located near the kidneys) function, and remain free from complications related to AKF. During a review of Resident 8's Minimum Data Set (MDS – a resident assessment tool), dated 7/25/2026, the MDS indicated the resident has modified independence (some difficulty in new situations only) in impaired cognitive (thought process). In addition, the MDS indicated the resident had AKF. During a concurrent interview on 8/6/2026 at 9:06 AM, Resident 8's medical records, the DON stated resident received CCHO diet from 5/18/2026 – 6/10/2026. The DON also stated Resident 8's Hospital inquires, dated 5/26/2026 and 6/6/2026, indicated the resident has AKF. The DON further stated Resident 8's hospital inquiry, dated 6/21/2026, indicated the resident has chronic kidney disease (CKD - your kidneys are hurt and cannot filter blood well) but the resident was not placed in renal diet to prevent further risk for abnormal laboratory test related to kidney failure. During an interview on 8/6/2026 at 10:15AM, the Registered Dietician (RD) stated if the resident has AKF or CKD, the resident should be placed on renal diet. RD also stated she was not made aware of Resident 8's AKF. During an interview on 8/6/2026 at 12:30PM, Registered Nurse 2 (RN 2) stated when admitting the resident, she should have called the doctor informing about Resident 8's diet to get an order for RD consult. RN 2 also stated she just followed the diet orders from the hospital and did not check about the resident's renal failure. During an interview on 8/6/2026 at 2:10PM, Physician 1 stated if the resident has a diagnosis of AKF, a high BUN and high creatinine, then the resident should be on a renal diet with low potassium (mineral found in food) and low sodium (mineral salt) to prevent high level of potassium in the blood which can affect the kidney and heart, and sodium which can cause fluid retention and overload. Physician 1 also stated it can be referred to the RD and to follow the RD recommendations. During an interview on 8/6/2026 at 2:46PM, the Director of Nursing (DON) stated Resident 8 should be on a renal diet for electrolyte imbalance. The DON also stated Resident 8 has a high BUN and high creatinine, so the facility needs to ensure a proper diet is given to Resident 8 but Resident 8 did not get the proper therapeutic diet. 2. During a review of Resident 16's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with the following but not limited to diagnoses of protein-calorie malnutrition (a dangerous health condition caused by not getting enough protein, calories, and other nutrients), dysphagia (difficulty swallowing), hyperlipidemia (high cholesterol or high fats in the blood). During a review of Resident 16's MDS, dated [DATE], the MDS indicated the resident is severely impaired in cognitive skills for daily decision making. The MDS also indicated the resident required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with activities of daily living. During a review of Resident 16's Change in Condition (CIC - any significant or noticeable shift in a person's physical, mental, or functional health that deviates from their usual baseline), dated 7/9/2026, the CIC indicated Resident 16 weigh 96 pounds (lbs – unit of measure) on June 14th , 2026 and weigh 80 lbs on July 6th, 2026. The CIC also indicated RD consult re-weight the resident weekly weight for 4 weeks. During a review of Resident 16's Physician Orders, dated 7/10/2026, the physician orders indicated RD consult. During a review of Resident 16's Care Plan with focus at nutritional risk, revised 7/10/2026, the care plan indicated RD consult as indicated. During an interview on 8/6/2026 at 9:23AM, Resident 16's CIC, dated 7/9/2026, was reviewed. The DON stated Resident 16 had an order for RD consult, and re-weigh the resident weekly for 4 weeks. During an interview on 8/6/2026 at 10AM, RD stated she did not assess Resident 16 for significant weight change of 16 pounds in a month because she was not notified by the facility staff. During an interview on 8/6/2026 at 10:52AM, Resident 16's CIC, dated 7/9/2026, was reviewed. DON stated Resident 16 should have been seen by RD but was not seen. RD also stated it is orders from the doctor that need to be followed. During an interview on 8/6/2026 at 11:35AM, RD stated the Registered Nurse (RN) did inform RD of Resident 16's weight loss but RD did not follow up. RD also stated she should have seen the resident, but RD did not and will follow up today. 3. During a review of Resident 114's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of heart failure (when the heard does not pump blood as well as it should) and end stage renal disease (the final, most severe stage of chronic kidney disease – when the kidneys can no longer support the body's needs). During a review of Resident 114's Mini Nutritional assessment dated [DATE], Resident 114's Mini Nutritional Assessment indicated Resident 114 had a score of 8 indicating he was at risk for malnutrition (getting too few, too many, or the wrong balance of nutrients and calories). During a review of Resident 114's Care Plan dated 5/12/2026, Resident 114's Care Plan indicated Resident 114 had potential for malnutrition as evidenced by Nutritional Screening Tool which indicated Resident 114 was at risk of malnutrition with a Mini Nutritional Assessment score of 8 and indicated interventions to consult the dietician and to monitor weight closely for gain/loss. During a review of Resident 114's Mini Nutritional assessment dated [DATE], Resident 114's Mini Nutritional Assessment indicated Resident 114 had a score of 7 indicating he was malnourished. During a review of Resident 114'S Minimum Data Set (MDS – a resident assessment tool), dated 6/16/2026, the MDS indicated the resident was cognitively intact (ability to think, remember, and reason) with cognitive skills for daily decision making. MDS also indicated Resident 115 needed set up or clean-up assistance (helper sets up or cleans up; resident completes activity) with upper body dressing (the ability to dress and undress above the waist) and eating. During an interview on 8/6/2026 at 7:55 AM with Resident 114, Resident 114 stated he had been losing weight. During a concurrent interview and record review on 8/6/2026 at 9:02 AM with the Registered Dietician (RD), Resident 114's Weights and Vitals Summary (5/9/2026–8/6/2026), SBAR dated 6/5/2026, and Order Summary Report dated 8/6/2026 were reviewed. The weight record showed Resident 114 weighed 160 lbs on 5/9/2026, with a most recent weight of 123 lbs on 8/5/2026. The SBAR documented that on 6/5/2026, Resident 114 had a 20 lb weight loss, equal to 7.5% within two weeks, and recommended to offer snacks and fluids. During the same interview and record review, Resident 114's Order Summary Report indicated no order for offering snacks and fluids to Resident 114. The RD stated because Resident 114 is on dialysis (a medical treatment that cleans the blood and removes extra fluid when the kidneys fail), it was not concerning for her that he had gone from 160 lbs to 123 lbs. The RD stated that after reviewing Resident 114's SBAR documentation, it would be beneficial to offer Resident 114 snacks two to three times per day, and an order should have been entered to implement this intervention. The RD stated there was no order entered to reflect the SBAR recommendation to offer Resident 114 snacks, which would have been important to implement since snacks provide additional calories throughout the day that could help stabilize Resident 114's weight and prevent further decline. During a concurrent interview and record review on 8/6/2026 at 11:47 AM with RD, Resident 114's SBAR documentation dated 6/5/2026 was reviewed. The SBAR indicated the RD would be consulted for Resident 114 due to a 7.5% weight loss within two weeks. The RD stated she was not made aware of the consult and, and had not conducted any weight variance monitoring for the facility over the past three months. The RD stated that following the 6/5/2026 SBAR, she should have been notified, the Nurse Practitioner should have been contacted for new orders, and orders for supplements and snacks should have been added. The RD further stated Resident 114 should have been placed on the weight variance monitoring list to capture any ongoing weight changes and reduce the risk of further weight loss. During an interview on 8/6/2026 at 11:58 PM with the Administrator (ADM), the ADM stated there was no full time RD consultant, and the facility RD was working per diem (as-needed work where an employee is hired and paid by the day only when needed). The ADM added that their regional consultant was available but did not come in every day. During an interview on 8/6/2026 at 1:46 PM with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated he was the one who created the SBAR documentation for Resident 114 on 6/5/2026. LVN 2 stated he could not remember if he notified the RD for consult per Resident 114's SBAR recommendation. During an interview on 8/6/2026 at 2:35 PM with the Director of Nursing (DON), the DON stated they did not have a full-time RD covering and only had coverage from the facility's RD consultant. The DON stated the facility should monitor and follow residents with fluctuating weights and experiencing weight loss and evaluating resident's nutrition and ensuring they are on the correct diets. The DON also stated this deficient practice puts the residents at risk for experiencing weight loss, dehydration and electrolyte imbalance. During a concurrent interview and record review on 8/6/2026 at 2:59 PM, the DON reviewed Resident 114's 6/5/2026 SBAR, which noted a 7.5% weight loss in two weeks and recommended offering snacks and fluids and consulting the RD. The DON stated Resident 114 should have been seen by the RD, added to the weight variance monitoring list, and had snacks ordered. The DON said the failure to follow these recommendations placed Resident 114 at risk for further weight loss.

Based on observation, interview and record review the facility failed to provide appropriate treatment and services to prevent complications related to gastrostomy tube (G-tube, a tube inserted through the abdomen to deliver nutrition and medications directly to the stomach) feeding for two (2) of eight (8) sampled (Resident 24 and 86) reviewed for tube feeding in accordance with the physician's order and facility's policy and procedure by failing to: 1. For Resident 24 the GT feeding was not administered according to the physician's order. This failure had the potential for Residents 24 experiencing fluid overload (when the body has too much water which can raise the blood pressure, force the heart to work harder and make it hard to breathe) which could then also lead to aspiration (when food, liquid or other material enters a person's airway and eventually the lungs by accident which can happen as a person swallows or when food comes back up from the stomach). 2a. Ensure Resident 86's gastrostomy tube was cleaned and replaced on 8/4/2026 before administering medications via g-tube to Resident 86 during medication administration. 2b. Ensure Licensed Vocational Nurse (LVN) 3 maintained clean technique, used gravity method to flush g-tube and did not detach syringe from feeding tube area into the water cup placed on bedside table to pull out water via syringe plunger during g-tube medication administration for Resident 86. These deficient practices increased the risk of contamination (harmful germs like bacteria or fungus have gotten into the feeding tube or the liquid food) and increased risk of infection for Resident 86. Findings; During a review of the facility's policy and procedure (P&P) titled, Enteral Tube Medication Administration, dated October 2017, the P&P indicated its purpose, To safely and accurately administer oral medications through an enteral tube. The P&P also indicated follow specific physician orders regarding liquid amounts and medication administration. During a review of the facility's P&P titled, Enteral Nutrition, dated November 2018, the P&P indicated, Adequate nutritional support through enteral nutrition is provided to residents as ordered. The P&P also indicated the nurse confirms that orders for enteral nutritional are complete including the volume and rate of administration. During a review of facility's P&P titled, Infection Prevention and Control Program, dated 9/18/2024, the P&P indicated, a. Important facets of infection prevention include: 2. Instituting measures to avoid complications or dissemination; 3. Educating staff and ensuring that they adhere to proper techniques and procedures. 1. During a review of Resident 24's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing), oropharyngeal phase (the phase of swallowing where food moves from the back of the mouth through the throat [pharynx] into the top of the feeding tube [esophagus]) and gastro-esophageal reflux disease (GERD - a chronic condition where stomach acid flows back up into the tube connecting your mouth and stomach, causing frequent heartburn and irritation). During a review of Resident 24'S Minimum Data Set (MDS - a resident assessment tool), dated 7/7/2026, the MDS indicated the resident was severely impaired (difficulty with or unable to make decisions, learn, remember things) with cognitive (ability to think, remember, and reason) skills for daily decision making. It indicated, Resident 24 is dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with lower body dressing (the ability to dress and undress below the waist), putting on/taking off footwear and toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). The MDS indicated, Resident 24 also needed substantial/maximal assistance (helper does more than half the effort) with rolling left and right in bed, going from lying down to sitting on the side of the bed, and upper body dressing (the ability to dress and undress above the waist). It further indicated Resident 24 was admitted with a feeding tube (G-tube). During a review of Resident 24's Care Plan dated 6/16/2026, Resident 24's Care Plan indicated Resident 24 had an enteral feeding tube to meet the resident's nutritional needs due to dysphagia and included interventions indicating putting Resident 24 on aspiration precautions. During a concurrent observation and interview on 8/4/2026 at 2:58 PM with Certified Nursing Assistant 1 (CNA 1) inside Resident 24's room, Resident 24's feeding pump displayed a rate of 60 ml (milliliters - a measure of fluid volume)/hr (hour), with 790 minutes remaining, 789 ml formula left and a total of 1273 ml delivered. CNA 1 verified Resident 24's feeding pump indicated the resident had received a total of 1273 ml of formula. During a concurrent observation and interview on 8/4/2026 at 3:02 PM with Assistant Director of Nursing (ADON) inside Resident 24's room, Resident 24's feeding pump displayed a rate of 60 ml/hr, with 786 minutes remaining, 786 ml formula left and a total of 1276 ml delivered. ADON verified Resident 24's feeding pump indicated the resident had received a total of 1276 ml of formula. During a concurrent interview and record review on 8/4/2026 at 3:18 PM with ADON, Resident 24's Order Summary Report dated 8/4/2026 was reviewed. Resident 24's Order Summary Report indicated an enteral feed order initiated on 8/3/2026 for every shift to continuously administer Glucerna 1.2 (feeding formula brand) at 60 ml/hr x 20 hours via (by) G-tube to provide 1200 ml/1440 kcal (unit of energy) in 24 hours. On at 2:00 PM and off at 10:00 AM if preset dose limit. ADON stated Resident 24's feeding pump indicated Resident 24 received a total of 1276 ml of formula which is more than the ordered dose total of 1200 ml in 24 hours. ADON further stated if the resident receives more than the ordered dose of feeding, it could result in the resident having gastrointestinal complications such as nausea, vomiting, diarrhea and/or aspiration. During an interview on 5/6/2026 at 2:47 PM with the Director of Nursing (DON), the DON if Resident 24's order is for the resident to receive 1200 ml total feed and the pump displays 1276 ml total fed, it indicated Resident 24 was overfed and the resident would exceed the requirement ordered with Resident 24 at risk for weight gain and fluid overload. 2. During a review of Resident 86's admission Record, dated 8/5/2026, the admission record indicated Resident 86 was admitted to the facility on [DATE] with diagnoses that included but not limited to dysphagia, oropharyngeal phase (trouble starting a swallow because nerves or muscles in the mouth and throat do not work right), anemia (blood lacks enough healthy red blood cells or hemoglobin to carry adequate oxygen to body's tissues), hyperlipidemia, unspecified, hypokalemia (low levels of potassium) and other specified postprocedural states. During a review of Resident 86's History and Physical (H&P) dated 4/16/2026, the H&P indicated Resident 86 had the capacity to understand and make decisions. During a review of Resident 86's MDS, dated [DATE], the MDS indicated Resident 86 needed moderate assistance for performing activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as oral hygiene, upper body dressing and personal hygiene, maximal assistance for showering, and dependent on facility staff for performing ADLs such as toileting hygiene, lower body dressing and putting on or taking off footwear. During a concurrent medication administration observation and interview on 8/4/2026 between 9:15 AM and 10:04 AM, LVN 3 prepared the six medications to be administered to Resident 86 via g-tube. LVN 3 stated she would use 30 milliliters ([mL] a metric unit of measurement, used for medication dosage and/or amount) water in between medications and 30 mL water to dissolve each medication, flush with 30 mL water before and after administered medications. LVN 3 was then observed, and she stated she pulled out approximately five (5) mL of residual. LVN 3 did not flush the g-tube syringe with water. LVN 3 administered Glucerna (a nutrition shake and meal supplement) via g-tube into feeding tube by gravity method (a way to send formula and medications into the feeding tube by the force of gravity). LVN 3 then administered cholestyramine (a medication used to treat chronic diarrhea [loose stool] and high cholesterol [a fat-like substance found in cells]) 4 grams ([gm] a metric unit of measurement, used for medication dosage and/or amount) powder that was dissolved in 180 mL of water, via gravity method into feeding tube. LVN 3 then detached the g-tube syringe from feeding tube, brought the g-tube syringe into a cup of water on bedside table, measured 30 mL water by pulling on to the syringe plunger from the water cup, then attached the g-tube syringe to feeding tube and flushed the feeding tube using the syringe with 30 mL water. LVN 3 administered three more medications via gravity method. LVN 3 then performed the same steps as described above by removing the g-tube syringe from feeding tube, bringing g-tube syringe to a water cup, pulling out 30 mL water using the plunger and attaching the syringe back to feeding tube to flush feeding tube with water in syringe. During a concurrent observation and interview on 8/4/2026 at 10:04 AM, LVN 3 showed the g-tube syringe package that indicated g-tube syringe was last changed on 8/3/2026. LVN 3 stated she should have flushed the feeding tube with water before administering Glucerna and also that the syringe was not changed on 8/4/2026 before medications were administered. LVN 3 stated she increased the risk of contamination by removing the g-tube syringe out of the feeding tube and using it to pull out water from water cup on bedside table. During an interview on 8/4/2026 at 1:14 PM and 1:36 PM with LVN 3, LVN 3 stated she (LVN 3) did not flush the feeding tube with 30 mL water after pulling out residual in feeding tube and before administering Glucerna into feeding tube via g-tube syringe via gravity method. LVN 3 it was important to flush feeding tube with water to make sure that g-tube was not clogged and to ensure medications moved smoothly through feeding tube. LVN 3 stated she should have continued to pour water to flush the feeding tube via gravity method instead of pulling out with plunger from the water cup because that increased the risk of contamination. LVN 3 stated the g-tube syringe should be changed every day to prevent contamination and to keep medication administration clean because medications could be different for morning and night. During an interview on 8/6/2026 at 11:30 AM with the Director of Nursing (DON), the DON stated the g-tube syringe should be changed every 24 hours to prevent risk of infection. The DON stated the licensed nurse was supposed to flush the g-tube with water before administering Glucerna and other medications to maintain g-tube patency and to prevent clogging of g-tubes. The DON stated g-tube syringe should not be removed from the resident's feeding tube area to the bedside medication cart area. The DON stated the licensed nurse should have left the syringe on g-tube/feeding tube to flush it with water using gravity method, to prevent infection risk.

Based on observation, interview, and record review, the facility failed to: 1. Ensure medications were administered in a timely manner, within 60 minutes of scheduled time (one (1) hour before and one (1) hour after) for eight of 26 residents of Station 1 on 8/4/2026, as per facility's policy and procedure (P&P) titled, Medication Administration - General Guidelines, dated 10/2017. 2. Clarify physician orders with overlapping pain scale for one of seven residents' (Resident 31's) hydrocodone (a controlled medication [medications that the use and possession of are controlled by the federal government] in combination with acetaminophen [APAP - a medication used to treat pain] used to treat severe pain). 3. Ensure one of four inspected medication carts (Station 1 Medication Cart 2) maintained accurate documentation of Resident 67's pregabalin (a controlled medication used to treat fibromyalgia [pain in muscles and soft tissues] related pain, neuropathic (nerve related) pain and a subset of seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) on accountability record or controlled medication count sheet/controlled drug record ([CDR] - a document indicating perpetual inventory and administration of controlled substances) after pregabalin was administered by Licensed Vocational Nurse (LVN) 4. 4. Ensure Resident 21's Levofloxacin (a medication used to treat bacterial infections) was administered in accordance with physician's orders, affecting one of four inspected medication carts (Station 4 Medication Cart 4). These deficient practices of failing to provide medications in a timely manner in accordance with physician's orders or professional standards of practice, clarify opioid (a class of drugs associated with high potential for dependency and overdose) orders and account for the use of controlled medications, placed Residents 21, 31, 67 and eight other facility's residents at an increased risk of hypertension (high blood pressure), abnormal blood glucose levels, potential opioid overdose, medication errors, unintended use and loss of controlled medications, respiratory depression (trouble breathing), progression of infection, sepsis and hospitalization. Findings: During a review of facility's P&P titled, Medication Administration - General Guidelines, dated 10/2017, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices.do so.The facility has sufficient staff to allow administering of medications without unnecessary interruptions. The P&P indicated, Medications are administered in accordance with written orders of the attending physician. Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after).on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. The P&P indicated, If a dose seems excessive considering the resident's age and condition, or a medication order seems to be.the nurse calls the provider pharmacy for clarification prior to administration.clarification. The interaction with the pharmacy and/or.as appropriate. During a review of facility's P&P titled, Controlled Substances, dated 11/2022, the P&P indicated, Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records; and d. Destruction, waste and return to pharmacy records. 1. During a concurrent observation and interview on 8/4//2026 between 9:15 AM and 10:04 AM with Licensed Vocational Nurse (LVN) 3, LVN 3 prepared and administered six medications to Resident 86. After medications were administered to Resident 86, the Director of Nursing (DON) stated another licensed nurse could assist LVN 3 with medication pass because it was already after 10:00 AM and there were more residents needed to receive medications that were scheduled for 8/4/2026 at 9:00 AM. During an interview on 8/4/2026 at 1:47 PM with LVN 3, LVN 3 stated she was working at Station 1 for the first time, and she was called into work to help facility with staffing. LVN 3 stated she was supposed to administer medications for 26 residents, three of whom were on g-tube, and she had two hours to administer medications and so we probably need more nursing staff. LVN 3 stated she was also training another licensed nurse (LVN 7) which slowed her down. LVN 3 stated, if the medications were given late, the effectiveness of medications would be affected and residents would not receive the benefits of medications, for example, if a resident was receiving high blood pressure medication and it was administered late, that would place resident at risk for high blood pressure, stroke (cerebrovascular accident [CVA], loss of blood flow to a part of the brain), heart attack and hospitalization. During a review of the report of residents who received medications later than 10 AM on 8/4/2026, the report indicated there were eight residents (Residents 107, 156, 138, 20, 71, 165, 24 and 161), two of which (Residents 24 and 20) received their respective medications before 10:30 AM on 8/4/2026. The medications that were administered after 10:30 AM on 8/4/2026 for six out of 26 residents (Residents 107, 156, 138, 20, 71, 165) included medications that were prescribed to treat conditions such as hypertension, diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), stroke prevention, congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), deep venous thrombosis (blood clot in deep vein such as in the lower leg or thigh) prevention and pain. During an interview on 8/6/2026 at 11:20 AM with the DON, the DON stated if medications were administered late, then they would have delayed efficacy. The DON stated they informed the physician and it was okay to administer medications for those residents as late as noon for that day. 2. During a review of Resident 31's admission Record (a document containing demographic and diagnostic information), dated 8/5/2026, the admission record indicated Resident 31 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to multiple myeloma (a rare cancer of plasma cells) not having achieved remission, fusion of spine thoracic region (a surgical operation that joins two or more mid-back bones), neoplasm (abnormal growth) of unspecified behavior of bone, soft tissue, and skin, pathological fracture (a broken bone because of an underlying disease or condition) in neoplastic disease and stable burst fracture (a bone fracture but some parts stay whole) of second lumbar vertebra. During a review of Resident 31's History and Physical (H&P) dated 8/1/2026, the H&P indicated Resident 31 had the capacity to understand and make decisions. During a concurrent observation and interview on 8/4/2026 at 2:09 PM with LVN 4, LVN 4 was observed preparing two medications for Resident 31. LVN 4 stated Resident 31 complained of pain in lower mid-back and described pain level of six (6)/10 or seven (7)/10 if sitting still but at 9 (nine)/10 or 10/10 when he moved. LVN 4 was observed taking Resident 31's blood pressure twice. LVN 4 stated the blood pressure reading was 98/59 (systolic blood pressure [SBP - measures the pressure in the arteries when the heart contracts to pump blood] at 98) and (diastolic blood pressure [DBP - measures the pressure in the arteries when the heart muscle relaxes between beats] at 59 and heart rate (HR) was at 94 beats per minute on 8/4/2026 at 2:14 PM. LVN 4 was observed taking Resident 31's BP again and stated the blood pressure reading was 112/72 and HR at 95 on 8/4/2026 at 2:15 PM. LVN 4 prepared the following two medications to be administered to Resident 31: a. One (1) tablet of hydrocodone-APAP 10-325 mg by mouth, with instructions every 6 (six) hours as needed for severe pain 8-10. b. One (1) tablet of methocarbamol (a medication used to relax and treat muscle spasms) by mouth 500 mg During a medication reconciliation review of Resident 31's Order Summary Report (a document containing a summary of all active physician orders), dated 8/5/2026, the order summary report indicated but not limited to the following physician orders: Hydrocodone-Acetaminophen oral tablet 10-325 milligram ([mg] metric unit of measurement, used for medication dosage and/or amount), give 1 (one) tablet by mouth every 6 (six) hours as needed for severe pain (seven [7]) out of 10 on a 10 scale), order date 7/29/2026, start date 7/29/2026. Hydrocodone-Acetaminophen oral tablet 5-325 mg, give 1 tablet by mouth every 6 hours as needed for severe pain (8-10) hold if respiratory rate is below 12 breaths per minute. Not to exceed three (3) grams ([gm] metric unit of measurement, used for medication dosage and/or amount) of acetaminophen in 24 hours from all sources and call doctor if ineffective, order date 7/29/2026, start date 7/29/2026. Acetaminophen tablet 325 mg, give 1 tablet by mouth every 4 (four) hours as needed for mild pain (1-4), not to exceed 3 gm of acetaminophen in 24 hours from all sources and call doctor if ineffective, order date 7/29/2026, start date 7/29/2026. Acetaminophen tablet 325 mg, give 2 (two) tablets by mouth every 4 hours as needed for moderate pain (5-7), not to exceed 3 gm of acetaminophen in 24 hours from all sources and call doctor if ineffective, 2 tablets = 650 mg, order date 7/29/2026, start date 7/29/2026. LVN 4 was not available for an interview on 8/5/2026. During a concurrent interview and record review on 8/5/2026 at 11:30 AM with Registered Nurse (RN) 2, the active physician orders for hydrocodone-APAP for Resident 31 and Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 8/1/2026 to 8/5/2026 and 7/1/2026 to 7/31/2026 were reviewed. The active orders for hydrocodone-APAP indicated an overlapping pain scale for 5-325 mg as needed for severe pain (8-10) and 10-325 mg dose as needed for severe pain (7-10). RN 2 stated both orders had same instructions so that was a duplication of therapy. RN 2 stated one of the orders should have said for moderate pain and the other for severe pain. RN 2 stated there was a risk that one nurse might follow the instructions to give hydrocodone-APAP 10-325 mg for severe pain and another nurse might follow instructions to give hydrocodone-APAP 5-325 mg for severe pain. RN 2 stated there was a risk of double dosing the medication, and also the resident did not have a medication to cover for moderate pain, so now the nursing staff was only giving medications for severe pain. RN 2 stated, since hydrocodone-APAP was an opioid, this placed Resident 31 at risk for potential overdose, respiratory depression, breathing difficulty, drowsiness and sedation. During an interview on 8/6/2026 at 11:56 AM with the DON, the DON stated there was a risk that the resident could receive lesser of the dose or could be higher than required dose for pain because there was an overlapping pain scale in the order instructions for hydrocodone-APAP 10-325 mg and hydrocodone-APAP 5-325mg. The DON stated opioids especially if administered concurrently with methocarbamol (in this situation) had the risk to cause hospitalization due to sedation and respiratory depression. 3. During a review of Resident 67's admission Record, dated 8/4/2026, the admission record indicated Resident 67 was admitted to the facility on [DATE] with diagnoses that included but were not limited to generalized muscle weakness and other symptoms and signs involving the musculoskeletal system. During a review of Resident 67's H&P dated 7/24/2026, the H&P indicated Resident 67 did not have decision making capacity. During a review of Resident 67's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 7/27/2026, the MDS indicated Resident 67's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was moderately impaired. The MDS indicated Resident 67 needed setup or clean-up assistance from the facility staff for performing activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as eating, and moderate assistance for oral hygiene, toileting hygiene, showering, upper body dressing, lower body dressing and putting on or taking off footwear. During a review of Resident 67's Order Summary Report, dated 8/4/2026, the order summary report indicated but were not limited to the following physician orders: Pregabalin oral capsule 75 mg, give 1 capsule by mouth three times a day for nerve pain, order date 7/23/2026, start date 7/24/2026. During a concurrent inspection, interview and record review on 8/4/2026 at 3:04 PM with LVN 4 of Station 1 Medication Cart 2, Resident 67's pregabalin 75 mg bubble packs (sealed card containing individual, daily, or weekly doses of medication in clear, push-through plastic bubbles) for morning AM, Noon and evening PM, facility's controlled medication count sheet (CDR) and the medication administration details in electronic medical record (eMAR) for pregabalin 75 mg were reviewed. Resident 67's pregabalin AM bubble pack contained four capsules, the Noon bubble pack contained 12 capsules, and the PM bubble pack contained 14 capsules, for a total quantity of 30 capsules. The facility's CDR indicated a quantity of 31 capsules remaining with the last dose documented as administered on 8/4/2026 and no time was documented. The administration details in eMAR indicated the following for 8/4/2026: a. One capsule of pregabalin 75 mg: Scheduled for 8/4/2026 9:00 AM, Effective Date: 8/4/2026 9:00 AM, Documented: 8/4/2026 10:50 AM by LVN 4. b. One capsule of pregabalin 75 mg: Scheduled for 8/4/2026 1:00 PM, Effective Date: 8/4/2026 12:22 PM, Documented: 8/4/2026 12:22 PM by LVN 4. LVN 4 stated she (LVN 4) forgot to document in the narcotic book and they like us to sign the book first and then sign off the MAR. LVN 4 stated there was a risk of medication error and medication overdose and/or resident might not get treated for pain. During an interview on 8/6/2026 at 12:02 PM with the DON, the DON stated the licensed nursing staff should sign the book after the controlled medication was popped and then document in MAR after medication was administered. The DON stated it was important to ensure accurate reconciling of controlled medications, and to prevent medication errors because if another nurse went in after this discrepancy and thought that the medication was not given, it could mislead them into giving the medication. The DON stated this could also place the resident at risk for sedation. 4. During a review of Resident 21's admission Record, dated 8/5/2026, the admission record indicated Resident 21 was admitted to the facility on [DATE] with diagnosis that included but was not limited to urinary tract infection. During a review of Resident 21's H&P dated 4/17/2026, the H&P indicated Resident 21 had the capacity to understand and make decisions. During a review of Resident 21's MDS dated [DATE], the MDS indicated Resident 21's cognition was intact. The MDS indicated Resident 21 needed setup or clean-up assistance from the facility staff for ADLs such as eating, supervision level assistance for oral hygiene and personal hygiene, moderate assistance for toileting hygiene, showering, upper body dressing, lower body dressing and maximal assistance for putting on or taking off footwear. During a review of Resident 21's Order Summary Report, dated 8/5/2026, the order summary report indicated but was not limited to the following physician order: Levaquin tablet 250 mg (generic name - levofloxacin), give 1 tablet by mouth one time a day for diagnosis of urinary tract infection (UTI) for 6 days, order date 8/2/2026, start date 8/3/2026, end date 8/9/2026. During a concurrent inspection, interview and record review on 8/5/2026 at 12:47 PM with LVN 5 of Station 4 Medication Cart 4, Resident 21's levofloxacin 250 mg bubble pack for morning AM, facility's medication count sheet and the medication administration details in electronic medical record (eMAR) for levofloxacin 250 mg were reviewed. Resident 21's levofloxacin 250 mg AM bubble pack contained four tablets. The facility's medication count sheet indicated a quantity of three tablets remaining with the last dose documented as administered on 8/5/2026 at 9:00 AM. The administration details in eMAR indicated one tablet of levofloxacin 250 mg was administered on 8/5/2026 at 8:40 AM. LVN 5 stated, I did not punch it so probably did not give the medication ,I probably did not give the medication, I must have forgotten to pop the medication. LVN 5 stated the levofloxacin should not be documented as administered if it was not administered to the resident. LVN 5 stated this placed Resident 21 at risk for untreated UTI and hospitalization. LVN 5 stated she would call the physician to check if she (LVN 5) could administer levofloxacin because it was not administered on 8/5/2026 at 9:00 AM. During a review of Resident 21's Medication Administration Audit Report dated 8/5/2026, the report indicated levofloxacin 250 mg was administered and documented as administered to Resident 21 on 8/5/2026 at 9:00 AM and 8/5/2026 at 2:05 PM by LVN 5. During a review of Resident 21's Care Plan Report, dated 8/2/2026, the care plan indicated, Resident had UTI related to bacterial infection Streptococcus agalactiae (a type of microorganism or bacteria) and interventions indicated, administer Levaquin 250 mg tablet by mouth once daily for 7 days as prescribed.During a review of Resident 21's Progress Notes dated 8/5/2026 at 1:28 PM, the progress notes indicated, called and notified the physician, notified that Resident 21 missed her Levaquin dose at 9 AM.new order to may give now, noted and carried out. During an interview on 8/6/2026 at 12:05 PM with the DON, the DON stated there was a risk of ineffective treatment of infection and worsening of infection, and there is a risk of hospitalization and health complications. The DON stated the facility would have undertreated the patient if the next nurse thought levofloxacin was administered to the resident, when it was not administered to the resident.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5 (five) percent during medication pass for three of seven sampled residents (Residents 19, 86 and 68) by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 3 checked Resident 19's respiratory rate (the number of breaths a person takes per minute, typically measured when at rest) in accordance with physician's orders, before administering oxycodone (a controlled medication [medications that the use and possession of are controlled by the federal government] used to treat severe pain). 2. Ensure Resident 86's cholestyramine (a medication used to treat chronic diarrhea [loose stool] and high cholesterol [a fat-like substance found in cells]) was administered separately and at a different time from other medications in accordance with manufacturer specifications, and potassium chloride (a medication used to treat low levels of potassium) was diluted with cold water according to physician's orders before administering via g-tube. 3. Ensure Resident 68's vitamin D (a vitamin used to treat low level of vitamin D and to support immune system and bone and muscle health) was administered in the correct dose in accordance with physician's orders. These deficient practices failed to administer medications in accordance with physician's orders, manufacturer's specifications and professional standards of practice, which resulted in a medication error rate of 15.38 percent, exceeding the 5 percent threshold, and placed Residents 19, 68 and 86 at risk for respiratory depression, g-tube occlusion, gastrointestinal (GI) tract irritation, fatigue, resident discomfort and hospitalization.Findings: During a review of facility's P&P titled, Medication Administration - General Guidelines, dated 10/2017, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices.do so.The facility has sufficient staff to allow administering of medications without unnecessary interruptions. The P&P indicated, Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) is compared with the medication label. If the label and MAR are different .the physician's orders are checked for the correct dosage schedule. The P&P indicated, Medications are administered in accordance with written orders of the attending physician. During a review of facility's P&P titled, Controlled Substances, dated 11/2022, the P&P indicated, Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records; and d. Destruction, waste and return to pharmacy records. 1. During a review of Resident 19's admission Record (a document containing demographic and diagnostic information) dated 8/5/2026, the admission record indicated Resident 19 was admitted to the facility on [DATE] with diagnoses that included but were not limited to fracture (a broken bone because of an underlying disease or condition) of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing and encounter for other orthopedic aftercare. During a review of Resident 19's History and Physical (H&P) dated 7/21/2026, the H&P indicated Resident 19 had decision making capacity. During a review of Resident 19's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 7/27/2026, the MDS indicated Resident 19's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was intact. The MDS indicated Resident 19 needed setup or clean-up assistance from the facility staff for performing activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as eating, and moderate assistance for oral hygiene, showering, upper body dressing and personal hygiene, and needed maximal assistance for ADLs such as toileting hygiene, lower body dressing and putting on or taking off footwear. During a concurrent observation and interview on 8/4/2026 at 8:44 AM with LVN 3, LVN 3 was observed preparing one medication to be administered to Resident 19. LVN 3 stated she had checked Resident 19's vital signs on 8/4/2026 at 8:42 AM and the blood pressure reading was 147/76 (systolic blood pressure [SBP - measures the pressure in the arteries when the heart contracts to pump blood] at 147) and (diastolic blood pressure [DBP - measures the pressure in the arteries when the heart muscle relaxes between beats] at 76 and heart rate (HR) was at 57 beats per minute. LVN 3 was not observed checking for Resident 19's respiratory rate before administering oxycodone 10 mg. LVN 3 stated Resident 19 had pain level of 8/10 in left hip. LVN 3 prepared the following medication: a. One tablet of oxycodone 10 mg by mouth with instructions every 4 hours as needed for severe pain. During a medication reconciliation review, Resident 19's Order Summary Report (a document containing a summary of all active physician orders) dated 8/5/2026, indicated but were not limited to the following physician orders: Oxycodone hydrochloride (HCl) oral tablet 10 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount), give 1 tablet by mouth every 4 hours as needed for diagnosis (Dx): left hip fracture status/post (s/p) open reduction and internal fixation (ORIF - when surgeons realign severe broken bones), severe pain (8-10) hold if sedated or respiratory rate (RR) less than 12, order date 7/23/2026, start date 7/23/2026. Oxycodone HCl oral tablet 5 (five) mg, give 1 tablet by mouth every 4 (four) hours as needed for Dx: left hip fracture S/P ORIF, moderate pain (5-7), hold if sedated or RR less than 12, order date 7/23/2026, start date 7/23/2026. During a review of Resident 19's Care Plan Report, dated 7/22/2026, the care plan indicated, Focus: black box warning (strictest safety notice required by the U.S. Food and Drug Administration [FDA] for prescription drugs, to highlight severe, life-threatening or disabling risks) for use of oxycodone.Interventions: Administer oxycodone as prescribed.Monitor respiratory rate and level of consciousness.monitor for signs of respiratory depression. During an interview on 8/4/2026 at 1:14 PM with LVN 3, LVN 3 LVN stated the order instructions for Resident 19's oxycodone indicated to hold the medication if Resident 19 was sedated or if respiratory rate was less than 12. LVN 3 stated she checked vitals such as blood pressure and heart rate, but she (LVN 3) did not check Resident 19's respiratory rate. LVN 3 stated Resident 19 was also on oxycodone 5 mg every 4 hours as needed for moderate pain. LVN 3 stated if RR was lower than 12 that would place Resident 19 at risk for respiratory depression, which could be life-threatening and requiring hospitalization. During an interview on 8/6/2026 at 11:25 AM with the Director of Nursing (DON), the DON stated it was important to check the resident's RR because oxycodone was an opioid and could cause respiratory depression and we wouldn't want to sedate residents further if they were already sedated and if respiratory rate was less than 12. The DON stated, the licensed nurse should have followed physician's orders and assessed respiratory rate prior to the administration of oxycodone and if the RR was outside of parameters, then oxycodone should have been held, and physician could be called depending on the situation. 2. During a review of Resident 86's admission Record dated 8/5/2026, the admission record indicated Resident 86 was admitted to the facility on [DATE] with diagnoses that included but not limited to dysphagia, oropharyngeal phase (trouble starting a swallow because nerves or muscles in the mouth and throat do not work as they should), anemia (blood lacks enough healthy red blood cells or hemoglobin to carry adequate oxygen to body's tissues), hyperlipidemia, unspecified, hypokalemia (low levels of potassium) and other specified postprocedural states. During a review of Resident 86's H&P dated 4/16/2026, the H&P indicated Resident 86 had the capacity to understand and make decisions. During a review of Resident 86's MDS dated [DATE], the MDS indicated Resident 86 needed moderate assistance for performing ADLs such as oral hygiene, upper body dressing and personal hygiene, maximal assistance for showering, and dependent on facility staff for performing ADLs such as toileting hygiene, lower body dressing and putting on or taking off footwear. During a concurrent medication administration observation and interview on 8/4/2026 between 9:15 AM and 10:04 AM with LVN 3 and LVN 7 (trainee), LVN 3 prepared the following six medications to be administered to Resident 86 via g-tube. LVN 3 stated she would use 30 milliliters ([mL] a metric unit of measurement, used for medication dosage and/or amount) water in between medications and 30 mL water to dissolve each medication, flush with 30 mL water before and after administered medications. LVN 3 stated and she was then observed pulling out approximately five (5) mL of residual. LVN 3 did not flush the g-tube syringe with water. LVN 3 administered Glucerna (a nutrition shake and meal supplement) via g-tube into feeding tube by gravity method (a way to send formula and medications into the feeding tube by the force of gravity). LVN 3 did not flush feeding tube with water. LVN 3 was then observed administering cholestyramine 4 (four) gram ([gm] a metric unit of measurement, used for medication dosage and/or amount) powder that was dissolved in 180 mL of water, via gravity method into feeding tube. LVN 3 did not dilute the potassium chloride with water as instructed on physician's order and pharmacy label before administering potassium chloride via g-tube. a. One tablet of vitamin C (a medication used to support wound healing and treat low levels of vitamin C) 500 mg, crushed individually and dissolved in water before administering via g-tube. b. One packet of cholestyramine (a medication used to treat chronic diarrhea [loose stool] and high cholesterol [a fat-like substance found in cells]) 4 gram ([gm] a metric unit of measurement, used for medication dosage and/or amount) powder that was dissolved in 180 mL of water. c. Five milliliters ([mL] a unit of measurement for volume) of levetiracetam (a medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) 100 mg/mL. d. One tablet of metoprolol tartrate (a medication used to treat high blood pressure and heart conditions) 25 mg with instructions to hold medication if BP was less than 100 or HR was less than 60 (crushed individually and dissolved in water before administering via g-tube). e. Six mL of potassium chloride 10 percent (20 milliequivalent [mEq] a unit of measurement for dose per 15 mL), with instructions to dilute with 4 ounces of cold water. f. Five mL of valproic acid (a medication used to treat seizures) 250 mg/5mL. During a concurrent observation and interview on 8/4/2026 at 10:04 AM, LVN 3 stated she did not and should have flushed the feeding tube with water before administering Glucerna and also before administering cholestyramine to make sure g-tube did not get clogged and to ensure medications moved smoothly. LVN 3 stated she also did not dilute potassium chloride solution with 4 ounces of water as instructed on physician's order. LVN 3 stated she did not know that cholestyramine was supposed to be separated from other medications and would need to check with supervisor. According to manufacturer's package labeling for Cholestyramine, the labeling indicated, Since cholestyramine resin may bind other drugs given concurrently, it is recommended that patients take other drugs at least 1 hour before or 4 to 6 hours after cholestyramine resin (or at as great an interval as possible) to avoid impeding their absorption. According to manufacturer's package labeling for potassium chloride solution, the labeling indicated, dilute the potassium chloride solution with at least 4 ounces of cold water.Gastrointestinal irritation: may cause gastrointestinal irritation if administered undiluted. Increased dilution of the solution and taking with meals may reduce gastrointestinal irritation. During a review of Resident 86's Order Summary Report dated 8/5/2026, the order summary report indicated but were not limited to the following physician orders: Cholestyramine oral packet 4 gm, give 1 packet via g-tube one time a day for diagnosis (dx): diarrhea, mix each packet with 180 mL of water/juice, order date 5/14/2026, start date 5/15/2026. Potassium Chloride liquid 20 mEq /15 mL (10 percent) give 6 mL via g-tube one time a day for Dx: hypokalemia (low potassium level), dilute with 4 ounces of cold water, order date 4/15/2026, start date 4/16/2026. During a review of Resident 86's Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 8/1/2026 to 8/4/2026, the cholestyramine was administered daily at the same time as other medications at 9:00 AM. During a review of Resident 86's MAR dated 7/1/2026 to 7/31/2026, the cholestyramine was administered daily at the same time as other medications at 9 AM. During an interview on 8/6/2026 at 11:40 AM with the DON, the DON stated it was important that the licensed nurse followed manufacturer guidelines to ensure cholestyramine was not given along with other medications to prevent binding of cholestyramine with other medications that would make them less effective. The DON stated the licensed nurse did not dilute the potassium chloride solution with water as instructed in physician orders, which increased the risk of GI irritation for the resident. During an interview on 8/6/2026 at 12:59 PM with the Consultant Pharmacist (RPH 1), RPH 1 stated that the cholestyramine packet should be mixed with six to eight ounces ([oz] a unit of measurement for volume) of liquid and via g-tube. RPH 1 stated the nursing staff should administer cholestyramine and wait to administer other medications. RPH 1 stated the other medications should be given one hour before cholestyramine or four hours after cholestyramine. RPH 1 stated it was important to separate the medications from cholestyramine because cholestyramine could decrease absorption of other medications or delay the movement of other medications. 3. During a review of Resident 68's admission Record, dated 8/13/2026, the admission record indicated Resident 68 was admitted to the facility on [DATE] with diagnoses that included but were not limited to other lack of coordination and other abnormalities of gait and mobility. During a review of Resident 68's MDS dated [DATE], the MDS indicated Resident 68's cognition was intact. The MDS indicated Resident 68 needed setup or clean-up assistance from the facility staff for ADLs such as eating and oral hygiene, supervision assistance for personal hygiene, moderate assistance for toileting hygiene, showering, upper body dressing and maximal assistance for lower body dressing and putting on or taking off footwear. During a concurrent observation and interview on 8/5/2026 at 8:49 AM with LVN 6, LVN 6 prepared the following four medications to be administered to Resident 68. LVN 6 stated Resident 68's blood pressure was 158/102, heart rate was 92, and pain level was at 8 or 9 but did not want hydrocodone (a controlled medication [medications that the use and possession of are controlled by the federal government] in combination with acetaminophen [APAP - a medication used to treat mild-to-moderate pain] used to treat severe pain) and requested acetaminophen. a. One capsule of gabapentin (a medication used to treat nerve pain) 300 mg. b. One tablet of amlodipine (a medication used to treat high blood pressure) 10 mg with instructions to hold medication if SBP was less than 110 or HR was less than 60 mm Hg. c. Two tablets of acetaminophen (a medication used to treat pain and fever) 325 mg. d. One capsule of vitamin D 25 microgram ([mcg] a unit of measurement for mass) During a review of Resident 68's Order Summary Report, dated, the order summary report indicated but were not limited to the following physician order: Cholecalciferol tablet 1000 units, give 2 tablets by mouth one time a day for supplement, order date 1/9/2026, start date During an interview on 8/5/2026 at 12:19 PM with LVN 6, LVN 6 stated she made a medication error in giving vitamin D to Resident 68 because he was supposed to receive two capsules of vitamin D 25 mcg. LVN 6 stated although it was vitamin D and it's a supplement, would not have lot of side effects, but it was for bones and Resident 68 could show low levels of vitamin D if he was not receiving the correct dose consistently and could feel weak. During an interview on 8/6/2026 at 11:53 AM with the DON, the DON stated, vitamin D should be administered as per physician orders because low levels of vitamin D could cause anemia and fatigue.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and distribution practices by failing to: 1. Ensure to store potentially hazardous foods outside of the temperature danger zone (41-135 degrees Fahrenheit [ F]), where harmful bacteria can multiply rapidly. 2. Ensure to discard produce by the labeled use by date. 3. Ensure to remove unlabeled and expired food from the resident refrigerator. These failures had the potential to contribute to harmful bacterial growth which could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or toxins) in 122 of 150 residents. 1. During a review of the 2022 FDA Food Code, Annex 3 section 3-601.16 titled Time/Temperature Control for Safety Food, Hot and Cold Holding the FDA food code indicated that bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature danger zone (41-135 F) too long. Up to a point, the rate of growth increases with an increase in temperature within this zone. Beyond the upper limit of the optimal temperature range for a particular organism, the rate of growth decreases. Operations requiring heating or cooling of food should be performed as rapidly as possible to avoid the possibility of bacterial growth. During a review of the facility's policies and procedures titled Food Receiving and Storage, the policy indicated that potentially hazardous foods should be stored at or below 41 F. During an observation of the facility's kitchen on 08/03/26 at 8:37 AM, the analog (non-digital) thermometer placed inside the walk in refrigerator read 47 F. During a concurrent review of a document titled Refrigerator Temperature Log posted on the refrigerator door, the recorded temperature under am temp for 08/03/26 was documented as 38 F. During an observation of the facility's kitchen on 08/03/26 at 10:37 AM, the internal thermometer in the walk in refrigerator read 50 F. During a concurrent observation and interview with Dietary Service Supervisor (DSS2), DSS2 confirmed that this measurement was within the temperature danger zone. Upon request, DSS2 poured a glass of soy milk from an unopened carton that had been stored in the refrigerator for an extended period, representing the actual temperature of foods held in the unit. Using a probe thermometer (a tool featuring a pointed metal stem that is inserted directly into food to measure its internal temperature), DSS2 measured the soy milk at 45 F and stated that it was within the temperature danger zone. During an interview in the facility's kitchen on 08/03/2026 11:50 AM with the Maintenance Service Director (MSD), the MSD stated that the original internal thermometer had been replaced and that a second thermometer was placed inside the refrigerator to confirm the internal temperature. During a concurrent observation, the MSD confirmed that both recently placed thermometers read 48 F. The MSD stated that no prior work orders or maintenance requests had been made or communicated to the MSD. During an observation of the facility's kitchen on 08/03/26 at 2:27 PM, two internal thermometers in the walk in refrigerator read 48 F. During a concurrent interview with the MSD, the MSD stated that an inspection of the condenser motor located on the roof was malfunctioning and MSD had replaced the faulty motor. The MSD stated that he had placed a third thermometer inside the refrigerator to further confirm the internal temperature. During an observation in the facility's kitchen on 08/04/2026 at 9:15 AM, the internal thermometer in the walk-in refrigerator read 36 F. During an interview in the facility's kitchen on 08/04/2026 at 9:30 AM with DSS2, DSS2 stated that a refrigerator operating at 48 F is not acceptable as it increases the risk for bacterial growth, can lead to spoiled or contaminated foods and may result in foodborne illness among residents who receive food from the kitchen. 2. During a review of the 2022 FDA Food Code section 3-701.11(A), the code indicated food that is unsafe shall be discarded. During an observation of the facility's kitchen on 08/03/26 at 8:15 AM, a bundle of herbs labeled as cilantro, wrapped in translucent plastic, was found in the walk in refrigerator. The herbs appeared discolored and yellowing with some leaves with dark brown color and slimy in texture. The bundle was labeled with a use-by date of 07/29/26. During an interview in the facility's kitchen on 08/04/26 at 9:30 AM with DSS2, DSS2 confirmed the labeled date of the cilantro and stated that it is not safe for resident consumption as it may promote foodborne illness. DSS2 stated that the bundle of cilantro should have been discarded on or prior to the use-by labeled date. 3. During a review of the facility's policies and procedures titled Food Brought in by Visitors dated 03/28/24, the policy indicated that all food should be labeled with the resident's name and receive date and will be discarded after 48 hours. During an observation of two resident refrigerators on 08/03/26 at 11:00 AM located in the activities room, the following findings were noted: -1 plastic container holding a yellow/red colored food mix of corn, sauce, and potentially meat (tamale) with no name or date. -1 glass food container holding an orange-colored liquid labeled with a name and room number with no date -1 tall cylindrical plastic container with visible debris and food stains inside, holding 2 patties of mixed corn [NAME] and black beans (pupusas) with no name or date. -1 translucent clear plastic container holding 3 small custard and fruit tarts labeled with no date -1 pint-sized plastic cup with lid and straw, appearing partially consumed and filled halfway with a green opaque liquid and a suspension of black tapioca balls with no date. -4 square plastic containers of [NAME] pasta, each held in an individual food storage bag, with no room number or date. -1 translucent plastic bag of tortillas in original commercial packaging with a printed best by date of 07/24/2026. -1 translucent plastic bag of tortillas in original commercial packaging with a printed best by date of 07/30/2026. -1 translucent plastic bag of tortillas in original commercial packaging with no name or date. -1 translucent plastic bag of shredded cheese in original commercial packaging with no name, room number, or date. During an interview on 08/04/26 at 1:00 PM with the Director of Nursing (DON), the DON confirmed that the facility policy requires discarding foods held for more than 48 hours. The DON stated that nursing staff are responsible for an initial review of foods while activities staff are responsible for daily monitoring. The DON stated the purpose of the facility's policy is to ensure residents do not consume spoiled food which can cause foodborne illness and gastrointestinal distress including symptoms such as diarrhea, nausea, vomiting, and potential dehydration. During a concurrent observation of the findings, the DON confirmed that food items in the refrigerator were not dated making it impossible to monitor compliance with the 48-hour policy. The DON further stated that expired foods items in the refrigerator should have been discarded on or prior to the manufacturer printed date.

Based on interview and record review, the facility failed to ensure one (1) of 3 sampled resident (Resident 31) was kept informed regarding his plan of care. This failure resulted in Resident 31 experiencing feelings of helplessness and anxiety due to not knowing what was going on with his care and had the potential for Resident 31 to not be able to exercise the right to choose his treatment plan. Findings: During a review of the facility's policy and procedure (P&P) titled, Resident Participation - Assessment/Care Plans, dated November 2025, the P&P indicated, The resident and/or the resident's representative are encouraged to participate in the resident's comprehensive assessments and in the development and implementation of the resident's care plans. The P&P also indicated: The resident and their legal representative are encouraged to attend and participate in the resident's assessments and in the development of the resident's person-centered care plan. The resident's/representative's right to participate in the development and implementation of the plan of care includes the right to: Participate in the planning process; Participate in establishing the resident's goals and expected outcomes of care; Be informed, in advance, of changes to the plan of care; Have access to and review the care plan. The care planning process: Facilitates the inclusion of the resident and/or representative. Facility staff support and encourage resident/representative participation in the care planning process by: Ensuring residents, representatives, and families understand the care planning process; Holding care planning meetings at times of day when the resident, representative, and family members can attend and are functioning at their best; Planning enough time for exchange of information and decision making. During a review of Resident 31's admission Record, the admission Record indicated the resident was self-responsible and initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of multiple myeloma (a type of blood cancer] and fusion of spine (a permanent surgical operation that joins two or more back bones [vertebrae/spine] together). During a review of Resident 31's History and Physical Examination (H&P), dated 6/30/2026, the H&P indicated Resident 31 had the capacity to understand and make decisions. During a review of Resident 31'S Minimum Data Set (MDS - a resident assessment tool), dated 7/7/2026, the MDS indicated the resident was cognitively intact (ability to think, remember, and reason) with cognitive skills for daily decision making. During a review of Resident 31's Interdisciplinary (a group of people with different job skills or training who work closely together to reach a shared goal) Care Conference dated 7/31/2026, Resident 31's Interdisciplinary Care Conference indicated Resident 31 was an attendee during a care conference to discuss the healed status of his two wounds . During an interview on 8/4/2026 at 8:55 AM with Resident 31, Resident 31 stated there is no communication between the doctors (MD) and residents at the facility. Resident 31 stated he had x-rays done on 8/2/2026 and did not receive any updates regarding the results of the x-ray and what was going on with his plan of care while at the facility. During a review of Resident 31's Order Summary Report, dated, 8/2/2026, Resident 31's Order Summary Report, indicated an order for x-rays of the lower lumbar (pertaining to the lower part of the back specifically the region between the ribs and hips) spine ordered on 8/2/2026. During a review of Resident 31's, Radiology Results Report, dated 8/2/2026, the Radiology Results Report, indicated Resident 31 had an x-ray of the lower lumbar area due to low back pain with the findings indicating Resident 31 had satisfactory alignment with orthopedic hardware (metal pieces like screw, plates, rods, and pins placed inside the body during surgery to hold broken bones together or help them heal) noted in the lower thoracic spine and osteoporosis (a medical condition that makes bones thin, weak and brittle) suggested. The Radiology Results Report, also indicated under impressions that Resident 31 had degenerative joint disease (DJD - a chronic condition where the protective cartilage cushioning the ends of bones wears down over time), and milk lumbar 1 (L1 - top bone in the lower back) and lumbar 2 (L2 - second bone down the lower back) compression fractures (a type of break where a bone collapses or gets squished down under heavy pressure) with ages indeterminate. During a concurrent interview and record review on 8/5/2026 at 10:54 AM with the Assistant Director of Nursing (ADON), the ADON verified that Resident 31 took an x-ray on 8/2/2026 which resulted same day and that a note on 8/4/2026 was documented indicating NP 1 was notified of the results and supplements were ordered, however, no documentation indicated Resident 31 was spoken to or notified of the results or plan of care. The ADON stated, if staff receive results, they can provide the resident with a copy while also informing them that only the MD is allowed to interpret the results. ADON further stated it is important to communicate with the resident regarding results and their plan of care because the resident has the right to know about their health information and medical records so that they know and understand what is going on with them. During another interview on 8/5/2026 at 11:08 AM with Resident 31, Resident 31 stated he had asked facility staff two to three times about the results of his x-ray taken on 8/2/2026 and has heard nothing which has left him feeling helpless due to not knowing about his own health problems. Resident 31 stated although he has complained to facility staff, he is still did not know his plan of care. During an interview on 8/5/2026 at 11:28 AM with Licensed Vocational Nurse 8 (LVN 8), LVN 8 stated if a resident's x-ray results are received, the findings are reported to the MD as soon as possible. LVN 8 also stated if the resident is inquiring about their results, staff are allowed to share the findings with the resident, however, staff are not allowed to interpret or diagnose and must let the resident know that they are awaiting final feedback from the MD. LVN 8 further stated it is important to communicate with the resident regarding results and their plan of care to ensure the resident stays involved and a part of their treatment plan, and is well informed and aware of what is going on. During another interview on 8/6/2026 at 7:58 AM with Resident 31, Resident 31 stated the last time he remembered doing a care conference with the facility staff was the week before 7/28/2026. Resident 31 stated he did not attend a care conference with facility staff on 7/31/2026. Resident 31 stated he could not remember ever seeing or speaking to NP 1 on 8/4/2026. Resident 31 further stated he just wants to be kept in the loop about his care and wants to know why he was being treated for certain things. During an interview on 8/6/2026 at 11:08 AM with Treatment Nurse (TXN) 1, TXN 1 stated they have interdisciplinary care conferences regarding Resident 31s wounds on Fridays. TXN 1 stated the residents are not present for the care conference, and it is the resident's treatment nurse who is responsible for relaying what is gone over in the meetings to the residents. TXN 1 further stated the treatment nurse for Resident 31 was Treatment Nurse 2 (TXN 2). During an interview on 8/6/2026 at 11:21 AM with TXN 2, TXN 2 stated on 7/31/2026 an interdisciplinary care conference was held regarding Resident 31's wounds. TXN 2 stated Resident 31 was not present for the care conference held on 7/31/2026. TXN 2 stated there is no documented evidence that what was discussed in the care conference was communicated to Resident 31. During an interview on 8/6/2026 at 12:32 PM with NP 1, NP 1 stated she was at the facility on 8/4/2026 and if she saw Resident 31, she would have documented a handwritten note in the resident's physical chart. During a concurrent interview and record review on 8/6/2026 at 12:42 PM with the ADON, Resident 31's physical chart and EMR dated 7/29/2026-8/6/2026 were reviewed. Resident 31's physical chart and EMR indicated no handwritten or digital note by NP 1. ADON stated there is no documented evidence that NP 1 had seen or spoken to Resident 31 regarding his x-ray results or plan of care when she was at the facility on 8/4/2026.

Based on interview and record review, the facility failed to ensure to provide the necessary care for one of five sampled residents (Resident 1) reviewed for unnecessary medications as psychotropic (any drug that affects the mental function, behavior, and mood) by failing to: 1. Ensure facility implemented nonpharmacological interventions (NPI - health treatments and strategies that do not use medications) before Resident 1 was administered as needed chlorpromazine (a medication used to treat intractable hiccough [severe involuntary spasms of the diaphragm lasting longer than one month], schizophrenia [a mental illness that is characterized by disturbances in thought] and bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs]). 2. Ensure monitoring for effectiveness of chlorpromazine for Resident 1 according to physician order and care plan. These deficient practices had the potential to expose Resident 1 to unnecessary medication and to significant adverse consequences (unwanted, uncomfortable, or dangerous drug side effects) resulting from the prolonged use of chlorpromazine that could lead to impairment or decline in functional (the gradual or sudden loss of a person's ability to do every day physical and mental tasks on their own) or psychosocial status (a person's mental, emotional, and social wellbeing, reflecting how they think, feel, and interact with world around them). Findings: During a review of facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated 6/2021, the P&P indicated, Facility should involve the resident or the resident's representative(s) in the discussion of potential non-drug and medication interventions to address the management of behaviors and the involvement should be documented in the resident's medical record. Psychotropic medications may be used to address behaviors only if non-drug approaches and interventions were attempted prior to their use. The P&P indicated, All medications used to treat behaviors .therapeutic effect. All residents receiving.monitored for: a. efficacy b. risks c. benefits d. harm or adverse consequences. During a review of Resident 1's admission Record (a document containing demographic and diagnostic information), dated 8/6/2026, Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to hiccough, anoxic brain damage (brain not getting oxygen at all), quadriplegia (partial or total loss of use in all four limbs and the torso), gastrostomy (g-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and dementia (a progressive state of decline in mental abilities) unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. During a review of Resident 1's History and Physical (H&P) dated 8/6/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 6/1/2026, the MDS did not indicate a cognition (mental action or process of acquiring knowledge and understanding through thought and senses) score. The MDS indicated that Resident 1 was dependent on facility staff for performing activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as oral hygiene, toileting hygiene, showering, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated, 88 indicating that facility did not attempt ADL of eating due to medical condition or safety concerns. During a review of Resident 1's Order Summary Report (a document containing a summary of all active physician orders), dated 8/6/2026, the order summary report indicated but not limited to the following physician orders: Chlorpromazine hydrochloride (HCl) oral tablet 25 milligram ([mg] metric unit of measurement, used for medication dosage and/or amount), give 1 tablet via g-tube every 8 hours as needed for intractable hiccups for 14 days, order date 7/29/2026, start date 7/29/2026, end date 8/12/2026. Anti-psychotic: Monitor side effects related to chlorpromazine HCl: 0. No side effect observed 1. Dry mouth 2. Constipation 3. Blurry vision 4. Disorientation/confusion 5. Hypotension 6. Dark urine 7. Yellow skin 8. Nausea and vomiting 9. Lethargy 10. Drooling 11. Extrapyramidal (EPS, movement disorders caused by changes in parts of the brain that manage muscle tone and posture) symptoms (tremors, gait issues, involuntary movement of mouth/tongue) 12. Weight gain, every shift, order date 7/28/2026, start date 7/29/2026. During a review of Resident 1's Care Plan Report, dated 3/10/2026, the care plan report indicated, Focus: Resident experiencing hiccough (hiccups); Goal: resident will demonstrate reduction or resolution of hiccups and maintain adequate comfort and oral intake; Interventions: administer chlorpromazine for hiccup management. Monitor frequency, duration and severity of hiccups. Assess for possible contributing factors such as gastric distention.effects. Provide comfort measures as tolerated. Report persistent or worsening hiccups to the provider for further evaluation. During a review of Resident 1's Care Plan Report, dated 7/29/2026, the care plan report indicated, Focus: Black Box Warning (strictest safety notice required by the U.S. Food and Drug Administration [FDA] for prescription drugs, to highlight severe, life-threatening or disabling risks) for use of chlorpromazine; Goal: Resident 1 will not experience side effects/interactions with use of chlorpromazine; Interventions: Administer medication as prescribed and monitor for therapeutic effectiveness. Monitor frequency, duration, and severity of hiccups. Monitor side effects.changes. Monitor blood pressure for orthostatic hypotension (a sudden drop in blood pressure that happens when standing up from sitting or lying position).Assess for changes in behavior.Report adverse reactions.promptly. During a review of Resident 1's Care Plan Report, dated 7/29/2026, the care plan report indicated, Focus: Resident 1 at risk for complications related to the use of psychotropic drugs medication: chlorpromazine.for 14 days; Goal: Resident 1 will be free from complications; Interventions: Gradual dose reduction as ordered.monitor of changes in mental status.monitor for continued need of medication.monitor for side effects.as needed. Obtain psych evaluation as ordered. During a review of Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 8/1/2026 to 8/6/2026, the MAR indicated Chlorpromazine oral tablet 25 mg was documented as administered to Resident 1 via g-tube every 8 hours as needed for intractable hiccups five times. During a review of Resident 1's MAR dated 8/1/2026 to 8/6/2026, the MAR indicated for Anti-psychotic: monitor episodes of chlorpromazine: Document non-drug interventions use , the MAR indicated # as 0 and NP as not applicable (NA), only for 8/1/2026. The MAR did not indicate any other dates with episodes monitoring and non-drug interventions use documentation. During a review of Resident 1's MAR dated 7/1/2026 to 7/31/2026, the MAR indicated Chlorpromazine oral tablet 25 mg was documented as administered to Resident 1 via g-tube every 8 hours as needed for intractable hiccups 26 times. During a review of Resident 1's MAR dated 7/1/2026 to 7/31/2026, the MAR indicated for Anti-psychotic: monitor episodes of chlorpromazine: Document non-drug interventions use , the MAR indicated # as 0 and NP as not applicable (NA), for 7/29/2026, 7/30/2026 and 7/31/2026. The MAR did not indicate any other dates with episodes monitoring and non-drug interventions use documentation. During a review of Resident 1's Consultant Pharmacist's (RPH 1) Medication Regimen Review (MRR) note dated 7/26/2026, the MRR note indicated, Resident 1 has an order for chlorpromazine 25 mg tablets - give 1 tablet via g-tube every 8 hours as needed for hiccups (5/23/2023).Since this medication is classified as an antipsychotic, its PRN (as needed) use needs to adhere to Centers for Medicare & Medicaid Services (CMS) guidelines as follow: 1/ the prescriber must write for intractable hiccups as part of the order. 2/ Non-pharmacological interventions (NPI) must be tried first. 3/ due to its classification of an antipsychotic.14 days per order - no exception. 4/ the prescriber must examine the resident before generating a new prescription (in person or via telehealth).5/Nursing needs to monitor for antipsychotic side effects, including weekly orthostatic hypotension, and its efficacy .6/ an informed consent.is written.Check with the prescriber.they are alternatives if the prescriber . Chlorpromazine as needed (PRN). During an interview on 8/6/2026 at 1:06 PM with RPH 1, RPH 1 stated she wrote several recommendations in July 2026 for Resident 1's chlorpromazine because it was an antipsychotic such as the facility should adhere to a 14-days treatment and examine the resident each time the chlorpromazine order was renewed and Resident 1 should be monitored for hiccups. During a concurrent interview and record review on 8/6/2026 between 2:03 PM and 3:26 PM with Registered Nurse (RN) 4 and Licensed Vocational Nurse (LVN) 12, the MAR for Resident 1's chlorpromazine administration and monitoring and care plan reports for July 2026 and August 2026 were reviewed. RN 4 stated, chlorpromazine was not used as an antipsychotic for Resident 1, but the medication is an antipsychotic, so we were monitoring for side effects from chlorpromazine, but we were not monitoring for any behaviors from having to take antipsychotic. RN 4 stated there was an active order for monitoring of chlorpromazine use but they stopped following the order regarding NPI interventions. RN 4 stated he could not explain why NPI were not documented. RN 4 stated Resident 1 did not have any side effects from chlorpromazine. RN 4 stated Resident 1 should have been monitored and was not monitored for side effects of orthostatic hypotension, and frequency, duration and severity of hiccups. LVN 12 stated it was important to monitor Resident 1 for the frequency and severity of hiccups, and for adverse effects and effectiveness of chlorpromazine to make sure that the medication was working for Resident 1. During an interview on 8/6/2026 at 3:32 PM with the Director of Nursing (DON), the DON stated the licensed nursing staff should have documented the severity and frequency of hiccups. The DON stated, if the licensed staff was not documenting then the facility would not know if there was an increase or decrease in hiccups because that would be how it will be evaluated if the medication was working and if it was effective or not effective for the resident. the DON stated the resident should also be monitored for side effects and if not monitored for orthostatic hypotension then resident could have hypotension (low blood pressure) from the medication and would not be safe for resident to continue to receive the medication.

Based on observation, interview and record review, the facility failed to develop and implement a resident centered care plan with measurable objectives, timeframe, and interventions for one of 3 sampled residents (Resident 1) in accordance with the facility's policy and procedure titled Care Plan Comprehensive. The facility failed to: 1. Implement nonpharmacological interventions (NPI - health treatments and strategies that do not use medications) before Resident 1 was administered as needed chlorpromazine (a medication used to treat intractable hiccough (a condition involving severe involuntary spasms of the diaphragm lasting longer than one month; commonly called hiccups), schizophrenia [a mental illness that is characterized by disturbances in thought] and bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs]). 2. Ensure monitoring of frequency, duration and severity of hiccups for Resident 1 according to physician order and care plan. These deficient practices failed to follow and implement care plan to ensure Resident 1 was monitored for effectiveness and adverse consequences (unwanted, uncomfortable, or dangerous drug side effects) resulting from the prolonged use of chlorpromazine that could lead to impairment or decline in functional (the gradual or sudden loss of a person's ability to do every day physical and mental tasks on their own) or psychosocial status (a person's mental, emotional, and social wellbeing, reflecting how they think, feel, and interact with world around them). Findings: During a review of facility's policy and procedure (P&P) titled, Care Plan Comprehensive, dated 8/25/2021, the P&P indicated, The facility's Interdisciplinary Team, in coordination with the resident and/or his/her family or representative, must develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives.comprehensive assessment. The P&P indicated, Care plan interventions are designed after careful consideration.rather than addressing only symptoms or triggers. The P&P indicated, Identifying problem areas.systematic clinical decision making. No single discipline can manage the task in isolation. The resident's physician.process. During a review of Resident 1's admission Record (a document containing demographic and diagnostic information), dated 8/6/2026, Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to hiccups, anoxic brain damage (brain not getting oxygen at all), quadriplegia (partial or total loss of use in all four limbs and the torso), gastrostomy (g-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and dementia (a progressive state of decline in mental abilities) unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. During a review of Resident 1's History and Physical (H&P) dated 8/6/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 6/1/2026, the MDS did not indicate a cognition (mental action or process of acquiring knowledge and understanding through thought and senses) score. The MDS indicated that Resident 1 was dependent on facility staff for performing activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as oral hygiene, toileting hygiene, showering, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated, 88 indicating that facility did not attempt ADL of eating due to medical condition or safety concerns. During a review of Resident 1's Order Summary Report (a document containing a summary of all active physician orders), dated 8/6/2026, the order summary report indicated but not limited to the following physician orders: Chlorpromazine hydrochloride (HCl) oral tablet 25 milligram ([mg] metric unit of measurement, used for medication dosage and/or amount), give 1 (one) tablet via g-tube every 8 (eight) hours as needed for intractable hiccups for 14 days, order date 7/29/2026, start date 7/29/2026, end date 8/12/2026. Anti-psychotic: Monitor side effects related to chlorpromazine HCl: 0. No side effect observed 1. Dry mouth 2. Constipation 3. Blurry vision 4. Disorientation/confusion 5. Hypotension 6. Dark urine 7. Yellow skin 8. Nausea and vomiting 9. Lethargy 10. Drooling 11. Extrapyramidal (EPS, movement disorders caused by changes in parts of the brain that manage muscle tone and posture) symptoms (tremors, gait issues, involuntary movement of mouth/tongue) 12. Weight gain, every shift, order date 7/28/2026, start date 7/29/2026. During a review of Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 8/1/2026 to 8/6/2026, the MAR indicated Chlorpromazine oral tablet 25 mg was documented as administered to Resident 1 via g-tube every 8 hours as needed for intractable hiccups five times. During a review of Resident 1's Care Plan Report, dated 3/10/2026, the care plan report indicated, Focus: Resident experiencing hiccups; Goal: resident will demonstrate reduction or resolution of hiccups and maintain adequate comfort and oral intake; Interventions: administer chlorpromazine for hiccup management. Monitor frequency, duration and severity of hiccups. Assess for possible contributing factors such as gastric distention.effects. Provide comfort measures as tolerated. Report persistent or worsening hiccups to the provider for further evaluation. During a review of Resident 1's Care Plan Report, dated 7/29/2026, the care plan report indicated, Focus: Black Box Warning (strictest safety notice required by the U.S. Food and Drug Administration [FDA] for prescription drugs, to highlight severe, life-threatening or disabling risks) for use of chlorpromazine; Goal: Resident 1 will not experience side effects/interactions with use of chlorpromazine; Interventions: Administer medication as prescribed and monitor for therapeutic effectiveness. Monitor frequency, duration, and severity of hiccups. Monitor side effects.changes. Monitor blood pressure for orthostatic hypotension (a sudden drop in blood pressure that happens when standing up from sitting or lying position) .Assess for changes in behavior .Report adverse reactions.promptly. During a review of Resident 1's Care Plan Report, dated 7/29/2026, the care plan report indicated, Focus: Resident 1 at risk for complications related to the use of psychotropic drugs medication: chlorpromazine .for 14 days; Goal: Resident 1 will be free from complications; Interventions: Gradual dose reduction as ordered.monitor of changes in mental status.monitor for continued need of medication .monitor for side effects.as needed. Obtain psych evaluation as ordered. During a concurrent interview and record review on 8/6/2026 between 2:03 PM and 3:26 PM with Registered Nurse (RN) 4 and Licensed Vocational Nurse (LVN) 12, the MAR for Resident 1's chlorpromazine administration and monitoring and care plan reports for July 2026 and August 2026 were reviewed. RN 4 stated, chlorpromazine was not used as an antipsychotic for Resident 1, but the medication is an antipsychotic, so we were monitoring for side effects from chlorpromazine, but we were not monitoring for any behaviors from having to take antipsychotic. RN 4 stated there was an active order for monitoring chlorpromazine use but they stopped following the order regarding Non pharmacological interventions (NPI). RN 4 stated he could not explain why NPI were not documented. RN 4 stated Resident 1 did not have any side effects from chlorpromazine. RN 4 stated Resident 1 should have been monitored and was not monitored for side effects of orthostatic hypotension, and frequency, duration and severity of hiccups. LVN 12 stated it was important to monitor Resident 1 for the frequency and severity of hiccups, and for adverse effects and effectiveness of chlorpromazine to make sure that the medication was working for Resident 1. During an interview on 8/6/2026 at 3:32 PM with the Director of Nursing (DON), the DON stated the licensed nursing staff should have documented the severity and frequency of hiccups. The DON stated, if the licensed staff was not documenting then the facility would not know if there was an increase or decrease in hiccups because that would be how it will be evaluated if the medication was working and if it was effective or not effective for the resident. the DON stated the resident should also be monitored for side effects and if not monitored for orthostatic hypotension then resident could have hypotension (low blood pressure) from the medication and would not be safe for resident to continue to receive the medication.

Based on observation, interview and record review, the facility failed to ensure one (1) of 33 sampled resident (Resident 3), investigated for smoking, was wearing an apron per smoking assessment in accordance with the facility's Policy and Procedure (P&P) titled Smoking, dated 8/9/2022. This deficient practice has the potential for Resident 3 to have injury or harm. During a review of the facility's Policy and Procedure (P&P) titled Smoking, dated 8/9/2022, the P&P indicated as identified by the smoking evaluation, residents who require assistance and/or monitoring for smoking safety are not allowed to smoke unaccompanied. The P&P also stated the interdisciplinary team (IDT - a group of people with different training and job skills who work together on a shared goal) will develop an individualized plan for safe storage, use of smoking materials, assistance and required supervision, if necessary, for residents who smoke. During a review of Resident 3's admission Record (AR), the AR indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of muscle weakness, abnormal gait and mobility and personal history of nicotine dependence. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 6/1/2026, the MDS indicated the resident is independent in cognitive skills for daily decision making. The MDS also indicated the resident required supervising/ touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with toileting hygiene, shower/bathe self, lower body dressing, putting on taking off footwear, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, toilet transfer, tub/shower transfer, walk 10 feet and walk 50 feet with two turns. During a review of Resident 3's Care Plan with focus on smoking with supervision, dated 9/16/2025, the care plan indicated to provide Resident 3 with smoking apron, if indicated. During a review of Resident 3's Smoking Evaluation, dated 6/1/2026, the evaluation indicated Resident cannot smoke safely without the use of a smoking apron. The evaluation also indicated the reason was the resident had poor safety awareness. During a concurrent observation and interview on 8/5/2026 at 9:12AM in the smoking patio area, Resident 3 was observed smoking without a smoking apron. The Activities Director (AD) stated Resident 3 does not have a smoking apron on. The AD explained she did not offer an apron to the Resident 3 because she did not know the resident required an apron for safety. During an interview on 8/5/2026 at 9:24AM, Resident 3's Smoking Evaluation, dated 6/1/2026, was reviewed. Registered Nurse 3 (RN) 3 stated Resident 3 required a smoking apron when smoking for safety reasons. RN 3 also stated Resident 3 has poor safety awareness. During an interview on 8/5/2026 at 11AM, the Director of Nursing (DON) stated Resident 3 must always wear a smoking apron when smoking for safety reasons. The DON also stated the resident has poor safety awareness because she has muscle weakness and poor gait and mobility. The DON further stated Resident 3 is not mindful of herself and can hit somewhere or someone in her surroundings.

Based on observation, interview, and record review, the facility failed to provide appropriate care and services for one (1) of four (4) sampled residents (Resident 70) reviewed for indwelling catheter (a tube inserted into the bladder to drain urine into a drainage bag) by failing to assess, monitor, and document signs and symptoms of urinary tract infection (an infection in any part of the urinary system) as indicated in the physician's order and care plan and and by not keeping the catheter drainage bag off the floor as required by the facility's Urinary Catheter Care Policy and Procedure. This deficient practice had the potential to result in delayed UTI identification, delayed treatment, worsening infection, and rehospitalization. Findings: During a record review of the facility's P&P titled, Catheter Care, Urinary, revised 2/2018, the P&P indicated observe for other signs and symptoms of urinary tract infection or urinary retention. Report findings to the physician or supervisor immediately. During a review of Resident 70's admission Record, the admission record indicated Resident 70 was initially admitted to the facility on [DATE] and readmitted on [DATE], with the diagnoses including but not limited to obstructive (blockage in the urinary tract that impedes urine flow) and reflux (the backward flow or urine from the bladder into the kidneys) uropathy, and benign prostatic hyperplasia (BPH, non-cancerous prostate gland enlargement that can cause urination difficulty), hydronephrosis (condition of the urinary tract where one or both kidneys swell obstructing the urine outflow) with renal and ureteral calculous obstruction (kidney stones or ureteral stones block the flow of urine), and neuromuscular dysfunction of bladder (when nerve or spinal cord problems disrupt the communication between the brain and bladder, impairing normal bladder control). During a record review of Resident 70's History and Physical (H&P, the initial clinical evaluation and examination of the resident), dated 2/25/2026, the H&P indicated Resident 70 does not have the capacity to understand and make decisions. During a record review of Resident 70's Minimum Data Set (MDS, resident assessment tool), dated 6/5/2026, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was intact. The MDS also indicated Resident 70 had an indwelling catheter. During a record review of Resident 70's Medication Administration Record (MAR) for the month of August 2026, the MAR indicated a physician order to monitor indwelling catheter for color, hematuria, odor, and sediments every shift. The MAR indicated there was no sediments on 8/3/2026 for all three shifts and no sediments on 8/4/2026 for the morning shift. During a review of Resident 70's Care Plan, dated 1/20/2026, the Care Plan indicated Resident 70 had a foley catheter (French scale, 16/10 cubic centimeter balloon) for benign prostatic hypertrophy with obstructive uropathy. The care plan interventions included monitoring the urine for sediment, cloudiness, odor, blood and amount and promptly reporting to the physician if any sediment, blood, cloudiness, odor, or fever was noted. During observations in Resident 70's room, the indwelling catheter showed a minimal amount of sediment on 8/3/2026 at 10:35 AM, a small amount of cloudy yellowish sediment on 8/4/2026 at 10:16 AM, and a moderate amount of cloudy brown sediment on 8/4/2026 at 3:03 PM. During a concurrent observation and interview on 8/4/2026 at 3:05 PM in Resident 70's room, Licensed Vocational Nurse (LVN) 6 stated the indwelling catheter contained approximately five to eight milliliters of brownish sediment. During a concurrent interview and record review on 8/4/2026 at 3:11 PM, LVN 6 stated that on 8/3/2026 the catheter had a small amount of sediment, and on 8/4/2026 it contained about three milliliters of light brown sediment. During a concurrent interview and record review on 8/4/2026 at 3:16 PM with LVN 6, reviewing Resident 70's TAR, Care Plan, Nurses Notes, and Change of Condition (COC) documentation, LVN 6 stated the licensed nurses did not-and should have-documented sediment on 8/3/2026 and 8/4/2026. LVN 6 further stated the nurses were required to document and notify the physician when sediment was present, as it represented a change in condition. LVN 6 stated there were no nurses notes or COC entries for the catheter sediment on either date, despite the Care Plan directing staff to report any urine sediment to the physician. During an interview on 8/6/2026 at 9:50 AM with the Assistant Director of Nursing (ADON), the ADON stated when the signs and symptoms of UTI were not reported to the physician the resident could develop urinary complications including UTI.

Based on interview and record review, the facility failed to ensure the facility and the physician reviewed and took timely action on a medication regimen review (MRR, consists of a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) irregularity, identified by the facility's pharmacy consultant for three of six sampled residents (Residents 7, 86, and 105) under unnecessary medications care area by failing to: 1. Ensure for Resident 7, the MRR for June 2026 was acted upon by the physician regarding famotidine (medication used to decrease stomach acid production). 2. Ensure for Resident 105, the June 2026 monthly MRR was evaluated. These deficient practices increased the risk that Residents 7, 86, and 105 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to their medication therapy potentially resulting in impairment or decline in their mental, functional, and psychosocial wellbeing. 3. Ensure for Resident 86, the facility's pharmacy and consultant pharmacist (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) identified the drug to drug interactions (occurs when two or more drugs react with each other, which may lead to unexpected side effects or alter the effectiveness of the medications) between cholestyramine (a medication used to treat chronic diarrhea [loose stool] and high cholesterol [a fat-like substance found in cells]) and other medications that were identified, reviewed,were clarified with a physician before the medications were administered concurrently via gastrostomy tube (g-tube - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) during medication pass. This deficient practice resulted in Resident 86 receiving cholestyramine inappropriately and concurrently with other medications via g-tube, possibly resulting in adverse (unwanted) consequences such as g-tube clogging and complications, reduced absorption and less effectiveness of other medications, resident discomfort, and hospitalization.Findings: During a record review of the facility's policy and procedure (P&P) titled, Medication Regimen Review (Monthly Report), dated 6/2021, the P&P indicated the consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. Resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented 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. 1. During a review of Resident 7's admission Record, the admission record indicated Resident 7 was readmitted to the facility on [DATE], with the diagnoses including but not limited to gastro-esophageal reflux disease (GERD, a condition in which the stomach contents leak backward from the stomach into the esophagus [food pipe]) without esophagitis (an inflammation and irritation of the tissues lining the esophagus), end stage renal disease (ESRD, failure of the kidney to filter out extra fluids and toxins from the body), and tracheostomy (a surgically created hole in the windpipe that provides an alternative airway for breathing) status. During a record review of Resident 7's physician's order, dated 1/21/2026, famotidine oral tablet 40 milligram (mg, unit of measurement): Give one tablet via gastrostomy tube (G-Tube, a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) one time a day for GERD. During a record review of Resident 7's History and Physical (H&P, the initial clinical evaluation and examination of the resident), dated 1/22/2026, the H&P indicated Resident 7 has fluctuating capacity to understand and make decisions. During a record review of Resident 7's MRR Note to Attending Physician/Prescriber, dated 6/19/2026, the note indicated Resident 7 has been on famotidine 40 mg every day for GERD since 1/2026, recommend trail reduction to maintenance dose 20 mg every day. The Physician/Prescriber Response was blank. During a record review of Resident 7's Minimum Data Set (MDS, resident assessment tool), dated 7/23/2026, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was severely impaired. The MDS indicated Resident 7 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) for toileting hygiene, shower/bathing self, and rolling left and right. During a concurrent interview and record review on 8/6/2026 at 8:04 AM with the Director of Nursing (DON) of Resident 7's MRR, the DON stated the MRR was done within 30 days. The DON stated the MRR was given to the physician to be signed and placed the Note to Attending Physician/Prescriber back into the MRR binder. The DON stated there was no Note to Attending Physician/Prescriber response for Resident 7. During a concurrent interview and record review on 8/6/2026 at 10:35 AM with the Assistant Director of Nursing (ADON), the ADON stated Resident 7's Note to Attending Physician/Prescriber for the famotidine should have been immediately followed up with since it may need clarification and communication from the doctor indicating the doctor's response to the MRR. During a follow up interview and record review on 8/6/2026 at 11:11 AM with the ADON of Resident 7's medical records, the ADON stated the pharmacist recommended the regimen and would suggest items that may possibly be overlooked by others and what are needed for resident specific regimens. The ADON stated Resident 7's famotidine 40 mg was prescribed since January 2026. The ADON stated there was no signed form from doctor for the Note To Attending Physician/Prescriber. The ADON stated there was no note addressing that the physician was notified of Resident 7's MRR in June 2026 and there were also no new orders or changes for famotine since 1/21/2026. The ADON stated the importance of following up with the MRR was to ensure an interdisciplinary approach for care was provided to Resident 7. 2. During a review of Resident 105's admission Record, the admission record indicated Resident 105 was readmitted to the facility on [DATE], with the diagnoses including but not limited to disruptive mood dysregulation disorder, acute respiratory failure (an inability to maintain adequate oxygenation for tissues or adequate removal of carbon dioxide from tissues) with hypoxia (lack of oxygen in the tissues to sustain bodily function), and type 2 diabetes mellitus (a disease that occurs when there is a problem in the way the body regulates and uses sugar as fuel). During a record review of Resident 105's H&P, dated 1/22/2026, the H&P indicated Resident 105 has fluctuating capacity to understand and make decisions. During a record review of the Consultant Pharmacist's Medication Regimen Review for the month of June 2026, Resident 105 was not included as a resident reviewed. During a concurrent interview and record review on 8/6/2026 at 11:33 AM with the ADON of the June 2026 MRR, the ADON stated Resident 105 was admitted on [DATE] and the Pharmacist should have conducted an MRR for Resident 105 for the month of June 2026. The ADON stated Resident 105's MRR was not reviewed by the Pharmacist for June 2026. The ADON stated the MRR was completed to ensure an interdisciplinary approach for care was provided to Resident 105. 3. During a review of facility's policy and procedure (P&P) titled, Consultant Pharmacist Reports, dated 6/2021, the P&P indicated, The consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains.minimizes adverse consequences related to medication therapy. The P&P indicated, Resident-specific irregularities and/or clinically significant risks results from or associated with medications are documented.as appropriate. During a review of facility's P&P titled, Medication Administration – General Guidelines, dated 10/2017, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. During a review of Resident 86's admission Record (a document containing demographic and diagnostic information) dated 8/5/2026, the admission record indicated Resident 86 was admitted to the facility on [DATE] with diagnoses that included but not limited to dysphagia, oropharyngeal phase (trouble starting a swallow because nerves or muscles in the mouth and throat do not work right), anemia (blood lacks enough healthy red blood cells or hemoglobin to carry adequate oxygen to body's tissues), hyperlipidemia, unspecified, hypokalemia (low levels of potassium) and other specified postprocedural states. During a review of Resident 86's History and Physical (H&P) dated 4/16/2026, the H&P indicated Resident 86 had the capacity to understand and make decisions. During a review of Resident 86's Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 7/20/2026, the MDS indicated Resident 86 needed moderate assistance for performing ADLs such as oral hygiene, upper body dressing and personal hygiene, maximal assistance for showering, and dependent on facility staff for performing activities of daily living (ADLs – routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting hygiene, lower body dressing and putting on or taking off footwear. During a concurrent medication administration observation and interview on 8/4/2026 between 9:15 AM and 10:04 AM with Licensed Vocational Nurse (LVN) 3 and LVN 7 (trainee), LVN 3 prepared the following six medications to be administered to Resident 86 via g-tube. LVN 3 stated she would use 30 milliliters ([mL] a metric unit of measurement, used for medication dosage and/or amount) water in between medications and 30 mL water to dissolve each medication, flush with 30 mL water before and after administered medications. LVN 3 stated and was observed pulling out approximately five (5) mL of residual. LVN 3 did not flush the g-tube syringe with water. LVN 3 administered Glucerna (a nutrition shake and meal supplement) via g-tube into feeding tube by gravity method (a way to send formula and medications into the feeding tube by the force of gravity). LVN 3 did not flush feeding tube with water. LVN 3 was then observed administering cholestyramine 4 gram ([gm] a metric unit of measurement, used for medication dosage and/or amount) powder that was dissolved in 180 mL of water, via gravity method into feeding tube. LVN 3 did not dilute the potassium chloride with water as instructed on physician's order and pharmacy label before administering potassium chloride via g-tube. a. One tablet of vitamin C (a medication used to support wound healing and treat low levels of vitamin C) 500 milligram ([mg] metric unit of measurement, used for medication dosage and/or amount), crushed individually and dissolved in water before administering via g-tube. b. One packet of cholestyramine (a medication used to treat chronic diarrhea [loose stool] and high cholesterol [a fat-like substance found in cells]) 4 gram ([gm] a metric unit of measurement, used for medication dosage and/or amount) powder that was dissolved in 180 mL of water. c. Five milliliters ([mL] a unit of measurement for volume) of levetiracetam (a medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) 100 mg/mL. d. One tablet of metoprolol tartrate (a medication used to treat high blood pressure and heart conditions) 25 mg with instructions to hold medication if BP was less than 100 or HR was less than 60 (crushed individually and dissolved in water before administering via g-tube). e. Six mL of potassium chloride 10 percent (20 milliequivalent [mEq] a unit of measurement for dose per 15 mL), with instructions to dilute with 4 ounces of cold water. f. Five mL of valproic acid (a medication used to treat seizures) 250 mg/5mL. During a concurrent observation and interview on 8/4/2026 at 10:04 AM, LVN 3 stated she did not and should have flushed the feeding tube with water before administering Glucerna and also before administering cholestyramine to make sure g-tube did not get clogged and to ensure medications moved smoothly. LVN 3 stated she did not know that cholestyramine was supposed to be separated from other medications and would need to check with supervisor. During a review of Resident 86's Order Summary Report (a document containing a summary of all active physician orders) dated 8/5/2026, the order summary report indicated but were not limited to the following physician order: Cholestyramine oral packet 4 gm, give 1 packet via g-tube one time a day for diagnosis (dx): diarrhea, mix each packet with 180 mL of water/juice, order date 5/14/2026, start date 5/15/2026. During a review of Resident 86's Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 8/1/2026 to 8/4/2026, the cholestyramine was administered daily at the same time as other medications at 9:00 AM. During a review of Resident 86's MAR dated 7/1/2026 to 7/31/2026, the cholestyramine was administered daily at the same time as other medications at 9:00 AM. During an interview on 8/6/2026 at 11:40 AM with the Director of Nursing (DON), the DON stated it was important that the licensed nurse followed manufacturer guidelines to ensure cholestyramine was not given along with other medications to prevent binding of cholestyramine with other medications that would make them less effective. During an interview on 8/6/2026 at 12:59 PM with the Consultant Pharmacist (RPH 1), RPH 1 stated that the cholestyramine packet should be mixed with six to eight ounces ([oz] a unit of measurement for volume) of liquid and via g-tube. RPH 1 stated the nursing staff should administer cholestyramine and wait to administer other medications. RPH 1 stated the other medications should be given one hour before cholestyramine or four hours after cholestyramine. RPH 1 stated it was important to separate the medications from cholestyramine because cholestyramine could decrease absorption of other medications or delay the movement of other medications. According to manufacturer's package labeling, titled Cholestyramine – cholestyramine powder for suspension, the document indicated, Since cholestyramine resin may bind other drugs given concurrently, it is recommended that patients take other drugs at least 1 hour before or 4 to 6 hours after cholestyramine resin (or at as great an interval as possible) to avoid impeding their absorption.

Based on interview and record review, the facility failed to implement timely and appropriate scabies outbreak control measures for facility staff after receiving two of two confirmed resident cases of scabies diagnoses that started on 6/5/2026 for 24 of 24 facility staff on 6/05/2026. The facility failed to: 1. Ensure Infection Preventionist Nurse (IPN) 1 create a close contact facility staff list for Resident 1 was diagnosed and confirmed with scabies on 6/5/2026. 2. Ensure IPN 1 inform and assess exposed facility staff from Resident 1 on 6/5/2026 and maintain ongoing and accurate surveillance for staff to identify new or unresolved cases of Scabies. IPN 1 did not start the staff surveillance line list until 7/06/2026. 3. Ensure IPN 1 and the Director of Nurses (DON) follow transmission-based precautions to prevent the spread of infection by ensuring facility exposed facility staff wear gown and gloves when providing resident care. 4. Inform exposed facility staff to self-monitor for signs and symptoms of scabies and initiate appropriate interventions. 5. Develop policies and procedures in line with the local health department and CDC guidance to screen exposed facility staff to recognize new cases of infection. As a result of this deficient practice, multiple staff had increased the risk of continued transmission of scabies to other staff and residents within the facility. CNAs 1 and 2, who had direct contact with Resident 1 reported experiencing untreated rashes and itching for weeks without being screened, assessed, or offered treatment, until 7/7/2026. Findings: During an initial tour of the facility on 7/7/2026 at 9 AM, the facility's entrance door was observed with a signage dated 7/7/2026 posted that indicated the facility had become infected with scabies. During a review of the facility's email thread with the Public Health Nurse (PHN), provided by the Infection Preventionist Nurse (IPN) and dated 6/9/2026, the email indicated the IPN contacted the PHN on 6/9/2026 and confirmed that the facility had one resident (Resident 1), who was hospitalized at the time, with a clinical diagnosis of scabies. The email indicated, if at any time a resident or staff is suspected of having scabies, they should be assessed and treated promptly. The email further indicated that the PHN requested the facility to ensure to provide prophylaxis to all other close contacts [of Resident 1]. The email indicated, for any staff identified as a close contact and opting to decline prophylaxis, they are required to wear a gown and gloves when providing patient care for at least 6 weeks after the last exposure and staff should be informed to self-monitor for any signs and symptoms of scabies and report immediately. During a review of facility's P&P titled Surveillance for Infections, (undated), the P&P indicated that the IPN is responsible conducting outcome surveillance to identify healthcare -associated infections and infections to help identify individual cases and facility trends to implement appropriate interventions. During a review of the facility's policy and procedure titled Scabies Identification, Treatment and Environmental Cleaning, revised 2016, the P&P indicated that staff exposed to scabies should report any rashes to the Infection Preventionist (IP) or Director of Nursing Services. During a scabies outbreak, the IPN and the facility's committee are responsible for coordinating interdepartmental efforts to ensure rapid and effective treatment, and contact precautions must be maintained until treatment is complete. The P&P indicated, for surveillance, the P&P indicated that staff should maintain a high index of suspicion for undiagnosed rashes, obtain skin scrapings to confirm suspected cases, and notify the local health department of outbreaks. Facilities should monitor for increases in scabies cases and maintain ongoing surveillance for residents and staff to identify new or unresolved cases. The P&P indicated, for control and treatment, the P&P indicated that crusted scabies involves large numbers of mites and increases transmission risk, including through contact with contaminated items and surfaces. Records should be maintained for each affected resident, including symptoms, skin scraping status, results, and the staff who provided care. During a review of a facility report titled Scabies Outbreak Line List for Healthcare Facilities: Employees, dated 7/6/2026, which the Infection Preventionist Nurse (IPN) 1 provided on 7/7/2026 at 12 noon, the record included six Certified Nurse Assistants (CNAs 1, 4, 5, 15, 16, and 17) and four Licensed Vocational Nurses (LVNs 1, 2, 3, and 6) which IPN 1 later stated that this record were a combined staff list that had direct contact with Residents 1 and 2. However, the staff line list did not include the required information identified in the report and were left blank for all staff identified in the list: Location/Description of rash Date of onset/symptoms Diagnosis evaluated by Usual work assignment Other work assignment Skin scraping (Yes or No) Scabicide dates Follow up results Family member symptoms Procedure Family member treatment During a review of a facility report titled Scabies Outbreak Line List for Healthcare Facilities: Employees, dated 7/6/2026, which Infection Preventionist Nurse (IPN) 1 later stated a revised version of the first line list given on7/7/2026 and were the staff members assigned and had direct contact with Residents 1 and 2. This version included an updated information for the three CNAs (CNA 1, 2, and 3) interviewed by IPN 1 on 7/7/2026. The completed staff line list indicated the following: CNA 1 developed a rash on her left wrist on 7/7/2026; no skin scraping was performed, and scabicide treatment was completed on 7/7/2026. CNA 2 developed rashes on her arms, chest, and neck on 7/7/2026; no skin scraping was performed, and scabicide treatment was completed on 7/7/2026. CNA 3 developed rashes on her arms on 7/7/2026; no skin scraping was performed, and scabicide treatment was completed on 7/7/2026. During a review of a facility report titled Scabies Outbreak Line List for Healthcare Facilities: Employees, dated 7/6/2026, which IPN 1 provided on 7/8/2026 at 4 PM, the record indicated a handwritten note that wrote Resident #1. This version included 13 CNAs (CNAs 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14) and 5 LVNs (LVNs 1, 2, 3, 4, and 5) names with their titles, which IPN 1 later stated that these staff list were the specific staff members that had direct contact with Resident 1 prior to discharge on [DATE]. Further review of this staff line list showed that not all required information fields were completed for 11 out of 13 CNAs (CNAs 1, 4, 5, 6, 7, 9, 10, 11, 12, 13, and 14) and all 5 involved LVNs (LVNs 1, 2, 3, 4, and 5). During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Further review of Resident 1's record indicated Resident 1 was discharged from the facility on 6/1/2026. During a review of Resident 1's Body Check, dated 5/29/2026, the assessment indicated Resident 1 had scattered redness to the back, abdomen, chest, bilateral upper extremities (both arms, shoulders, or hands), bilateral lower extremities (both legs) with scattered excoriations (the loss of the superficial layer of the skin, usually caused by scratching, scraping, or friction). During a review Resident 1's physician order dated 6/1/2026, to transfer to GACH for evaluation. During a review of Resident 1's progress notes dated 6/1/2026 timed at 1:52 PM, the note indicated Resident 1 was transferred to GACH due to nausea and vomiting. During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE]. During a review of Resident 2's progress notes dated 6/25/2026 authored by Treatment Nurse (TN) 1, the note indicated Resident 2 was seen by PA 1 for generalized body dermatitis with 100% erythematous papules (small, raised, solid bumps on the skin that are red in color). During a review of Resident 2's Lab Results Report with collection and reported date of 7/02/2026, the Report indicated Sarcoptes, Scabies Adults and Egg (a microscopic, parasite that burrows into the upper layer of human skin, causing the intensely itchy condition known as scabies). During an interview on 7/07/2026 at 11:20 AM with the Director of Nursing (DON), the DON stated the facility had received a verbal report from Resident 1's Nurse Practitioner (NP) that Resident 1, who had been transferred to the general acute care hospital (GACH) on 6/1/2026, was tested and clinically diagnosed with scabies on 6/05/2026. The DON stated the facility's Infection Preventionist Nurse (IPN 1) contacted the local public health department on 6/9/2026 to notify them and obtain guidance. During an interview on 7/07/2026 at 11:44 AM with IPN 1, IPN 1 stated that after the DON informed her of Resident 1's positive scabies test and diagnosis at the [GACH], she contacted the local Public Health Department on 6/9/2026. IPN 1 stated she spoke with a PHN who provided verbal guidance and later sent her an email on the same day, 6/9/2026. IPN 1 stated that Resident 2 was evaluated by Dermatology on 6/25/2026. IPN 1 further stated that on 7/2/2026, the facility received Resident 2's positive scabies test results. Upon receiving Resident 2's diagnosis, IPN 1 stated she notified the local Public Health Department again on 7/2/2026 and created a line list of close contact staff and residents on 7/6/2026 (four days after notifying the local public health department). IPN 1 stated she did not create a close contact staff surveillance list for Resident 1 and 2 until 7/06/2026. IPN 1 stated she should have created a close contact staff list on 6/09/2026, when she received the guidance from the PHN after Resident 1 was diagnosed with scabies on 6/5/2026, to monitor and identify any staff who might have been infected, in order to prevent potential spread of scabies to other residents and staff in the facility. During another interview on 7/07/2026 at 12 noon, IPN 1 provided the first version of the facility's staff line list titled Scabies Outbreak Line List for Healthcare Facilities: Employees, dated 7/6/2026. During a concurrent record review of the staff line list, IPN 1 stated that these staff line list were a combined staff list that had direct contact with Residents 1 and 2. IPN 1 stated this staff line list that identified six Certified Nurse Assistants (CNAs 1, 4, 5, 15, 16, and 17) and four Licensed Vocational Nurses (LVNs 1, 2, 3, and 6) were left blank under the fields that required information because there was no staff that reported any rashes since 7/6/2026. During another interview on 7/8/2026 at 9:30 AM, IPN 1 provided a second version of the facility's staff line list titled Scabies Outbreak Line List for Healthcare Facilities: Employees, dated 7/6/2026. During a concurrent record review of this staff line list, IPN 1 stated that this version included CNAs 1, 2, and 3 because these three CNAs were the staff members assigned to Resident 1 and had direct contact with the resident prior to Resident 1's discharge on [DATE]. IPN 1 stated that CNAs 1, 2, and 3 reported an onset of rashes that started on 7/7/2026, so they were offered scabicide prophylaxis on 7/7/2026 and advised not to come to work until further notice. During a telephone interview on 7/08/2026 at 11:11 AM with CNA 1, CNA 1 stated that on 7/07/2026 she was instructed to go to IPN 1's office upon arriving at work. CNA 1 stated the IPN 1 asked whether she had any rashes, and CNA 1 confirmed she did, showing the IPN a dry rash on her wrist. CNA 1 stated she had experienced a very itchy rash for a few weeks. CNA 1 stated she had not been informed prior to 7/07/2026 that Resident 1, whom she had cared for before the resident was hospitalized on [DATE], had tested positive for scabies. During the same interview, CNA 1 stated that before 7/07/2026, no one at the facility asked her if she had a rash or offered treatment. CNA 1 stated that if she had been notified earlier, she would have taken the treatment because she had been very itchy for weeks and would have known to protect herself while caring for other residents. CNA 1 stated IPN 1 provided her with a cream on 7/07/2026 and instructed her to go home, with clearance to return to work four days later, on 7/10/2026. During an interview and concurrent record review on 7/08/2026 at 12:58 PM of a printed email thread dated 6/9/2026 between the Public Health Nurse (PHN) and IPN 1, IPN 1 stated she did not read the portion of the PHN's recommendations instructing: Kindly ensure to provide prophylaxis to all other close contacts. For any staff identified as a close contact and opting to decline prophylaxis, they are required to wear a gown and gloves when providing patient care for at least 6 weeks after last exposure. IPN 1 stated that had she read that part of the PHN's email on 6/9/2026, she would have created a list of close contact staff to identify all employees exposed to Resident 1 and would have offered prophylactic treatment accordingly. During a telephone interview on 7/08/2026 at 1:30 PM with CNA 2, CNA 2 stated that on 7/07/2026 IPN 1 asked whether she had any rashes. CNA 2 stated and confirmed she had very itch rashes a few weeks ago and had started to dry now. CNA 2 stated she had not been informed prior to 7/07/2026 that Resident 1, whom she had cared for before the resident was hospitalized on [DATE], had tested positive for scabies. CNA 2 further stated that before 7/07/2026, no one at the facility asked her if she had a rash or offered treatment. CNA 2 stated that if she had been notified earlier, she would have taken the treatment right away to protect herself while caring for other residents. During an interview on 7/8/2026 at 4:00 PM, IPN 1 provided a third version of the facility's staff line list titled Scabies Outbreak Line List for Healthcare Facilities: Employees, which included a handwritten notation, Resident #1, and was dated 7/6/2026. During a concurrent record review, IPN 1 stated this version identified 13 Certified Nurse Assistants (CNAs 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14) and five Licensed Vocational Nurses (LVNs 1, 2, 3, 4, and 5) who had direct contact with Resident 1 prior to the resident's discharge on [DATE], since she did not create a line listing on 6/9/2026 upon receiving guidance from the PHN. During the same interview, IPN 1 further stated she would have to ask the staff members included in the revised line list to complete the required information for 11 of the 13 CNAs (CNAs 1, 4, 5, 6, 7, 9, 10, 11, 12, 13, and 14) and all five LVNs (LVNs 1, 2, 3, 4, and 5), as those fields were left blank. During a review of the CDC guidelines titled Public Health Strategies for Crusted Scabies Outbreaks in Institutional Settings (2023) and Public Health Strategies for Scabies Outbreaks in Institutional Settings (2025) showed that scabies spreads easily in nursing homes and requires early detection, treatment, isolation, and strong infection control practices. The guidelines direct facilities to maintain high suspicion for scabies even without typical symptoms, screen new patients and employees for compatible skin conditions, recognize staff reinfection as a possible sign of undetected resident cases, and ensure trained personnel obtain and examine skin scrapings when scabies is suspected. During a review of County of Los Angeles Public Health guidelines titled Scabies Prevention and Control Guidelines for Healthcare Settings, dated 2026, the guidelines indicated that exposed individuals may be infectious immediately, even without symptoms, and remain communicable until treatment eliminates mites and eggs. Outbreak investigations must identify contributing risk factors and implement corrective actions, with an outbreak defined as an increase in scabies cases above baseline within a specific timeframe and location. Healthcare associated transmission is likely when two or more staff in the same unit develop scabies within six weeks without outside exposure. Recommended actions include promptly placing suspected residents on contact precautions, removing symptomatic staff from work for evaluation, and preparing complete line lists of symptomatic individuals and their contacts for assessment.

Based on observation, interview, and record review, the facility failed to ensure that a resident's physician order for skin scraping and specimen collection, completed by Physician Assistant (PA) 1, was communicated to the laboratory on 6/25/2026, for one of three sampled residents (Resident 2), who was suspected of scabies and required confirmation of diagnosis, in accordance with the facility's policy and procedure (P&P) titled Lab and Diagnostic Test Result. This deficient practice had the potential to result in delayed or inaccurate diagnosis, inappropriate or unnecessary treatment, and increased risk of transmitting scabies to other residents and staff. Findings: During a review of the facility's P&P titled Lab diagnostic Test Result, with a revision dated of November 2018, the P&P indicated, the physician would identify and order diagnostic and laboratory testing based on the resident's diagnostic and monitoring needs. The P&P also indicated that staff would process test requisitions and arrange for test During a review of Resident 2's admission Record (AR), the AR indicated that the resident was admitted to the facility on [DATE], with diagnoses that included dysphagia (difficulty swallowing) and Alzheimer's disease (a progressive brain disorder that gradually destroys memory and thinking skills). During a review of Resident 2's History and Physical (H&P), dated 2/16/2026, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's Wound Assessment Note, dated 6/25/2026 authored by PA 1, the note indicated Resident 2's skin scraping to rule out scabies was completed at bedside. During a review of Resident 2's progress notes dated 6/25/2026 authored by Treatment Nurse (TN) 1, the note indicated Resident 2 was seen by PA 1 for generalized body dermatitis with 100% erythematous papules (small, raised, solid bumps on the skin that are red in color). The note indicated Resident 2 required skin scraping was completed at bedside by PA 1. During a review of a Lab Test Request form, the form indicated a draw date of 7/02/2026 under Other Tests, which included a handwritten note indicating skin scrape for scabies, along with other blood tests marked on the form. The request form also included a handwritten note in the blank space at the bottom of the form that read, skin scrape for scabies in the fridge. During a review of Resident 2's Lab Results Report with collection and reported date of 7/02/2026, the Report indicated Sarcoptes, Scabies Adults and Egg (a microscopic, parasite that burrows into the upper layer of human skin, causing the intensely itchy condition known as scabies). During a review of Resident 2's telephone orders created on 7/06/2026 and printed on 7/8/2026, authored by the Infection Preventionist Nurse (IPN), the order indicated skin scraping. During an interview on 7/7/2026 at 11:20 AM with the Director of Nursing (DON), the DON stated that Resident 2's Physician Assistant (PA 1) was in the facility on 6/25/2026, conducted an assessment, and performed a skin scraping on Resident 2. The DON stated the facility received the laboratory results on 7/2/2026 confirming Resident 2 was positive for scabies. The DON further stated she did not know why the laboratory took a week to return the positive results and explained that it is sometimes normal for the laboratory to take longer with certain tests. During an interview on 7/7/2026 at 3:30 PM with Treatment Nurse (TN) 1, TN 1 stated that Resident 2 had a generalized body rash for a few weeks and had previously been seen by dermatology for assessment and treatment. TN 1 stated that during the dermatology PA 1's visit on 6/25/2026, PA 1 decided to perform a skin scraping test at Resident 2's bedside. TN 1 stated the Infection Preventionist Nurse (IPN) provided the PA with the test kit and supplies. TN 1 stated that once PA 1 completed the procedure, she handed the specimen to TN 1, and TN 1 placed Resident 2's skin scraping specimen in the facility's laboratory specimen refrigerator. TN 1 stated she did not enter an order for Resident 2's skin scraping test and did not complete a Test Request Form because the IPN had provided PA 1 with the testing kit, so she assumed the IPN was responsible for ensuring the order was entered and the Test Request Form completed to notify the laboratory to collect the specimen. TN 1 stated the IPN did not ask her or give her any instructions. During an interview and record review on 7/7/2026 at 4:27 PM of Resident 2's Test Request Form dated 7/2/2026, the IPN stated that on 6/25/2026, PA 1 was in the facility conducting assessments on residents. The IPN stated she asked PA 1 to perform a skin scraping on Resident 2 because the resident's generalized body rash had not resolved despite other treatments. The IPN stated she provided PA 1 with the test kit while PA 1 was rounding with TN 1. The IPN stated she assumed TN 1 would call the laboratory, enter the order for Resident 2's skin scraping, and complete a Test Request Form. The IPN stated that, per facility procedure, the nurse who obtains the specimen is responsible for entering the order, notifying the laboratory, and completing a Test Request Form so the laboratory can pick up the specimen for testing. The IPN stated she did not know who completed the Test Request Form on 7/2/2026 and stated this was likely the reason the facility did not receive the results until 7/2/2026, because the laboratory had not been informed that the skin scraping was performed on 6/25/2026. The IPN stated the laboratory should have been notified and an order entered on 6/25/2026 to prevent delays in diagnosis and treatment, and to prevent potential exposure and spread of scabies to other residents and staff.

Based on observation, interview, and record review, the facility failed to ensure the timely availability, ordering, and administration of a prescribed medication (Pregabalin 50 mg, three times daily) for one of three sampled residents (Resident 1). The facility failed to obtain required physician signatures, follow pharmacy procedures, coordinate with appropriate prescribers, communicate medication availability issues among licensed nursing staff to administer Pregabalin as ordered. The facility's failures caused staff to fail to administer 20 scheduled doses of the controlled medication Pregabalin to Resident 1, leaving the resident with uncontrolled neuropathic pain for more than seven days and negatively affecting their quality of life. Findings: During a review of Resident 1's General Acute Care Hospital (GACH) Transfer/Discharge Medication Review and Order Sheet dated 6/2/2026, the order indicated to continue Pregabalin for diabetic neuropathy (nerve damage caused by long-term high blood sugar and fat levels)] and to manage certain types of seizures) 50 mg, one capsule orally three times a day. During a review of Resident 1's admission Record (AR), the AR indicated the resident was admitted on [DATE] with diagnoses that included sepsis (the body's extreme, life-threatening response to an infection), muscle weakness, and sciatica (pain that radiates from the lower back, through the buttock, and down one leg). During a review of Resident 1's Progress notes dated 6/2/2026 timed 8:06 PM indicated Resident 1 was admitted to the facility and admission orders were verified with the MD (Physician 1). The note indicated all orders noted and carried out. During a review of Resident 1's History and Physical Assessment (H&P) dated 6/3/2026 indicated resident had the capacity to understand and make decisions. During a review of Resident 1's Physician Order dated 6/2/2026, a telephone order indicated to give Pregabalin Oral Capsule 50 mg, 1 capsule by mouth three times a day for neuropathic pain starting on 6/3/2026. During a review of Resident 1's Minimum Data Set (MDS, an assessment and screen tool) dated 6/8/2026 indicated Resident 1's cognition was intact. The MDS indicated Resident 1 required partial/moderate assistance for activities of daily living. During a subsequent review of Resident 1's Progress notes dated 6/3/2026 timed 8:12 AM, the note indicated awaiting delivery of Pregabalin Oral Capsule 50 mg give 1 capsule by mouth three times a day for neuropathic pain. During a review of Resident 1's Progress notes dated 6/3/2026 timed 1:20 PM, the note indicated the Pregabalin was not available, and the staff would follow up with pharmacy. During a review of Resident 1's Progress notes dated 6/3/2026 timed 5:49 PM, the note indicated an entry wait for pharmacy delivery. During a review of Resident 1's Progress notes dated 6/4/2026 timed 9:54 AM, the note indicated the Pregabalin order was pending the physician's signature. The note further indicated that according to the facility's pharmacy, to hold the medication until it arrives. During a review of Resident 1's Progress notes dated 6/4/2026 timed 1:02 PM, the note indicated to hold the Pregabalin until the MD signs the order. During a review of Resident 1's Progress notes dated 6/5/2026 timed 10:37 AM, the note indicated the Pregabalin was not available and the pharmacy was called. The note indicated per pharmacy, the licensed nurses could not pull from the facility's Cubex system (Cubex Medication System, an automated inventory management system and smart dispensing cabinet used in medical practices by tracking, securing, and recording high-value supplies and medications), because the physician has not signed the prescription and medication was not ordered as needed [PRN]. The note indicated the physician (Physician 1) and Resident 1 were made aware. During a review of Resident 1's Progress notes dated 6/5/2026 timed 2:02 PM, the note indicated the Pregabalin was not available and the MD was aware. During a review of Resident 1's Medication Administration Record (MAR) from 6/3/2026 to 6/8/2026 scheduled at 9 AM, 1 PM, and 5 PM -the MAR indicated the Pregabalin was not administered to Resident 1 due to medication not delivered by Pharmacy. On 6/9/2026 at 9 AM and 1 PM - the MAR indicated the Pregabalin was not administered to Resident 1 due to medication not delivered by Pharmacy. During a review of Resident 1's MAR, dated 6/5/2026 at 1:18 PM, the MAR indicated Resident 1 received one time of tramadol 25 MG for 9/10 (severe) pain level by LVN 1. During a review of Resident 1's MAR for 6/9/2026 timed at 5 PM - the MAR indicated the Pregabalin was documented administered by LVN 2 but during a later interview, the medication was not actually given to the resident. During a review of Resident 1's Progress Notes dated 6/10/2026 timed at 9:13 AM, the order indicated medication on hold, pending Physician 1's signature and that Physician 1 is aware and per Physician 1, to put the medication on hold. During a review of Resident 1's Physician Order dated 6/10/2026 timed at 9:44 AM, a telephone order indicated Physician 1 ordered to hold Pregabalin 50 mg pending the physician's signature. Further review of the resident's records indicated the Pregabalin was not administered due to the medication being on hold. During a review of Resident 1's Physician Order dated 6/10/2026 timed at 11:41 AM, a telephone order indicated Physician 1 ordered to resume Pregabalin 50 mg. During a review of Resident 1's Progress notes dated 6/10/2026 timed at 1:26 PM by LVN 1, the Note indicated the prescription was signed and Pregabalin was pulled from the facility's Cubex system. The medication was still pending pharmacy delivery. During a review of Resident 1's MAR for 6/10/2026 at around 1 PM - the MAR indicated the Pregabalin was administered by LVN 1 from the Cubex. During a review of the facility's Cubex Medication System Transaction Report, dated 6/10/2026 timed at 1:28 PM, the report indicated two capsules of Pregabalin 25 mg (50 mg) were removed from the Cubex for Resident 1 by RN 1 (and administered by LVN 1 in the MAR). During a review of Resident 1's [DATE]/10/2026 at 5 PM- the MAR indicated the Pregabalin was documented administered by LVN 2 but during a later interview, the medication was not actually given to the resident. During a review of the facility's Pharmacy Delivery Receipt dated 6/10/2026, the receipt indicated Resident 1's Pregabalin 50 mg capsule, a total of 30 doses was delivered to the facility on 6/10/2026 at 5:50 PM. During a review of the Pharmacy Copy for Resident 1's Physician's Order, dated 6/10/2026, signed and ordered by Physician 3 (Resident 1's pain specialist), the signed order indicated Physician 3 ordered Pregabalin Oral Capsule 50 mg one capsule by mouth three times a day for neuropathic pain. The Pharmacy Copy indicated the pharmacy received this Physician's Order on 6/10/2026 timed 12:08 PM. During a review of Resident 1's care plan for Missed dose(s) of Pregabalin 50 mg developed on 6/7/2026, the care plan indicated the resident would remain free from pain or discomfort while awaiting medication availability and timely resumption of therapy. During a review of Resident 1's records from 6/2/26 to 6/11/26, the records did not indicate a follow up to obtain the required physician signature to prevent a delay in the delivery of the Pregabalin medication to be administered to the resident since 6/3/2026. During the continued MAR review from 6/3/2026 to 6/15/2026, the Pregabalin was signed as administered to Resident 1 by the licensed nurses 16 times and Pregabalin was not administered 20 times. During a review of Resident 1's printed Controlled Drug Record for Pregabalin 50 mg capsules, with start date on 6/11/2026, the record showed the following administration details: -On 6/11/2026 at 8:11 AM, one dose administered leaving a remaining quantity of 29. -On 6/11/2026 at 12:38 PM, one dose administered, leaving 28. -On 6/11/2026 at 5:57 PM, one dose administered, leaving 27. -On 6/12/2026 at 8:11 AM, one dose administered leaving 26. -On 6/12/2026 at 12:46 PM, one dose administered leaving 25. -On 6/12/2026 at 5:07 PM, one dose administered leaving 24. -On 6/13/2026 at 8:28 AM, one dose administered leaving 23. -On 6/13/2026 at 12:54 PM, one dose administered, leaving 22. -On 6/13/2026 at 4:28 PM, one dose administered, leaving 21. -On 6/14/2026 at 9:03 AM, one dose administered, leaving 20. -On 6/14/2026 at 1:48 PM, one dose administered, leaving 19. -On 6/14/2026 at 5:40 PM, one dose administered, leaving 18. -On 6/15/2026 at 8:40 AM, one dose administered, leaving 17. A total of 13 doses were recorded administered to Resident 1. During a review of Resident's Progress Notes (PN), dated 6/15/2026 timed 10 AM, the notes indicated Resident 1 was discharged to home. During a telephone interview on 6/22/2026 at 12:01 PM with Family Member (FM) 1, FM 1 stated that Resident 1 was admitted to the facility on [DATE] and had been prescribed Pregabalin three times daily for neuropathic pain. FM 1 stated that Resident 1 did not receive the Pregabalin medication for more than a week. FM 1 reported informing multiple nurses at the facility on several occasions that Resident 1 needed the pain medication, but the nurses repeatedly responded that the pharmacy was waiting for the physician's signature and authorization before delivering the Pregabalin. FM 1 stated that during the time [Resident 1] did not receive the Pregabalin, Resident 1 experienced and verbalized uncontrolled pain in her lower legs for over a week. During a concurrent interview and record review on 6/22/2026 at 12:40 PM with Licensed Vocational Nurse (LVN) 1, Resident 1's Progress Notes, dated 6/5/2026 timed 10:26 AM, was reviewed. LVN 1 stated she called and informed Resident 1's primary physician (Physician 1) on 6/5/2025 and notified Physician 1 that Resident 1's Pregabalin was not delivered since it was ordered on admission to start on 6/3/2026 because the pharmacy required a signed prescription from the physician before the medication would be delivered to the facility. LVN 1 further stated Physician 1 informed her that the facility can contact the facility's Medical Director (Physician 2) who could sign the prescription on his behalf. LVN 1 stated she did not contact the facility's Medical Director (Physician 2) regarding Resident 1's prescription for Pregabalin. LVN 1 stated she waited a few days (7 days) until the facility's pain management specialist (Physician 3) came to the facility, at which time she presented Resident 1's prescription of Pregabalin for Physician 3's authorization and signature. During a concurrent interview and record review on 6/22/2026 at 12:45 PM with LVN 1, Resident 1's Progress Notes, dated from 6/2/2026 to 6/10/2026, were reviewed. LVN 1 stated she could not find documentation indicating other licensed nurses had contacted the physicians (Physicians 1, 2, or 3) regarding the signature required by Pharmacy to deliver the Pregabalin at the facility. During another interview on 6/22/2026 at 12:48 PM with LVN 1, LVN 1 further stated Resident 1's Pregabalin was ordered to start on 6/3/2026 and when the nurses found out the medication was not available due to pending signature from the admitting physician (Physician 1), the nurses should have contacted Physician 1 right away on 6/3/2026 to obtain the signature. LVN 1 stated if the admitting physician (Physician 1) was not available and could not sign the prescription, the nurse should have called Physician 2, the Medical Director or Physician 3, the facility's pain specialist, to sign the prescription as soon as possible to prevent the delay of administering the Pregabalin to Resident 1. LVN 1 stated there was no licensed nurses that called and followed up with any physicians for the signature on 6/3/2026 and 6/4/2026. LVN 1 stated there were no other licensed nurses that followed up with any physician to obtain the signature on 6/6/2026, 6/7/2026, 6/8/2026, and 6/9/2026. During an interview on 6/22/2026 at 2:43 PM with the Assistant Director of Nursing (ADON), the ADON stated that Pregabalin is a controlled medication that requires a physician's signature before the pharmacy can release it to the facility. The ADON explained that when licensed nurses discovered Pregabalin was unavailable due to a pending physician signature, they should have contacted Physician 1 immediately. The ADON further stated that if the resident's admitting physician was not available or unable to sign the prescription, licensed nurses should contact the facility's medical director or pain management specialist for the required signature. The ADON emphasized that nurses should not wait for the physician to arrive at the facility to sign the prescription. The ADON further stated that because licensed nurses did not contact a physician in a timely manner to obtain the signature for Resident 1's Pregabalin, Resident 1 did not receive her routine pain management medication for seven days, resulting in discomfort and negatively affecting her quality of life. During a concurrent interview and record review on 6/23/2026 at 2:45 PM with ADON, the facility's policy and procedures (P&P) titled, Medication Ordering and Receiving from Pharmacy, dated 1/2026, was reviewed. The ADON stated the controlled medications prescribed for a specific resident are delivered to the facility only if a valid written or electronic prescription had been received by the pharmacy prior to dispensing. The ADON stated it was important for nurses to be aware of the procedure and notified the physician for signature to prevent future delay of care for the residents.

Based on interview and record review, the facility failed to ensure that residents receive adequate supervision and assistance to prevent avoidable accidents when the facility receptionist (unlicensed staff) assisted one of two sampled residents (Resident 6) during a fall on 6/25/2026 at 8:30 PM. Receptionist (REC), an unlicensed staff, assisted Resident 6, who required partial/moderate assistance, off the floor and onto the couch without waiting for a licensed nurse to assess and transfer the resident, in accordance with the facility's policy and procedure (P&P) for Fall Management and the REC's job description. This failure had the potential to result in further injury or avoidable accidents following the fall. On 6/27/2026, Resident 6 complained of severe pain and swelling to the right foot. On the same day, Resident 6 was transferred to a General Acute Care Hospital (GACH) due to severe pain and was diagnosed with fractures of the 4th and 5th metatarsal necks (a break in the neck of two of the five long bones in the forefoot, located just behind the toe joints). Findings: During a review of the REC's Job Description titled Receptionist dated 3/10/2026 indicated the primary purpose of the position was to perform clerical support in an efficient manner in accordance with procedures and as directed by the supervisor. The Job Description did not indicate any duties or responsibilities for direct resident care. A review of the facility's policy and procedure (P&P) titled Fall Management dated 5/26/2021indicated patients will be assessed for falls risk as part of the nursing assessment process. The P&P indicated those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. The P&P indicated that when a patient (resident) falls, staff should Observe/check for injury, which was not implemented immediately when REC witnessed Resident 6 fell on 6/25/2026, prior to moving the resident and lifting Resident 6 off the floor unassisted. During a review of Resident 6's admission Record (AR), the AR indicated a readmission to the facility on 8/5/2025 with diagnoses of unspecified fracture of upper end of right tibia, muscle weakness, and abnormalities of gait and mobility. During a review of Resident 6's History and Physical (H&P) dated 9/18/2025, the H&P indicated Resident 6 had the capacity to understand and make decisions. During a review of Resident 6's Fall risk care plan initiated on 1/28/2026 with target date 7/6/2026, the care plan indicated Resident 6 was at risk for falls related to resident transferring himself unassisted from bed to wheelchair. The care plan indicated Resident 6 will maintain safety awareness during unassisted transfers and will transfer safely without fall. During a review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 4/21/2026, the MDS indicated Resident 6's cognition was intact. The MDS indicated Resident 6 required partial/moderate assistance for chair/bed-to-chair transfer and sit to stand. During a review of Resident 6's physician orders dated 6/25/2026, the order indicated a physician order to apply ice to the right foot. During a review of Resident 6's Progress notes dated 6/25/2026 timed at 8:30 PM, the Note indicated, Licensed Vocational Nurse (LVN) 7 left the building for his lunch break at 8:05 PM and observed Resident 6 in the lobby, sitting in his wheelchair and talking to peers (Residents 7 and 8. The Note indicated when LVN 7 returned from lunch at 8:35 PM, the Receptionist (REC) notified him of Resident 6's fall while trying to transfer from his wheelchair to the couch in the lobby at 8:30 PM. The Note indicated pain assessment was performed, and Resident 6 had no complaints of pain, discomfort, or distress during that time. The Note indicated with the help of three staff members, Resident 6 was successfully transferred to his wheelchair and back to his room in his bed. The Note indicated no skin alterations, tears, redness, or any injuries observed from full skin assessment. The Note indicated Resident 6 was able to move bilateral upper and lower extremities without complications. During further review of Resident 6's Progress Note, the Note indicated an addendum to progress note dated 6/25/2026 timed at 8:30 PM a clarification that Resident 6 was noted on left side-lying on the floor between wheelchair and couch. The Progress Note indicated according to the REC and Resident 6's interview, Resident 6 was assisted by [REC] staff from floor to couch. The Progress Note indicated the writer noted Resident 6 sitting upright in the couch and denied hitting his head during the fall and no noted changes in level of consciousness (LOC). The Progress Note indicated Resident 6 performed range of motion (ROM) without complain of pain, had no apparent injuries to visible skin and declined to go back to his room for further skin assessment. During a review of Resident 6's Progress notes dated 6/25/2026 timed at 11:25 PM, the Note indicated Resident 6 was assessed and complained of foot pain. The Note indicated pain medication and ice therapy was offered, but Resident 6 declined. The Note indicated non-pharmacological interventions were implemented, including assisting the resident into bed and positioning him comfortably to help alleviate pain, as well as elevating the affected foot on a pillow for support. The Note indicated Resident 6 was encouraged to rest and limit weight-bearing on the affected foot as tolerated. The Note indicated Resident 6 was educated on available pain management options and instructed to notify nursing staff if pain worsened or if he decided he would like pain medication. The Note indicated Resident 6 remained stable with no signs of acute distress. The note indicated the Physician was notified 6/25/2026 at 8:45 PM. During a review of Resident 6's physician orders dated 6/26/2026, the order indicated a STAT (immediately) X-ray (a type of medical imaging that uses radiation to take pictures of the inside of the body) of the right foot. During a review of Resident 6's Radiology Results Report dated 6/26/2026, the report indicated the resident had an x-ray procedure for the right foot for 3+ and complete views. The report indicated acute to subacute 3rd, 4th, and 5th metatarsal neck fractures. During a review of Resident 6's Progress notes dated 6/27/2026 timed at 2:20 AM, the Note indicated that Resident 6's right foot appeared swollen and complained of 10/10 (severe) pain. The Note indicated the physician ordered to transfer Resident 6 to the GACH Emergency Department (ED). During a review of Resident 6's physician orders dated 6/27/2026 timed at 7:41 AM the telephone order indicated for Resident 6 to transfer to the GACH ED. During a review of Resident 6's General Acute Care Hospital's (GACH) Radiology Results dated 6/27/2026, the report indicated the x-ray result for the right foot that showed acute to subacute fracture along the head of the 5th metatarsal bone with 2-millimeter (mm, unit of measure) displacement. During a review of Resident 6's physician order dated 6/27/2026, the order indicated a physician order to wear a CAM Boot and for non-weight bearing (NWB) to the right foot. During a review of Resident 6's physician order dated 6/27/2026, the order indicated a physician order for pain management consultation for pain management. During a review of Resident 6's Interdisciplinary Care Conference Note written on 6/27/2026, the Note indicated that on 6/25/2026 at 8:30 PM, Resident 6 had a witnessed fall in the facility lobby. The note indicated the facility's Receptionist (REC) observed Resident 6 transfer himself from the wheelchair to the couch located at the facility lobby and slipped to the ground. The Note indicated during Resident 6's interview with the Director of Nursing (DON) and Administrator (ADM), Resident 6 did not feel any pain at the time of the fall because his foot was numb. The Note indicated Resident 6 reported transferring self from wheelchair back to bed and was not in pain until trying to sleep for the night on 6/25/2026. During the same review of Resident 6's Interdisciplinary Care Conference Note dated 6/27/2026, the Note further indicated staff reported Resident 6 had pain but declined Norco (brand-name prescription medication containing a combination of hydrocodone [an opioid pain reliever] and acetaminophen [Tylenol, widely used to treat minor aches, pains, and fever]) to Resident 6. The Note indicated Resident 6 was transferred to the General Acute Care Hospital (GACH) on 6/27/2026 and returned the same day with Controlled Ankle Motion (CAM) boot (fracture boot, an orthopedic brace used to immobilize the foot and ankle, support healing, and reduce weight-bearing stress) in place to the resident's right foot. The Note indicated imaging was done in the GACH that showed acute to subacute fracture of 4th and 5th metatarsal neck whereas facility imaging showed 3rd, 4th, and 5th metatarsal neck fractures. The Note indicated recommendations that included staff education on not moving the resident prior to a Registered Nurse (RN) assessment and Resident 6 was to await staff assistance prior to initiating any transfer. During a review of Resident 6's Progress Notes dated 6/27/2026 timed at 4:43 AM, the Note indicated Resident 6 was transferred to the GACH. During a review of Resident 6's Progress Notes dated 6/27/2026 timed at 8:30 AM, the Note indicated Resident 6 returned from the GACH. During an interview on 6/29/2026 at 10:45 AM, the DON stated Resident 6 fell at the facility lobby while trying to transfer from his wheelchair to the couch and slipped. The DON stated the fall was witnessed by the REC and two other residents (Resident 7 and 8). The DON stated Resident 6 had sustained fractures to the right foot: 3rd, 4th, 5th metatarsal. The DON stated the REC picked up Resident 6 by herself. The DON stated the REC informed the DON that she panicked because the residents had asked her to take a picture of them at the lobby and then Resident 6 fell so she helped Resident 6 back from the floor to the couch unassisted. The DON stated an in-service was initiated and the staff were fully aware of what happened. The DON stated the REC should not have helped Resident 6 and should have waited for a licensed staff to assist Resident 6 back to couch because Resident 6 could have gotten more injured during an unassisted transfer back to the couch. The DON stated Registered Nurse (RN) 3 and LVN 7 advised the REC not to move any resident without licensed staff assistance. During an interview on 6/29/2026 at 11:48 PM, LVN 7 stated that on 6/25/2026 when Resident 6 fell at the lobby, he was on his lunchbreak, but when he came back, he observed Resident 6 sitting upright on the lobby couch and did not observe any injuries or bleeding. LVN 7 stated he and RN 3 asked Resident 6 if he wanted to go back to his room to do a full body assessment and Resident 6 declined. LVN 7 stated pain medication was offered to Resident 6 on 6/25/2026 and the resident told him he was not in any pain. During a telephone interview on 6/29/2026 at 12:15 PM, RN 3 stated on 6/25/2026 during the 3 PM to 11 PM shift, the REC came to the Nursing Station and informed him Resident 6 fell. RN 3 stated REC told him she panicked when she saw Resident 6 fall and instantly went to the resident and tried to bring him to the couch. RN 3 stated by the time REC went to the Nursing Station, Resident 6 was on the couch. During a telephone interview on 6/29/2026 at 12:37 PM, the REC stated she observed Resident 6 transfer from the wheelchair to get on the couch. REC stated Resident 6 fell to the floor, and she got up and said to Resident 6, here let me give you a hand. The REC stated she stood in front of Resident 6 and put her hands out in front of her to pull Resident 6 up, not realizing his legs are weak, I tried to lift him and he was too heavy for me to lift. The REC stated she told Resident 6, you are too heavy, let me go behind you. The REC stated she stood behind Resident 6's right shoulder put both my arms under Resident 6's armpits and tried to lift him up with all my might and put him on the couch and immediately after, I was concerned about my lower back. The REC stated after she assisted Resident 6 on to the couch, she told the RNS on duty and was informed she should have called someone for help, everything happened so fast. The REC stated that RN 3 and LVN 7 assessed Resident 6 and explained that, upon being hired, they were instructed not to pick up residents when they fall. The REC added that she should have followed this instruction. The REC stated Resident 6 did not complain of any pain during the time he was at the facility lobby with his peers (Residents 7 and 8).

Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with professional standards of practice for one of three sampled residents (Resident 1). Licensed Vocational Nurse (LVN) 2 documented in Resident 1's Medication Administration Record (MAR) that Pregabalin (a controlled medication [a medication carries the risk of abuse, misuse, and physical or psychological dependence] used to treat nerve pain) 50 mg was administered to the resident on 6/9/2026 at 5 PM and 6/10/2026 at 5 PM. However, the medication was not available in the facility at those times or delivered by the pharmacy and was not administered to the resident. On 6/10/2026 at 5:50 PM, the medication was delivered by the pharmacy, approximately 24 hours after LVN 2 documented giving the medication to Resident 1. This deficient practice failed to ensure accurate medication documentation and had the potential to cause medication related errors, compromise the resident's clinical care, and mislead healthcare providers relying on the MAR for treatment decisions. Findings: During a review of Resident 1's General Acute Care Hospital (GACH) Transfer/Discharge Medication Review and Order Sheet dated 6/2/2026, the order indicated to continue Pregabalin for diabetic neuropathy (nerve damage caused by long-term high blood sugar and fat levels)] and to manage certain types of seizures) 50 mg, one capsule orally three times a day. During a review of Resident 1's admission Record (AR), the AR indicated the resident was admitted on [DATE] with diagnoses that included sepsis (the body's extreme, life-threatening response to an infection), muscle weakness, and sciatica (pain that radiates from the lower back, through the buttock, and down one leg). During a review of Resident 1's Progress notes dated 6/2/2026 timed 8:06 PM indicated Resident 1 was admitted to the facility and admission orders were verified with Physician 1. The note indicated all orders noted and carried out. During a review of Resident 1's Physician Order dated 6/2/2026, a telephone order indicated to give Pregabalin Oral Capsule 50 mg, 1 capsule by mouth three times a day for neuropathic pain starting on 6/3/2026. During a review of Resident 1's History and Physical Assessment (H&P) dated 6/3/2026 indicated resident had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, an assessment and screen tool) dated 6/8/2026, the MDS indicated Resident 1's cognition was intact. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) for shower/bathing self, upper and lower body dressing, putting on/taking off footwear, rolling left and right, sit to lying, lying to sitting on the side of the bed, sit to stand, and chair/bed-to-chair transfer. During a review of Resident 1's Medication Administration Record (MAR) for June 2026, the MAR indicated the following information for Pregabalin 50 mg capsule on the following dates: On 6/3/2026, 6/4/2026, 6/5/2026, 6/6/2026, 6/7/2026, 6/8/2026 scheduled at 9 AM, 1 PM, and 5 PM -the MAR indicated the Pregabalin was not administered to Resident 1. On 6/9/2026 at 9 AM and 1 PM - the MAR indicated the Pregabalin was not administered. On 6/9/2026 at 5 PM - the MAR indicated the Pregabalin was documented as administered by LVN 2. On 6/10/2026 at 9 AM - the MAR indicated the Pregabalin was on Hold by LVN 1. On 6/10/2026 at 1 PM - the MAR indicated the Pregabalin was administered as indicated by LVN 1 in the MAR, taken from the facility's Cubex. On 6/10/2026 at 5 PM- the MAR indicated the Pregabalin was documented as administered by LVN 2. During a subsequent review of Resident 1's Progress notes from 6/3/2026 to 6/5/2026, the Notes indicated the Pregabalin Oral Capsule 50 mg was not available at the facility due to a pending authorization signature required from the ordering physician and the pharmacy instructed the facility to hold administration until delivered. During a review of Resident 1's Progress notes dated 6/5/2026 timed 10:37 AM, the note indicated the Pregabalin was not available and the pharmacy was called. The note indicated per pharmacy, the licensed nurses could not pull from the facility's Cubex system (Cubex Medication System, an automated inventory management system and smart dispensing cabinet used in medical practices by tracking, securing, and recording high-value supplies and medications), because the physician has not signed the prescription and medication was not ordered as needed [PRN]. The note indicated the physician (Physician 1) and Resident 1 were made aware. During a review of Resident 1's Progress notes dated 6/5/2026 timed 2:02 PM, the Note indicated the Pregabalin was not available and the MD was aware. During a review of the facility's Cubex Medication System Transaction Report, there was no Cubex record showing Pregabalin capsules were removed on 6/9/2026 at 5 PM by LVN 2 or any other licensed nurses. During a review of Resident 1's Progress notes dated 6/10/2026 timed 9:13 AM, the Note indicated medication on hold, pending the physician's signature, the note indicated the physician was aware and to put on hold. During a review of Resident 1's Physician Order dated 6/10/2026 timed at 9:44 AM, a telephone order indicated Physician 1 ordered to hold Pregabalin 50 mg pending the physician's signature. Further review of the resident's records indicated the Pregabalin was not administered due to the medication being on hold. During a review of Resident 1's Physician Order dated 6/10/2026 timed at 11:41 AM, a telephone order indicated Physician 1 ordered to resume Pregabalin 50 mg. During a review of Resident 1's Progress notes dated 6/10/2026 timed at 1:26 PM by LVN 1, the Note indicated the prescription was signed and Pregabalin was pulled from the facility's Cubex system. The medication was still pending pharmacy delivery. During a review of the facility's Cubex Medication System Transaction Report, there was no Cubex record showing Pregabalin capsules were removed on 6/10/2026 at 5 PM by LVN 2 or any other licensed nurses, which contradicts LVN 1's MAR documentation indicating the medication was administered to Resident 1 at that time. During a review of the facility's Pharmacy Delivery Receipt dated 6/10/2026, the receipt indicated Resident 1's Pregabalin 50 mg capsule, a total of 30 doses was delivered to the facility on 6/10/2026 at 5:50 PM. During a telephone interview on 6/22/2026 at 12:01 PM with Family Member (FM) 1, FM 1 stated that Resident 1 was admitted to the facility on [DATE] and had been prescribed Pregabalin three times daily. FM 1 stated that Resident 1 did not receive the medication for more than a week. FM 1 reported informing multiple nurses on several occasions that Resident 1 needed the pain medication, but the nurses repeatedly responded that the pharmacy was waiting for the physician's signature and authorization before delivering it. FM 1 stated that during this time without the medication, Resident 1 experienced uncontrolled pain in her lower legs for over a week. During a concurrent interview and record review on 6/23/2026 at 3 PM with LVN 2, LVN 2 stated that she documented Resident 1 as having received Pregabalin 50 mg on the MAR for 6/9/2026 at 5 PM and 6/10/2026 at 5 PM; however, the medication was not delivered to the facility until 6/10/2026 at 5:50 PM. LVN 2 stated she did not borrow Pregabalin from other residents and did not obtain it from the facility's Cubex system. LVN 2 confirmed that she did not administer Pregabalin 50 mg to Resident 1 on either 6/9/2026 or 6/10/2026 at 5 PM, but nevertheless documented the doses as administered on the MAR. LVN 2 stated she should have documented that the Pregabalin was not administered to Resident 1 on 6/9/2026 at 5 PM and 6/10/2026 at 5 PM. During a concurrent interview and record review on 6/23/2026 at 3:02 PM with the Assistant Director of Nursing (ADON), Resident 1's Physician Orders dated 6/2/2026, the MAR for June 2026, the facility's Cubex Medication System transaction report dated 6/10/2026, the Pharmacy Delivery Receipt dated 6/10/2026, and Resident 1's Controlled Drug Record for Pregabalin (6/11/2026-6/15/2026) were reviewed. The ADON stated there was no Cubex record showing Pregabalin capsules were removed on 6/9/2026 at 5 PM or 6/10/2026 at 5 PM. The ADON stated LVN 2 did not administer Pregabalin 50 mg to Resident 1 at those times, although the doses were documented as given on the MAR. The ADON stated that LVN 2's documentation did not accurately reflect the care Resident 1 received, and such discrepancies could compromise resident safety and lead to medication errors. The ADON further stated that professional standards require licensed nurses that included LVN 2 to document medications only after administering them. During a review of the facility's Policy and procedures (P&P) titled, Guidelines for Charting and documentation, dated 4/2012, the P&P indicated the purpose of charting and documentation is to provide a complete account of the resident's care, treatment, response to the care, signs symptoms and the progress of the resident's care. The P&P indicated charting to be concise, accurate and complete. During a review of the facility's P&P titled, Administering Medications, dated 4/2019, the P&P indicated The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. During a review of the facility's P&P titled, Code of Conduct, dated 11/16/2020, the P&P indicated the facility was committed to following all applicable policies, laws and licensing/accreditation requirement relating to quality of care and patient safety, and uphold the professional standard of care, report patient safety concerns, and engage in quality improvement.

Based on observation, interviews, and record reviews, the facility failed to ensure one of three sampled residents (Resident 1), who was totally dependent with care of daily living, abnormal posture with a left knee contracture (a permanent tightening or shortening of muscles, tendons, or skin that causes a joint to become stiff and locks it into a bent position), non-verbal, and had an altered mental status, was free from fall and injury in accordance Resident 1's care plan (CP), titled Resident utilizes LALM for Wound/Skin Management, dated 1/31/2026, and the facility procedure, titled Repositioning, revised 2013 and Fall Management, dated 5/26/2021 by failing to: 1. Ensure Certified Nurse Assistant (CNA) 1 requested for staff assistance before repositioning Resident 1 to the side during linen change while the resident was on a Low Air Loss Mattress (LALM, mattress that operates using a blower-based pump that was designed to circulate a constant flow of air) on 5/7/2026 at 4:30 AM. 2. Ensure CNA 1 did not transfer Resident 1 back to bed, prior to LVN 2 observing, checking and assessing Resident 1's injuries in accordance with the facility's Policy and Procedure (P&P) titled, Fall Management, dated 5/26/2021. 3. Ensure the Director of Nursing (DON) and the Administrator (ADM) thoroughly investigate the root cause of the fall and injury by interviewing CNA 1 who witnessed the fall and to update care plan to reflect new interventions to prevent recurrent fall. These deficient practices resulted in Resident 1 sliding off the bed and fall on the floor striking Resident 1's head on the nightstand on 5/7/2026 at 4:30 AM. Resident 1 sustained a wound measuring 0.5 x (times) 0.1 x 0.1 centimeter (cm, unit of length) with scratch, swelling, bruising on the right outer eye with active bleeding, and complete bilateral anterior jaw dislocation with superior migration (a severe medical emergency when both sides of the lower jaw have popped entirely out of their sockets, moved forward in front of the joint ridge, and shifted forcefully). Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis that included hemiplegia (paralysis that affects only one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (occurs as a result of disrupted blood flow to the brain), dementia (a progressive state of decline in mental abilities), left knee contracture, abnormal posture, and muscle weakness. During a review of Resident 1's CP, titled Resident utilizes LALM for Wound/Skin Management, dated 1/31/2026, the CP indicated Resident 1 utilized LALM for wound/skin management. The goal was for Resident 1 to have no complications with the use of LALM. The CP interventions included providing Resident 1 with two-person physical assistance during transfers and bed mobility. During a review of Resident 1's Physician's Order (PO), dated 2/3/2026, the PO indicated Resident 1 was using LALM every shift for wound management. During a review of Resident 1's Minimum Data Set (MDS- a required standardized assessment and care planning tool) dated 2/6/2026, the MDS indicated Resident 1's cognitive skills (ability to think and process information) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 1 was non-verbal and unable to understand others. The MDS indicated Resident 1 was dependent (helper does all the effort, resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required to complete the activity) on toileting, hygiene and rolling left and right (the ability to roll from lying back to left and right side and return to lying on back on the bed). During a review of Resident 1's Situation, Background, Assessment and Recommendation (SBAR, a standardized communication framework used in nursing homes to concisely convey critical resident information among providers), dated 5/7/2026, documented by LVN 1, the SBAR indicated Resident 1 had a scratch with bleeding and slight purple discoloration on the right outer eye area. The SBAR indicated Resident 1 was agitated, moving her arm up and down and grabbing/scratching her gown. The SBAR indicated Resident 1 was in bed while Rehabilitation Nurse Aide (RNA) 1 reported to LVN 1 that Resident 1 was bleeding on the right outer eye area and slight amount of blood was on Resident 1's pillowcase. The SBAR indicated LVN 1 assessed Resident 1 and noted scratches with small amount of bleeding and slight purple-green discoloration on Resident 1's right outer corner of the right eye. The SBAR indicated Resident 1's Primary Care Clinician (NP 1) was made aware on 5/7/2026 at 9 AM, and NP 1 recommended to monitor Resident 1 for any vision issues and to start treatment by Treatment Nurse (TXN) 1. During a review of Resident 1's Body check, dated 5/7/2026, documented by TXN 1, the assessment indicated Resident 1 had a right outer eye scratch 0.5 x 0.1 x 0.1 cm with scant sanguineous drainage (the leakage of fresh blood from an open wound) with no odor, 100 % pink. During a review of Resident 1's Nurses Progress Note (NPN), dated 5/8/2026 timed at 8:43 AM, the NPN indicated Resident [1] noted with swelling/bruising to the orbital region (the bony eye socket and everything inside it) during assessment. Initial image (picture) obtained yesterday (5/7/2026) with follow-up image obtained early this morning (5/8/2026) showing worsening appearance/swelling to the affected [right eye] area. Charge nurse previously followed up with MD (MD 1), who advised monitoring for any vision impairment or obscured vision The NPN indicated, Resident [1] is not alert/oriented at baseline and unable to appropriately verbalize symptoms or participate in a reliable vision assessment. No identifiable or witnessed fall reported at this time. Follow-up communication completed with the NP (Nurse Practitioner 1) regarding worsening condition and updated images were provided for review. The NPN indicated Resident [1] also noted to be on aspirin therapy, increasing concern for possible underlying injury/bleeding. Orders subsequently received to transfer resident to the hospital for further evaluation of head trauma and for CT imaging (Computed Tomography scan, is a noninvasive medical imaging test that combines a series of X-rays [a painless medical imaging test] taken from different angles of the bones, organs and soft tissues) of the head/brain. EMS (Emergency Medical Services, a system that responds to emergencies in need of highly skilled pre-hospital clinicians) activated and resident transferred out to hospital in stable condition for further workup and management. Responsible party (Resident 1's responsible party) notified. Continued monitoring including neuro checks and documentation completed throughout shift before transfer. During a review of Resident 1's PO, dated 5/8/2026, the order indicated for staff to transfer Resident 1 to GACH 1 for CTA (Computed Tomography Angiography, an X-ray that uses contrast materials to examine blood flow in blood vessels) of head/brain. During a review of Resident 1's GACH 1 ED (Emergency Department) Note, dated 5/8/2026 timed at 11:16 AM, the ED Note indicated Resident 1 arrived at the ED via ambulance for evaluation of wounds, bruising and swelling to the right eye area with unknown cause. The ED Note indicated there was no report of the residents falling to the ground. The ED Note indicated Resident 1 was found with a small scratch to the right side of the face just above her right eye as well as a small area of bruising immediately adjacent to the right eye, ecchymosis to the right orbit (a black eye or a bruise around the eye socket). The ED Note indicated there had been no reports of trauma. The ED Note indicated Resident 1's diagnosis that included bilateral anterior jaw dislocation, and right orbit ecchymosis. The ED note indicated Resident 1 would require transfer to a higher level of care for OMFS consultation. During a review of GACH 1's CT scan result, dated 5/8/2026, the CT scan result indicated complete bilateral anterior jaw dislocation with superior migration. During a review of GACH 2's History & Physical - Adult (H&P), dated 5/9/2026, the H&P indicated Resident 1 presented with right-sided deficits, contractures of the lower extremities (legs), baseline nonverbal and non-ambulatory (not able to walk without assistance or at all). The H&P indicated Resident 1 was brought to GACH 1 from SNF 1 for multiple bruises and facial fractures. The H&P indicated SNF 1 stated no reported trauma and the wound was self-inflicted. During an observation on 5/12/2026 at 9 AM in Resident 1's room, Resident 1 was not in the room. Resident 1's bed has a LALM, and a three-drawers nightstand was on the left side of Resident 1's bed. During an interview on 5/12/2026 at 9:30 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, on 5/7/2026, at 8:30 AM, RNA 1 called LVN 1 into Resident 1's room and reported that RNA 1 saw blood on the resident's right outer eye. LVN 1 stated LVN 1 noticed fresh blood on the Resident 1's pillowcase, approximately the size of a small egg and Resident 1 was also bleeding above the corner of Resident 1's right eye. LVN 1 stated, LVN 1 called MD 1'office but spoke to NP 1 and received an order from NP 1 to monitor Resident 1's right eye wound and assess Resident 1 for any vision changes. LVN 1 stated, LVN 1 took care of Resident 1 again on 5/8/2026, at 7 AM (morning shift) and noticed the wound on Resident 1's right eye got bigger and the bruise was more purple in color. LVN 1 stated LVN 1 reported her finding to Registered Nurse (RN) 1 who contacted NP 1 again. LVN 1 stated NP 1 ordered to send Resident 1 to GACH 1 for further evaluation due to a concern for trauma. During an interview on 5/12/2026 at 9:45 AM with RNA 1, RNA 1 stated on 5/7/2026, at around 8 or 8:30 AM when RNA 1 put on Resident 1's splint (a device that hold bones and joints in place so they can heal after a fracture, injury or surgery), RNA 1 saw small amount of fresh blood on Resident's pillowcase and on Resident 1's right eye. RNA 1 stated RNA 1 called LVN 1 right away to let LVN 1 know about Resident 1's condition (bleeding on the right eye). During a phone interview on 5/12/2026 at 1:45 PM with CNA 1, CNA 1 stated on 5/6/2026, CNA 1 worked from 11PM-7AM shift (night shift) and took care of Resident 1. CNA 1 stated, at around 4:30 AM in the morning of 5/7/2026, CNA 1 changed Resident 1's adult incontinence brief by herself without staff assistance. CNA 1 stated, CNA 1 was standing on the right side of Resident 1's bed when Resident 1 was laying on the resident's right side. CNA 1 stated, CNA 1 turned Resident 1 over to Resident 1's left side to clean the resident's bottom by turning the resident's right leg. CNA 1 stated the LALM was slippery and Resident 1's right leg was contracted and stiff, which caused Resident 1 to be pulled downward, the resident slid out of bed and landed on the floor. CNA 1 stated, Resident 1 landed on Resident 1's bottom and Resident 1's head hit the nightstand, which was on the left side of Resident 1's bed. CNA 1 stated, Resident 1 ended up on the floor while leaning on the nightstand. CNA 1 stated, CNA 1 could not catch Resident 1 because Resident 1 was falling to the other side of the bed (the left side of the bed). CNA 1 stated I asked if the resident (Resident 1) was ok, but the resident did not respond so I (CNA 1) thought the resident was fine. CNA 1 stated, CNA 1 saw some blood around Resident 1's right eye area so CNA 1 wiped the blood and pulled Resident 1 back to bed alone without asking a staff for assistance. CNA 1 stated, CNA 1 did not report the incident to CNA 1's supervisor (LVN 2) or tell anyone regarding Resident 1's fall (on 5/7/2026, at 4:30 AM) because CNA 1 had to attend to other residents. CNA 1 further stated, nobody from the facility has asked CNA 1 anything related to Resident 1's fall. CNA 1 stated you are the first person to ask me about the resident's (Resident 1's) fall [the fall on 5/7/2026, at 4:30 AM]. During a review of CNA 1's handwritten letter provided by the facility, dated 5/12/2026, (untimed), the letter indicated CNA 1 worked night shift (11PM-7AM) on 5/6/2026 and took care of Resident 1. The letter indicated on 5/7/2026, at 4:30 AM, during the morning care, CNA 1 turned Resident 1 to Resident 1's left side and reached for the protective chuck (incontinent pad). Resident 1's right leg pulled Resident 1's body down and Resident 1 ended up sliding on the floor on her bottom in a sitting position and hitting her head on the nightstand. The letter indicated The Resident (Resident1) didn't make any sound, just opened her eyes. The letter indicated CNA 1 asked if Resident 1 was ok but no sound or responds and the resident didn't appear to be in pain. The letter indicated CNA 1 picked up the resident (Resident 1) and put her back in bed in a sitting position. During an interview on 5/12/2026 at 3:50 PM with the Assistant Director of Nursing (ADON), the ADON stated CNA 1 should have reported the fall incident to the licensed nursing staff (LVN 2) immediately after Resident 1's fall (on 5/7/2026, at 4:30 AM), and should not handle the situation (Resident 1's fall with injuries) by herself. The ADON stated, after Resident 1's fall, the Registered Nurse (RN) should have assessed Resident 1 to make sure the resident was safe and reported the fall to the doctor (MD 1) right away for treatment and monitoring orders. The ADON stated, It's important to know if the resident (Resident 1) had a fall and hit her (Resident 1's) head because the doctor needs to know regarding Resident 1's fall right away so Resident 1 could receive immediate and correct treatment to prevent any complication from the injuries due to the Fall. During an interview on 5/12/2026 at 4:47 PM with the DON, the DON stated, the DON did not interview CNA 1 when the DON investigated the root cause of Resident 1's fall/injuries. The DON stated, CNA 1 told the DON that CNA 1 was overwhelmed so CNA 1 did not inform any staff member from the facility about Resident 1's fall. During a concurrent interview and record review on 5/13/2026 at 12:45 PM with the Director of Staffing Development (DSD), the facility's competency skills check titled, Positioning/Transferring, Changing Resident in Low Air Loss Mattress, undated, was reviewed. The competency skills check indicated all positioning/transferring/changing of a resident on a LALM must always use two-person assist/technique for safety; CNA/Nurse position themselves on one side, the other CNA/nurse on the opposite side of bed. The DSD stated that the competency skills check is part of the facility's policy. The DSD stated, LALM is one of the risk factors that contribute to the residents' fall because of the air distribution in the mattress, which can make one side of the bed raised higher than the other side of bed and increase the fall risk for all residents. During a concurrent observation and interview on 5/13/2026 at 1 PM with the DSD in Resident 1's room, the DSD stated that Resident 1's mattress was a LALM. The DSD sat on the right side of Resident 1's bed, the mattress immediately sank on the right side and raised on the opposite side, the unbalanced surface making it easier to slide and fall off bed. The DSD stated that two-person assistance is required to make sure the resident (in general) will not slide out of bed. During a current interview and record review on 5/13/2026 at 1:30 PM conducted with the DSD, CNA 1's competency skills set and the policy and procedure titled, Positioning/Transferring, Changing Resident in Low Air Loss Mattress, dated 8/25/2025, was reviewed. The DSD stated that CNA CNA1 received training on the procedure for positioning/transferring, changing resident in LALM on 8/25/2026. The DSD stated she expected CNA 1 to follow the facility's policy and procedure to ensure the resident's safety during repositioning, transferring and changing the resident in LALM. During a concurrent interview and record review on 5/13/2026 at 1:40 PM conducted with TXN 1, Resident 1's care plan with the focus of Resident utilizes LALM for wound/skin management, dated 1/31/2026, was reviewed. TXN 1 stated, Resident 1's care plan interventions indicated to provide 2-person physical assistance with transfers and bed mobility. TXN 1 stated, bed mobility included repositioning, transferring resident in and out of bed, turning while changing. TXN 1 stated, because the LALM can move due to alternate pressure, Resident 1 would be at higher risk for fall while CNA 1 repositioning and changing the resident so 2-person assist is required. During an interview on 5/13/2026 at 3:30 PM with the ADON, the ADON stated Resident 1 should have 2-person physical assistance because Resident 1 was on LALM. ADON added, the LALM has air filled in it and the pressure can shift so patients are at higher risk of sliding from the bed to a lower surface. The ADON stated, CNA 1 needed to ask or wait for someone (another available staff member) to help CNA 1 with turning and cleaning Resident 1 because the resident was on LALM. The ADON stated, when Resident 1 slid out of bed, CNA 1 needed to report the incident right away so appropriate interventions could have been implemented immediately to prevent a delay in complications from the injuries due to the fall. The ADON stated that immediate prevention should have been provided such as Register Nurse (RN in general) who could have done neuro check (checks how different parts of your nervous system are working), perform comprehensive assessment (complete and through assessment). The ADON stated that facility staff could have transferred Resident 1 immediately to the hospital for CT scan due to trauma to Resident 1's head from a witnessed fall. During an observation and attempt to interview Resident 1 on 5/15/2026 at 10 AM, Resident 1 had purple discoloration around Resident 1's right eye area, and Resident 1's lower lip had scabs, and medical wires were in the resident's mouth. Resident 1 was awake and not able to make any sound or answer any questions. During an interview on 5/15/2026 at 2 PM with NP 1, NP 1 stated on 5/7/2026 NP 1 was informed that Resident 1 had a skin scratch on the side of Resident 1's right eye, so NP 1 ordered nursing staff (LNV 1) to monitor Resident for visual changes and provide wound care. NP 1 stated NP 1 asked LVN 1 if Resident 1 had a fall because it was significant to know, especially if Resident 1 hit the head with injuries. NP 1 stated if Resident 1 had a fall and hit the resident head Resident 1 should be transferred to the hospital right away for higher level of care and evaluation. NP 1 stated if NP 1 knew Resident 1 had fallen and struck Resident 1's head on the nightstand, NP 1 would have ordered for LVN 1 to call 911 (emergency telephone number) so Resident 1 could be transferred to the acute hospital immediately as head trauma requires prompt assessment and imaging to prevent delays in necessary care and treatment. NP 1 stated that neuro checks alone might not be sufficient given Resident 1's condition (dementia and nonverbal), Resident 1 would not be able to communicate Resident 1's feeling and what had happened to Resident 1. During an interview on 5/15/2026 at 2:10 PM with the DON, the DON stated that for residents (in general) on a LALM, the DON expected CNAs (all CNAs) to follow the facility's policy and procedure that required a two-person assist to ensure resident safety. The DON stated that because the alternating pressure of the LALM increased the risk of falls, two-person physical assistance is required when turning or repositioning the resident (any resident) for peri care per facility's policy. During an interview on 5/15/2026 at 3:15 PM with Resident 1's family member (FAM) 1, FAM 1 stated, FAM 1 was very upset and disappointed with the care provided by the facility. During a review of the facility's policy and procedures (P&P) titled, Repositioning, revised 2013, the P&P indicated, the procedure for repositioning the resident in bed included to check the care plan to determine resident's specific positioning needs including special equipment, resident level of participation and the number of staff required to reposition the resident. During a review of the facility's P&P titled, Positioning/Transfer and Changing Resident with Low Air Loss Mattress, revised 10/24/2024, the P&P indicated the policy establishes techniques, responsibilities, and protocols for transferring, repositioning and changing of residents on an Air Loss Mattress to ensure safety of the resident and employee; Positioning, repositioning, transferring and changing a resident is a primary responsibility of nursing assistants. During a review of the facility's P&P titled, Bed, Special - Low Air Loss Therapy, revised 11/2012, the P&P indicated: It is the policy of the facility to utilize low air loss therapy under the direction of a physician's order. Facility staff working directly with the low air loss therapy unit will have training in its use by company representatives or a trained facility staff member. During a review of the facility's P&P titled, Fall Management, dated 5/26/2021, the P&P indicated: patients experiencing a fall will receive appropriate care and investigation of the case. If the patient falls: observe/check for injury, document accident/incident in the clinical record, update care plan to reflect new intervention, notify physician and responsible party, interdisciplinary to review post fall.

Based on interview and record review, the facility failed to ensure the continuity of care for one of 2 sampled residents (Resident 1) during their admission to the facility transitioning from a general acute care hospital (GACH) by failing to reconcile Resident 1's admission orders as evidenced to include vancomycin (an antibiotic or medication used to treat infection). This failure led to a break in course of therapy for Resident 1 and a delay of more than 24 hours to administer vancomycin (an antibiotic to treat Clostridioides difficile, also known as C. diff or C. difficile, which is a highly contagious bacterium that infects the large intestine, causing severe inflammation and watery diarrhea) that had a potential to worsen resident's infection and health condition.During a review of Resident 1's admission record, the record indicated Resident 1 was originally admitted to the facility on [DATE] and last readmitted on [DATE], with diagnoses that included: Chronic Obstructive Pulmonary Disease (COPD, is a progressive, inflammatory lung disease that restricts airflow and causes breathing difficulties), dysphasia (a language disorder caused by brain damage that impairs your ability to produce, understand, or process spoken and written language) following cerebral infarction (a medical emergency that occurs when blood flow to an area of the brain is blocked or significantly reduced), and need for assistance with personal care. During a review of Resident 1's Minimum Data Set (MDS, a mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes), dated 3/2/2026, MDS indicated Resident 1 had no speech (absence of spoken words), rarely or never able to express ideas and wants, rarely or never understood others. Resident 1 had short- and long- term memory problems, and severely impaired cognitive skills for daily decision making. Resident 1 was dependent (helper does all of the effort) on others for self-care and mobility. During an interview on 5/15/2026 at 11 AM, the Director of Nursing (DON) reviewed Resident 1's census list and stated Resident 1 was readmitted to the facility from GACH on 4/24/2026 at 6:12 PM. During a concurrent interview and record review of the Physician's Order on 5/15/2026 at 11 AM with the DON, the DON stated Resident 1's Physician's Orders on 4/25/2026 at 2:24 PM to be given vancomycin orally (by mouth) in suspension (a liquid medication where solid particles of the drug do not dissolve completely) 50 milligrams (mg, unit to measure mass) per (/) milliliter (ml, unit to measure volume) to give 2.5 ml via G-Tube (a soft, flexible medical device surgically inserted into the abdomen to the stomach and used to deliver nutrition, hydration, and medications) every 6 hours. During a concurrent review of the pharmacy delivery receipt, the receipt indicated the facility received Resident 1's vancomycin on 4/25/2026 at 6:38 PM. During an interview on 5/15/2026 at 12:24 PM, and a concurrent review of Resident 1's medication administration record (MAR) for April 2026, DON stated Resident 1 received the first dose of vancomycin at the facility on 4/25/2026 around 6 PM. DON was not sure why there was a delay on Resident 1's vancomycin that was ordered on 4/25/2026 and not on 4/24/2026 during the admission at the facility. DON also stated the admitting nurse was responsible to reconcile and verify medication orders on admission which was not done. During an interview on 5/15/2026 at 1:01 PM, the Registered Nurse (RN) 1 stated, the RN on duty usually conducts the admission assessment and reconcile the physicians orders from the GACH to the facility. RN 1 stated new antibiotic order usually takes 2 - 4 hours for the pharmacy to deliver, and the facility has automated dispensing cabinet (ADC, a computerized medication storage system) for first doses and emergency use. However, RN 1 stated Resident 1's vancomycin oral suspension was not stocked in the facility's ADC. RN 1 did not remember why Resident 1's vancomycin order was entered a day after resident's admission. During an interview on 5/15/2026 at 2:50 PM, DON stated there was no documentation explaining why Resident 1's vancomycin oral suspension order was not ordered on 4/24/2026 but delayed until 4/25/2026 at 2:14 PM, while Resident 1's other medications were ordered shortly after the admission on [DATE]. DON acknowledged that the admitting nurse missed Resident 1's antibiotic order. During a review of the facility's policy, admission Assessment and Follow Up: Role of the Nurse (revised September 2012), the policy indicated upon admission, the nurse should conduct an admission assessment, including contacting the attending physician to obtain admission orders and record in the resident's medical record of orders obtained from the physician.

Based on observation, interview, and record review, the facility failed to ensure one of 3 sampled residents reviewed with pressure ulcers (Resident 6) and admitted without a pressure ulcer (skin damage due to prolonged unrelieved pressure and skin friction) received treatment and services to protect skin integrity (the state of skin being intact, healthy, and free from damage), promote healing, and prevent the development and worsening of pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence) by failing to: 1. Conduct a skin assessment and risk evaluation upon admission and weekly during the first month after admission on [DATE] to determine the treatment and services Resident 6 required to prevent the development of pressure ulcers in accordance with the facility's policy and procedure titled, Skin Integrity Management, effective 5/26/2021. 2. Develop a comprehensive care plan (CP) with specific interventions to prevent the development of pressure ulcers for Resident 6 from admission 1/7/2026 through 1/16/2026. 3. Ensure LVN 3 measured Resident 6's pressure ulcer upon initial identification on 1/13/2026 to facilitate appropriate treatment orders. 4. Provide necessary wound treatments on 1/13/2026 and 1/14/2026 upon identification of a Stage 3 pressure ulcer (a serious, full-thickness skin injury appearing as a deep crater, extending through the skin into subcutaneous fat, but not exposing muscle, tendon, or bone) and deep tissue injury (DTI- a serious form of pressure ulcer/sore involving damage to underlying soft tissue, often presented as purple or maroon localized, intact skin) on Resident 6's sacrococcyx (tail bone) as ordered by the physician. As a result of these deficient practices, Resident 6 developed a deep tissue injury and Stage 3 pressure ulcer on the sacrococcyx, characterized by purple discoloration and measuring 5 cm in length, 7 cm in width, and 0.2 cm in depth, with a light amount of serosanguineous drainage (thin, watery, pink to light red fluid from a wound). The wound required surgical debridement (removal of damaged tissue or foreign objects). In addition, these deficient practices placed Resident 6 at risk for infection, discomfort, and pain at the pressure ulcer site Findings: During a review of the facility's policy and procedure (P&P) titled, Skin Integrity Management, effective 5/26/2021, the P&P indicated the following: The facility is to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds. Complete comprehensive evaluation of the [resident] upon admission/re-admission to the center. Complete risk evaluation on admission/readmission, weekly for the first month, quarterly, and with significant change in condition. Perform wound observations and measurements upon initial identification of altered skin integrity, weekly, and with anticipated decline of wound. Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments, as indicated. Implement pressure ulcer prevention for identified risk factors. Determine the need for support surface for bed and chair. During a review o/f the facility's policy and procedure (P&P) titled, Care Plan Comprehensive, effective 8/25/2021, the P&P indicated the following: An individualized comprehensive care plan that includes measurable objectives and timetables to [NAME] the resident's medical, physical, mental, and psychosocial needs shall be developed for each resident. The facility's Interdisciplinary Team (IDT) must develop and implement a comprehensive person-centered care plan for each resident. Each resident's comprehensive care plan is designed to incorporate risk and contributing factors associated with identified problems, aid in preventing or reducing declines in the resident's functional status and/or functional levels, and reflect currently recognized professional standards of practice for problem areas and conditions. The comprehensive care plan includes services that are to be furnished to attain or maintained the resident's highest practicable physical, mental, and psychosocial well-being. Assessments of residents are ongoing, and care plans are reviewed and revised as information about the resident and the resident's condition change. The IDT is responsible for evaluation and updating of care plans when there has been a significant change in the resident's condition. During a review of Resident 6's admission Record (AR) indicated the resident was admitted on [DATE] with diagnoses that included muscle weakness, lack of coordination, and paraplegia (paralysis of the legs and lower body). The AR did not indicate presence of pressure ulcers. During a review of Resident 6's History and Physical (H&P), dated 1/8/2026 indicated the resident does not have the capacity to understand and make decisions. The H&P indicated Resident 6 had no pressure ulcer. During a review of Resident 6's Physical Therapy Evaluation note (a comprehensive initial assessment where a therapist gathers your medical history, strength assessment, flexibility, balance, and function), dated 1/7/2026, the evaluation indicated that Resident 6 required maximal assistance (the helped does more than half the effort) to roll left and right in bed. During a review of Resident 6's Occupational Therapy Evaluation note (an assessment of an individual's abilities and challenges in daily activities to identify strengths and barriers, leading to a personalized treatment plan to improve function and independence), dated 1/10/2026, indicated that Resident 6 required maximal assistance in activities and personal hygiene. During a review of Resident 6's skin assessment note titled, Braden Scale for Predicting Pressure Ulcer Risk (BSP, an assessment tool used to determine a resident's risk factors for developing pressure ulcers), dated 1/7/2026 and timed at 4:41 PM, indicate the facility did not complete the BSP to indicate the resident's risk for developing pressure ulcer. The BSP also did not have a signature of a facility staff who initiated the assessment. During a review of Resident 6's care plans developed from 1/7/2026 to 1/16/2026 indicated there was no documented evidence a care plan was developed for pressure ulcers that address interventions to prevent the development and worsening of pressure ulcers, including providing maximal assistance to roll left and right in bed. During the review of Resident 6's Interdisciplinary (IDT) Care Conference (a conference conducted by a group of facility staff, the resident and responsible party to discuss the individualized care plan for the residents) held on 1/9/2026, the team did not document or address that Resident 6 had a pressure ulcer. During a review of Resident 6's Body Check from 1/7/2026-1/13/2026 indicated no documented evidence that Resident 6 was identified having skin breakdown, pressure ulcers, or open wounds. During a review of Resident 6's Change in Condition (CIC) Evaluation, dated 1/13/2026, timed at 4:48 PM, and documented by LVN 3, the CIC indicated that Resident 6 had a DTI on the left buttock and a Stage 3 pressure ulcer with surrounding DTI on the sacrococcyx. The CIC indicated that Resident 6's physician was notified on 1/13/2026 at 3:09 PM with recommendations for a wound consultation and treatment order. During a review of Resident 6's medical records revealed no documented evidence of physician orders for wound treatment for the newly developed Stage 3 pressure ulcer on Resident 6's sacrococcyx, despite LVN 3 informing the physician about the ulcer on 1/13/2026. During a review of Resident 6's physician's orders dated 1/14/2026 (obtained one day after the pressure ulcer was identified), new treatment orders were issued for Resident 6 which included the following: Cleanse sacrococcyx (area of the buttocks) Stage 3 with NS (normal saline, a sterile cleaning solution), pat dry and apply medi-honey (a medication to treat wounds) with barrier cream to surrounding skin and cover with foam dressing [one time] now Cleanse left buttocks DTI with NS, pat dry and apply zinc oxide (a cream that helps treat or prevent skin irritation like cuts, burns or diaper rash) and leave open to air (uncovered) one time. During a review of Resident 6's Medication Administration Records (MAR) and Treatment Administration Records (TAR) for January 2026 indicated that Resident 6 did not receive any initial wound or skin treatments, including treatment for pressure ulcers, on 1/13/2026-after LVN 3 identified a Stage 3 pressure ulcer on Resident 6 and documented it in a CIC note at 4:48 PM on the same day. Furthermore, the MAR and/or TAR did not contain documented evidence that wound treatments were performed on 1/14/2026, despite the physician's orders for Stage 3 wound treatments, including the application of Medi-Honey and zinc oxide to Resident 6's sacrococcyx and left buttocks, as ordered on 1/14/2026. During a review of Resident 6's BSP after the identification of the Stage 3 pressure ulcer, dated 1/16/2026, timed at 2:26 PM, the BSP indicated that Resident 6 was at moderate risk of developing a pressure ulcer. During an observation on 1/13/2026 at 2:48 PM, Resident 6 was lying bed supine (lying on the back) without a low air loss mattress. During an interview on 1/13/2026 at 2:49 PM with Family Member (FM) 3, FM 3 stated that Resident 6 was admitted to the facility on [DATE] without skin breakdown, redness and pressure ulcer. FM 3 stated, while assisting a nurse (Certified Nursing Assistant (CNA) 1) with changing Resident 6's soiled incontinent brief at approximately 11:43 AM today, she observed redness on the resident's buttock that was not previously present. FM 3 stated she did not know how long the resident had been soiled and confirmed that Resident 6 had been lying on a regular mattress and not on a Low Air Loss mattress since admission to the facility. FM 3 showed the surveyor a picture that she took of Resident 6's buttocks that showed an open skin. During an interview on 1/13/2026 at 3:13 PM, CNA 1 stated that she offered to change Resident 6's incontinence brief around 9:00 AM, but Resident 6 refused. CNA 1 further stated that at approximately 11:45 AM, she assisted FM 3 in changing Resident 6's incontinent brief, which contained a small amount of stool. CNA 1 reported that she did not know how long Resident 6 had been wearing the soiled brief. CNA 1 stated that FM 3 cleaned and wiped Resident 6's buttock/sacrococcyx area while she held the resident. CNA 1 explained that because she was assisting with holding Resident 6, she did not observe the skin on the buttock area during the change and was unaware that Resident 6 had an open wound. During an interview on 1/13/2026 at 3:07 PM with Licensed Vocational Nurse (LVN) 3, LVN 3 stated FM 3 reported to her that Resident 1 had skin redness on his buttock area about an hour ago today. LVN 3 stated she had not assessed Resident 1's skin, but the picture that FM 3 showed her looked like Resident 1's skin was broken. LVN 3 stated she had not notified the doctor about Resident 6's skin condition (Stage 3) at this time yet. During another interview on 1/13/2026 at 3:20 PM with LVN 3, LVN 3 stated upon skin assessment on 1/13/2026 Resident 6 was observed with skin breakdown on the buttocks that the facility had not identified before. LVN 3 stated she informed the doctor at 3:09 PM and is currently awaiting a response. On 1/14/2026, during a review of Resident 6's medical records, the records did not indicate documented evidence that Resident 6's pressure ulcer on the buttocks was assessed for size and appearance such as presence of drainage if any, color of the pressure from 1/13/2026 and 1/14/2026. During a review of the Wound Assessment, dated 1/15/2026, signed by the Physician Assistant (PA), the PA documented that Resident 6 had a Stage 3 pressure ulcer on the sacrococcyx with purple discoloration, measuring 5 centimeter (cm) in length, 7 cm in width, and 0.2 cm in depth. The ulcer had a light amount of serosanguineous drainage. The intervention included applying Medi Honey with dry dressing and continuation of pressure reduction and offloading. The Note also indicated that a surgical debridement (removal of damaged tissue or foreign objects from a wound) was performed on the resident. During a concurrent observation and interview on 1/16/2026 at 12:40 PM with TN 1 inside Resident 6's room, Resident 6 was observed lying in bed without the LAL mattress. TN 1 stated Resident 6 should be on a LAL mattress. During a concurrent interview and record review on 1/16/2026 at 12:42 PM with TN 1, Resident 6's CIC, dated 1/13/2026 and timed at 4:48 PM was reviewed. TN 1 stated according to the CIC Resident 6 was found to have a pressure ulcer on 1/13/2026 which did not include the measurements of the wound and initial wound treatments. TN 1 added that measurements of the wound is part of the nurse's assessment and wounds must be measured so they can track if the wound is getting better or worsening. During the same concurrent interview and record review on 1/16/2026 at 12:42 PM with TN 1, Resident 6's records were reviewed. TN 1 stated a care plan was not developed for Resident 6 that indicates interventions to prevent the development of pressure ulcers when the resident was admitted on [DATE] and a CP to prevent worsened pressure ulcer that was identified on 1/13/2026. TN 1 added that a care plan to prevent pressure ulcer should include interventions such as repositioning the resident at least every two hours and using LAL mattress and keeping the resident clean and dry by changing the incontinent brief immediately when soiled. During another concurrent interview and record review of Resident 6's Wound Assessment, dated 1/15/2026 on 1/16/2026 at 1:02 PM with TN 1. TN 1 stated that the wound assessment indicated that Resident 6's sacrococcyx wound was a Stage 3 pressure ulcer. TN 1 stated that Resident 6 should be on a low air loss mattress as a pressure reduction to prevent further worsening of the wound. During a concurrent interview and record review on 1/16/2026 at 1:54 PM with RN 2, RN 2 stated Resident 6's BSP was not completed since the resident was admitted to the facility on [DATE]. RN 2 stated the BSP was incomplete because it lacked markings, score, and category to indicate the Resident 6's risk for pressure ulcer. RN 2 explained the BSP is a tool used by the facility to determine interventions to prevent pressure injuries and emphasized that Resident 6's paraplegia the resident at higher risk. RN 2 added that not having proper interventions could lead to pressure injuries, such as the stage 3 ulcer that developed on Resident 6's sacrococcyx. During an interview on 1/16/2026 at 1:54 PM, during an interview and record review with RN 2, Resident 6's medical records were reviewed, including the MAR, TAR and a CIC dated 1/13/2026 timed at 4:48 PM. RN 2 stated Resident 6's TAR indicated facility staff did not perform wound treatments on Resident 6's buttocks pressure ulcer on 1/13/2026 and 1/14/2026 (two days). RN 2 stated that not conducting wound treatment for two days could indicate a delay in care, potentially worsening the pressure ulcer. During a concurrent wound treatment observation and interview on 1/16/2026 at 2:31 PM, with TN 1 and CNA 1 in Resident 6's room, Resident 6 wound was observed dark purplish, located in the middle of the sacrococcyx, measuring approximately 5 cm in length and 7 cm in width, with two circular open areas bordered by peeled skin. TN 1 stated Resident 6's had a DTI with openings classified as Stage 3 pressure ulcer. During a concurrent interview and record review on 1/16/2026 at 2:42 PM with LVN 3, LVN 3 stated she received a telephone physician order for Resident 6's Stage 3 pressure ulcer treatment on 1/13/2026 but she did not transcribe the physician's order in the TAR and MAR and the physician order. LVN 3 explained that she did not know how to enter the physician orders in the electronic MAR/TAR and was waiting on the Treatment Nurses (TN 1 or TN 2) to put the initial treatment orders for Resident 1's Stage 3 pressure ulcer. LVN 3 stated she did not perform initial wound treatments to Resident 6's newly identified Stage 3 pressure ulcer to the sacrococcyx and buttocks because it was already the end of her shift and assumed the facility's treatment nurses would perform the initial wound treatments after the specific wound treatments was clarified with a wound physician. During an interview on 1/16/2026 at 3:39 PM with Physical Therapist (PT) 1, PT 1 stated that Resident 6 requires the help of 2 people to turn and reposition in bed. During a concurrent wound treatment observation and interview on 1/20/2026 at 1:35 PM with TN 2, TN 2 removed Resident 6's wound dressing at the sacrococcyx and observed an open wound. TN 2 stated Resident 6 had Stage 3 pressure ulcer at sacrococcyx with red and moist wound bed and slough (a yellowish, soft, and often stringy material that forms in wounds as a result of dead or dying tissue, protein buildup, and bacterial contamination). During an interview on 1/20/2026 at 4:35 PM with TN 2, TN 2 stated the interventions to prevent a resident who was admitted to the facility without a pressure ulcer could be turning and repositioning, maintaining clean and dry skin, changing the resident more often for urine and feces, and providing good intake and hydration. During an interview on 1/20/2026 at 5:04 PM with the Director of Nursing (DON) 1, the DON 1 stated BSP was part of the admission assessment, and it should be completed within 24 hours. The DON stated it was important to complete [NAME] Scale, which the facility staff assessed the possibility of a resident's skin issue depending on the resident's mobility, activity, and nutrition, to prevent any skin breakdown. The DON 1 stated to ensure a resident, who was admitted into the facility without a pressure ulcer, not to develop a pressure ulcer in the facility, the facility staff were doing weekly body check, repositioning, and using low air loss mattress based on the assessment. The DON 1 stated a Care Plan for the pressure ulcer for Resident 6 should be developed when the change of condition was created and the interventions should be implemented timely to ensure proper wound healing. During an interview on 1/20/2026 at 5:04 PM with the Director of Nursing (DON) 1, the DON 1 stated BSP was part of the admission assessment, and it should be completed within 24 hours. The DON stated it was important to complete [NAME] Scale, which the facility staff assessed the possibility of a resident's skin issue depending on the resident's mobility, activity, and nutrition, to prevent any skin breakdown. The DON 1 stated to ensure a resident, who was admitted into the facility without a pressure ulcer, not to develop a pressure ulcer in the facility, the facility staff were doing weekly body check, repositioning, and using low air loss mattress based on the assessment. DON 1 stated a Care Plan for the pressure ulcer for Resident 6 should be developed when the change of condition was created and the interventions should be implemented timely to ensure proper wound healing.

Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Residents 1 and 2) reviewed for the use of a mechanical lift (a device used to assist with transfers and movement of individuals who require support for mobility beyond manual support), implemented interventions, provided adequate supervision and assistance to prevent falls and injury, while transferring from chair to bed to prevent accidents/ hazards by failing to: 1. Ensure Certified Nurse Assistants (CNAs) 2 and 3 provide Resident 1 with a full body, extra-large size sling (a flexible strap or belt used in the form of a loop to support or raise a weight) while using the mechanical lift, in accordance with the resident's Lift Transfer Assessment, during the resident's transfer from chair to bed on 5/16/2025. As a result, Resident 1 fell and landed on the floor when she slipped out from the small sling that was used by CNAs 2 and 3 to transfer the resident with the mechanical lift. 2. Implement interventions to reduce hazards and risks by not providing specific training and evaluation regarding the use of the correct size of a sling for resident transfers when using a mechanical lift. This deficient practice resulted to Resident 1 sustaining a golf-sized large bump, posterior swelling at the back of the head, pain at the back of the head, nausea/vomiting and transfer to the General Acute Care Hospital (GACH) via 911 emergency services (Emergency Medical Services, refers to the system that provides out-of-hospital medical care and transport to individuals in need, typically after a medical emergency or accident), on 5/16/2025. 3. Ensure at least two CNAs transfer Resident 2 using the mechanical lift on 6/10/2025, in accordance with the facility's policy and procedure (P&P) titled Lifting Machine, Using a Mechanical, when CNA 1 transferred Resident 2 by herself, with the mechanical lift from bed to the shower chair (a four-legged seat with rubberized feet made to provide support for bathtubs or showers). This deficient practice had the potential for Resident 2 to experience a fall and physical injuries while being transferred using the mechanical lift. Cross reference to F656 and F726. Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 4/22/2008 and readmitted on [DATE] with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (a medical condition that occurs when the blood flow to the brain is disrupted), muscle weakness, lack of coordination, contractures (a permanent tightening of the muscles, tendons [connects muscles to bones], skin, and nearby tissues that causes the joints to shorten and become very stiff) of right hand and right shoulder, osteoarthritis (the swelling and tenderness of one or more joints) of the left hand, abnormalities of gait (manner of walking or moving on foot) and mobility. During a review of a facility record titled Lift Transfer Reposition, dated 1/7/2025, the record indicated Resident 1 was not able to transfer independently or with staff supervision without using a device. The assessment indicated, Resident 1 required a total lift (mechanical lift) with the use of a full body, extra-large size sling type for the mechanical life device. During a review of Resident 1's Minimum Data Set (MDS-resident assessment tool), dated 5/12/2025, the MDS indicated Resident 1's cognition (ability to think, remember, and reason) was intact. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort, helper lifts, holds or supports trunk or limbs, but provides less than half the effort) in transfer to and from bed to a chair and in toilet transfer (get on and off a toilet or commode) and needed maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) in tub/shower transfer (get in and out of tub/shower). During a review of Resident 1's physician order, dated 5/16/2025, the order indicated to transfer Resident 1 to the GACH via 911 EMS. During a review of Resident 1's record titled Change in Condition Evaluation, dated 5/16/2025, the record indicated Resident 1 was transferred to the GACH emergency room (ER) due to injury at the back of the head, after slipping out of the sling during transfer from wheelchair to bed. During a review of Resident 1's Progress Notes, dated 5/16/2025 timed at 4:48 PM documented by Registered Nurse (RN) 1, the Note indicated Resident 1 was sent to the GACH via 911 at 4:38 PM. During a review of Resident 1's Progress Notes, dated 5/16/2025 timed at 5:12 PM documented by Director of Nurses (DON) 2 (previous DON), the Note indicated Resident 1 was sent to the GACH via 911 due to possible hematoma (a closed wound where blood collects and fills a space inside your body because it cannot flow or drain out) at the back of the head. During a review of Resident 1's Progress Notes, dated 5/16/2025 timed at 11:48 PM documented by Licensed Vocational Nurse (LVN) 1, the Note indicated on 5/16/2025 at 4 PM, LVN 1 received Resident 1 during the night shift (11 PM to 7 AM), after a fall from the mechanical lift sling with two CNAs present during the fall. The Note indicated Resident 1 was alert and oriented with vital signs within normal limits (no abnormalities) and no complaint of dizziness or pain. The Note indicated, there was a possible hematoma presented on the back of Resident 1's head with the size of a tennis ball. During a review of Resident 1's GACH ED Physician Notes, dated 5/16/2025 electronically signed by the GACH Physician at 8:17 PM, the GACH ED Note indicated [Resident 1] was admitted to the GACH ED via EMS with a chief complaint of fall with head injury that was accidental as she was being transported by [facility] staff and hit her head. The GACH ED Note indicated, [Resident 1] hit her head on the back, reported no pain, but there is a large bump on the back of her head, with physical exam indicating a firm, 4 x 4-centimeter (cm - unit of measurement) round hematoma on the back of her head. The GACH ED Note indicated a Computerized Tomography (CT, a diagnostic imaging procedure that produces images of the inside of the body) of Resident 1's brain performed on 5/16/2025, indicated a posterior scalp (the back of the scalp, which is the area of skin covering the back of the head) soft tissue (the non-bone parts of the body that connect, support, or surround other structures and organs) swelling and no other acute abnormalities. The GACH ED Note indicated Resident 1's diagnosis as Closed head injury (a traumatic brain injury where the skull remains intact) without concussion (a mild blow to the head that affects brain function). The GACH ED Note indicated an ice pack was applied to Resident 1's head and was offered Tylenol (an over-the-counter pain medication) for pain but declined. The GACH ED Note indicated Resident 1 was discharged back to the facility, the same evening, on 5/16/2025. During a review of Resident 1's Progress Notes, dated 5/17/2025 documented at 1:22 AM, the Notes indicated, Resident 1 was readmitted back to the facility from GACH with diagnosis of closed head injury without concussion. During a review of Resident 1's Progress Note, dated 5/17/2025 timed at 1:34 AM, documented by LVN 1, the Note indicated Resident 1 had three episodes of nausea and vomiting, LVN 1 was informed by the GACH nurse (unidentified) that Resident 1 had a concussion and would have nausea and vomiting for three days. The Note indicated Resident 1's CT result was negative (no significant abnormalities seen) and Resident 1's physician was made aware. During a review of Resident 1's Interdisciplinary (IDT) Care Conference (a meeting where healthcare professionals from different disciplines collaborate to discuss a patient's care plan) documentation by DON 2, dated 5/19/2025, the IDT note indicated an IDT discussion for Resident 1's fall incident on 5/16/2025 at 4 PM. The IDT note indicated Resident 1 slipped out of the sling of the mechanical lift and fell on the floor while being transferred by two CNAs (CNAs 2 and 3). The IDT note indicated the sling was inspected by DON 2 with no signs of tear or breakdown. The IDT note further indicated Resident 1 was checked for any injury while on the floor. Resident 1 had a golf size area at the back of [the] head and was transferred to the bed with an aid of sheet and five nursing staff. Ice was applied to the back of the head. The IDT note indicated Resident 1 was transferred out via 911 and returned later that evening with no significant injuries identified. The IDT note further indicated It was noted that the sling used during transfer . may have been too small. This may have contributed to shift in her balance and consequence fall. The small sling was removed, and staff was instructed to use a larger size sling. During a review of Resident 1's Interdisciplinary Care Conference, dated 5/28/2025, the notes indicated a weekly IDT meeting was held to follow up on the fall incident that happened on 5/16/2025. The note indicated, the facility's Rehabilitation (care that can help a person get back, keep, or improve abilities that you need for daily life) Department reevaluated Resident 1's sling on 5/28/2025, to ensure that they were appropriate and the right size for Resident 1 and three slings were assigned and labeled specifically for Resident 1's use only. During an observation and interview of Resident 1, inside her room on 6/10/2025 at 11:55 AM, Resident 1 was observed sitting on the wheelchair. Resident 1 stated on 5/16/2025, two CNAs (CNAs 2 and 3) used the mechanical lift to transfer her from her wheelchair to the bed. Resident 1 then stated one CNA (could not recall which CNA) hooked the four corners of the slings to the mechanical lift. Resident 1 stated she felt the sling that was being used by the CNAs (CNAs 2 and 3) were too tight and asked the CNAs (CNAs 2 and 3) to wait, but CNAs 2 and 3 did not wait and started lifting her up in the air with the mechanical lift. Resident 1 stated while in the air, Resident 1 saw one of the sling connectors at the left upper corner come off the hook of the mechanical lift. Resident 1 then stated she slipped out of the sling and fell to the floor. Resident 1 stated she hit the back of her head onto the floor. Resident 1 stated that after the fall, she experienced pain at the back of the head and had nausea and vomiting. She stated after the fall, the nurses came to help her, and she was sent to the hospital. During a telephone interview on 6/11/2025 at 11:40 AM with CNA 2, CNA 2 stated she was asked to help Resident 1's CNA (CNA 3) in transferring Resident 1 from the wheelchair to her bed on 5/16/2025. CNA 2 stated she did not touch Resident 1. CNA 2 stated she stood in front of Resident 1 and observed CNA 3 strap the mechanical lift sling into the mechanical lift. CNA 2 stated she asked CNA 3 if the sling straps were secured, and CNA 3 said yes. CNA 2 stated she then proceeded to operate the mechanical lift and lift Resident 1. CNA 2 stated one of the sling straps came loose causing Resident 2 to fall off the mechanical lift from her back side and hit her head on the floor. CNA 2 stated she went to call an LVN. CNA 2 stated she was not aware that the resident's slings use for the mechanical lift come in different sizes. CNA 2 stated she had not been in serviced on how to use the mechanical lift or slings at the facility. During a telephone interview on 6/11/2025 at 12:06 PM with CNA 3, CNA 3 stated that on 5/16/2025, Resident 1 asked to be changed so she asked CNA 2 to help her transfer Resident 1 from the wheelchair to the bed using the mechanical lift. CNA 3 stated, she hooked up three sling ties to the mechanical lift and CNA 2 hooked the fourth tie of the mechanical lift. CNA 3 stated she remembered telling CNA 2 that she was ready; as the mechanical lift went up, CNA 3 remembered Resident 1 moving to fix her buttocks and then fell to the floor. CNA 3 stated, the previous DON of the facility (DON 2), came into Resident 1's room after Resident 1's fall incident and explained to her (CNA 3) and CNA 2 that the blue sling used in Resident 1's mechanical lift was too small because the hole where Resident 1's buttocks went in was too small. CNA 3 stated she did not understand what DON 2 meant about the color of the sling. CNA 3 stated she was not trained by the facility on the colors/sizes of the slings to differentiate the correct sling size to use when moving the resident with the mechanical lift. CNA 3 stated, she was only trained on how to hook the mechanical lift sling into the mechanical lift when moving a resident. During a concurrent interview on 6/11/2025 at 3:46 PM and record review of Resident 1's Lift Transfer Reposition, dated 1/7/2025, and the Comprehensive Care Plans developed from facility readmission dated 5/17/2025 to 6/11/2025, the MDS Nurse (MDSN) stated the facility had assessed Resident 1 for the use of a mechanical lift for transfers on 1/7/2025 and the CNAs had been using the mechanical lift to transfer Resident 1, but the licensed nurse did not develop a comprehensive care plan to address the use of mechanical lift for the safety of Resident 1's transfers that addresses the appropriate slings to use. 2. During a review of Resident 2's AR, the AR indicated the facility admitted Resident 2 on 6/13/2019 and readmitted on [DATE] with diagnoses that included contracture, quadriplegia (paralysis from the neck down, affecting all four limbs), contracture of upper arm muscle, contracture of right ankle, convulsion (seizure disorder - sudden surge of electrical activity in the brain when a person experiences abnormal behavior, symptoms, and sensations, sometimes including loss of consciousness), seizure, contracture of left knee and left ankle, and history of falling. During a review of Resident 2's History and Physical (H&P), dated 4/19/2024, the H&P indicated Resident 2 did not have the capacity to understand and make decision. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity, requiring the assistance of 2 or more helpers for the resident to complete the activity) in bed to chair transfer, toilet transfer (get on and off a toilet or commode), and shower transfer (get in and out of shower). During a review of a facility record titled Lift Transfer Reposition, dated 4/28/2025, the record indicated Resident 2 was not able to transfer independently or with supervision without using a device. The assessment indicated, Resident 2 required a total lift device with the use of a full body, medium size sling type. During an observation on 6/10/2025 at 10:38 AM, in Resident 2's room, Resident 2 was observed positioned in a sling and lifted in the air by a mechanical lift. During the observation, the Assistant Director of Nursing (ADON), entered Resident 2's room while CNA 1 was operating the mechanical lift to transfer Resident 2 from the bed to a shower chair by herself. Resident 2 was positioned in a sling in mid-air. The ADON stated the facility's policy indicated the use of mechanical lift for transferring a resident required two people assistance. The ADON stated CNA 1 who was transferring the resident with the mechanical lift by herself put the resident at risk for fall and injury because the resident required two persons assist. During a subsequent interview on 6/10/2025 at 10: 45 AM with CNA 1, CNA 1 stated she was aware that two people were required to transfer a resident with the use of a mechanical lift. CNA 1 stated she saw other staff were busy, so she did not ask other staff for assistance before she transferred Resident 2 with the mechanical lift by herself. CNA 1 stated transferring Resident 2 with a mechanical lift by herself potentially have caused an accident to the resident and hurt Resident 2. During a concurrent observation and interview on 6/11/2025 at 11:15 AM with Laundry Staff (LS) 1, multiple blue slings with numbers written on the corner of the slings were hung in the facility's Laundry Room. LS 1 stated that whenever CNAs would use the mechanical lift for residents, the CNAs would go and ask LS 1 for a sling. LS 1 stated the blue slings were used for transferring. LS 1 stated the blue slings had different color edges, light blue and purple. LS 1 stated the slings of the mechanical lift were the same size regardless of the color difference on the edge on the blue slings (light blue and purple). LS 1 stated she just gives the CNAs any blue slings when the CNAs asked her for a sling. During a concurrent observation and interview on 6/11/2025 at 11:17 AM with LS 1, LS 1 held one blue sling with the light blue edge and one blue sling with purple edge overlapping each other, and observed the blue sling with the light blue edge was larger than the sling with the purple edge. LS 1 stated she did not know the slings with different color edges were different sizes. LS 1 stated no one informed her or given her in-service of what sling sizes to provide the CNAs when they ask for a sling. During an interview on 6/11/2025 at 11:28 AM with the Maintenance Director (MD), the MD stated he was responsible for purchasing the slings for the mechanical lift in the facility, but he did not know there are different sizes and/or colors on the edge of the slings presented. During an interview on 6/11/2025 at 11:30 AM with the Housekeeping Supervisor (HKS), the HKS stated he did not know the connection between the different colors of the edge of the blue slings and the different sizing of the slings for each resident that uses the mechanical lift. The HKS stated he did not have any written document of the information and did not have any posting in the laundry area to guide the laundry staff such as LS1, when the laundry staff gives out the slings to the CNAs. During an interview on 6/11/2025 at 12:47 PM with CNA 1, CNA 1 stated she went to the facility's Laundry Room and asked the laundry staff for a sling for the resident she would use a mechanical lift to transfer the resident. CNA 1 stated the slings were the same and there was no difference in sizes. During an interview on 6/11/2025 3:30 PM with the Director of Staff Development (DSD), the DSD stated facility staff should choose the appropriate size of a sling when transferring a resident with a mechanical lift by identifying the correct color of the edge of the blue sling. The DSD stated if the wrong sling was used for the resident during transfers with the mechanical lift, it could lead to fall and injuries. The DSD stated she was new at the facility and had not trained the CNAs or conducted any skills competencies for the use of the mechanical lift and choosing the correct slings when transferring a resident according to the resident's weight and assessment. During a concurrent interview and record review of a facility record titled Portable Lift (mechanical lift) Competency Check List (undated), on 6/11/2025 at 4:35 PM with Director of Nursing (DON) 1, DON 1 stated the CNA competency check list for the portable lift does not include assessing for the mechanical lift sling size or reviewing resident assessments for recommended sling size based on the resident's weight. DON 1 stated using the correct size of a sling when transferring a resident with a mechanical lift could capture the resident's whole body and ensure the residents' safety during transferring to prevent falls and injury. DON 1 stated two staff were required to transfer a resident when using a mechanical lift to ensure resident's safety. During a review of the undated facility's policy and procedure (P&P) titled, Lifting Machine, Using a Mechanical, the P&P indicated at least two nursing assistants are needed to safely move a resident with a mechanical lift. The P&P indicated to measure the resident for proper sling size and purpose, according to manufacturer's instruction, double check the sling and machine's weight limits against the resident's weight, visually check the size to ensure it is not too large or too small, and attach sling straps to sling bar (a bar that attaches to the mechanical lift, providing connection point for slings, which support the resident during movement), according to manufacturer's instructions. During a review of the facility's mechanical lift manufacturer's manual (a step-by-step document that guides workers through production processes, machine operation, and safety procedures) titled, Battery Operated Patient Lift, the manual indicated the mechanical lift should be used for transferring residents to and from/to a wheelchair, bed, commode, shower chair, floor, or similar. The P&P indicated to select a sling that will properly fit the resident and have the appropriate weight capacity and ensure that the sling and lift have compatible connection points. The P&P indicated under Sling Use Warnings to Use compatible slings and always ensure the sling is the correct size and capacity for the patient being transferred.

Based on observation, interview and record review, the facility failed to implement an effective pain management (the process of alleviating pain), in accordance with the physician's order, the resident's goals and comprehensive care plans for pain for one of three sampled residents (Resident 3) reviewed for pain, who has a diagnosis of chronic pain syndrome (persistent pain that lasts weeks to years) by: 1. Failing to ensure licensed nurses follow up with Resident 3's physician to sign a required medication order refill form (a document used to request a new supply of a medication that has previously been prescribed by the physician), after the resident missed the scheduled dose of fentanyl patch (a pain patch that applied on the skin and delivers pain relief through the bloodstream. It is used to treat severe, persistent pain in individuals who are already tolerant to opioid [very strong pain medications that treats severe pain] pain medications and who needs around-the-clock [lasting 24 hours a day], long-term pain relief) every 72 hours on 6/1/2025. 2. Failing to ensure licensed nurses assess Resident 3's pain level, evaluate pain characteristics and monitor for non-verbal signs/symptoms of pain, in accordance with the resident's care plan titled, Alterations in Comfort due to Uncontrolled Pain. Upon Resident 3's interview on 6/11/2025, Resident 3 verbalized he was in severe pain during the time the fentanyl patch was not administered (6/1/2025 to 6/7/2025), however, the SBAR (Situation, Background, Assessment, Recommendation) Summary for Providers, dated 6/5/2025 indicated Resident 3 was not experiencing pain, despite the resident's verbalizing severe pain. As a result, Resident 3 experienced unrelieved pain when the resident missed two doses of fentanyl patch on 6/1/2025 and 6/4/2025. The fentanyl patch was later applied to Resident 3 for pain as ordered on 6/7/2025. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 3 on 7/18/2023 with diagnoses that included quadriplegia (severe medical condition characterized by the partial or total loss of function in all four limbs), chronic pain syndrome, depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life), anxiety disorder (a group of mental disorders characterized by significant feelings of fear that affect with daily activities), left hip osteoarthritis (the swelling and tenderness of one or more joints [places where two bones meet]), and opioid dependence (a state where the body adapts to the presence of opioids) During a review of Resident 3's History and Physical (H&P) dated 7/28/2023, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's care plan, revised on 2/28/2024, the care plan indicated Resident 3 exhibited or had the potential to demonstrate verbal behaviors related to depression and anxiety. The goal indicated for the resident to demonstrate effective coping skills related to verbal behavior. The care plan interventions included to monitor for pain and administer pain medication as ordered. During a review of Resident 3's care plan, revised on 10/23/2024, the care plan indicated Resident 3 exhibits or was at risk for alterations in comfort due to uncontrolled pain. The goal indicated for the resident to not experience pain and would achieve acceptable level of pain control. The care plan interventions included to apply one patch transdermally (delivered through the skin) every 72 hours for chronic pain management, evaluate pain characteristics, utilize pain scale, monitor for non-verbal signs/symptoms of pain and medicate as ordered. During a review of Resident 3's physician order, dated 10/30/2024, the order indicated Resident 3 to apply one patch of Fentanyl transdermal patch 25 micrograms/hour (mcg/hr - unit of measurement), every 72 hours, transdermally, at bedtime for chronic pain syndrome. During a review of Resident 3's Minimum Data Set (MDS-resident assessment tool), dated 4/4/2025, the MDS indicated Resident 3's cognition (ability to think, remember, and reason) was intact. The MDS indicated Resident 3 was dependent (helper does all of the effort to complete the activity) in shower/bathe self, toilet hygiene and lower body dressing. During a review of Resident 1's physician orders dated 5/12/2025, the order indicated to administer 30 mg oxycodone HCL every 6 hours as needed for moderate to severe pain, 5-10 (pain scale - a tool used to help individuals describe and quantify their pain. It typically uses a numerical or visual scale, such as the 0-10 scale, where 0 represents no pain and 10 represents the worst pain imaginable). During a review of Resident 3's Medication Administration Record (MAR) for the month of May 2025, the MAR indicated, the facility applied fentanyl patch to Resident 3 on 5/29/2025. During a review of Resident 3's eMAR (electronic medical administration record) Progress Note (PN), dated 6/1/2025 timed at 3:30 PM, the eMAR PN indicated, Resident 3's fentanyl patch was Waiting for authorization for refill. During a review of Resident 3's Medication Administration Record (MAR) for the month of June 2025, the MAR indicated Resident 3's next fentanyl Patch schedule should be every 72 hours, on 6/1/2025, 6/4/2025, and 6/7/2025. The MAR indicated Resident 3 missed two doses of fentanyl patches, on 6/1/2025 and 6/4/2025. The MAR indicated the fentanyl patch was applied to Resident 3 on 6/7/2025 (6 days later than scheduled). During a review of a facility record titled SBAR (Situation, Background, Assessment, Recommendation) Summary for Providers, dated 6/1/2025 timed at 11 PM, the SBAR indicated Resident 3 had a Change in Condition related to Resident 3 missing the fentanyl patch doses due to No medication available. The SBAR indicated the facility contacted the facility's pharmacy and a new order from Resident 3's physician was needed. The SBAR indicated, the facility notified Resident 3's physician and a new order was obtained and faxed to the pharmacy. The SBAR indicated, the new order for the fentanyl patch was On waiting for authorization and delivery. During a review of Resident 3's eMAR Progress Note (PN), dated 6/2/2025 timed at 11:17 PM, the eMAR PN, indicated the fentanyl patch was still Pending delivery. During a review of Resident 3's eMAR Progress Note (PN), dated 6/5/2025 timed at 8:05 PM, the eMAR PN indicated Resident 3's fentanyl patch was not available because Resident 3's physician had not signed the medication refill form. During a review of Resident 1's MAR with dates 6/1/2025 to 6/6/2025, the MAR indicated Resident 3 had received 30 mg oxycodone HCL every 6 hours as needed for moderate to severe pain, 5-10, on 6/1/2025, 6/2/2025, 6/3/2025, 6/4/2025, 6/5/2025, and 6/6/2025 with pain scale that ranges between 5 to 8. During a review of Resident 3's SBAR Summary for Providers, dated 6/5/2025 timed at 8:27 PM, the SBAR indicated, Resident 3 missed his Fentanyl patch because the physician did not sign the medication refill form, and that the physician would come the next day (6/6/2025) to sign the form. The SBAR indicated Resident 3's physician stated to offer Resident 3 oxycodone hydrochloride (HCL) (pain medication for moderate to severe pain that wears after 4 to 6 hours) 30 mg as needed for moderate to severe pain. However, the SBAR indicated, Resident 3 was not in pain or discomfort. During an interview and record review on 6/10/2025 at 2 PM with the Director of Nursing (DON) 1, DON 1 stated Resident 3's next fentanyl patch dose was to be administered on 6/1/2025, when the Licensed Vocational Nurse (LVN 7) needed to administer during the evening shift on 6/1/2025, and noticed the facility had run out of fentanyl patches for Resident 3. DON 1 stated LVN 7 called the Pharmacy to reorder refills for the fentanyl patch but the Pharmacy stated they would need to obtain a new order from Resident 3's physician. DON 1 stated LVN 7 called Resident 3's physician and obtained a telephone order which they faxed to the pharmacy that evening. DON 1 stated there was no documented evidence in Resident 3's records to indicate if facility staff had followed up with the pharmacy or Resident 3's physician to sign the medication order refill form needed for the pharmacy to refill and deliver Resident 3's fentanyl patches until the SBAR note dated 6/5/2025, 5 days after the initial missed dose on 6/1/2025. During an interview on 6/10/2025 at 2:13 PM with Pharmacist 1, Pharmacist 1 stated the facility should never run out of medication. Pharmacist 1 stated the facility staff should be reordering the resident's medication before the medication [NAME] out just in case there are any problems with the reordering, so it can be resolved before the medication is due, to ensure a resident never goes without missing any medication. During an interview on 6/11/2025 at 9:23 AM with Licensed Vocational Nurse (LVN 3), LVN 3 stated she was working during evening shift on 6/5/2025. LVN 3 stated that during medication pass she noticed Resident 3's fentanyl patch was not available. LVN 3 stated she was not aware it had not been available since 6/1/2025. LVN 3 stated she called the pharmacy to order the medication and was told they could not refill Resident 3's fentanyl patch medication until Resident 3's physician signed the medication order refill form. LVN 3 stated she then called Resident 3's physician who informed her he would be coming into the facility the following day (6/6/2025) and would sign the medication order refill form. LVN 3 stated she normally works the morning shift (7 am to 3 pm) and was not endorsed to follow up on Resident 3's missing medication. LVN 3 stated if the previous shift licensed nurses endorsed to her to follow up the reordering of the fentanyl patch, LVN 3 stated she would have followed up with Resident 3's physician and the pharmacy ahead of time. During an interview on 6/11/2025 at 11 AM with Resident 3, Resident 3 sounded upset. Resident 3 stated he was upset because he was missing his fentanyl patch medication and stated I keep bugging them (licensed nurses) for 9 days. Resident 3 stated he was in a lot of pain and would ask the nurses every day for the patch, but nurses would blame it to the other nurses from other shifts saying the other nurses had not ordered the medication. Resident 3 stated he was in a lot of pain, but facility staff would not believe him because They (facility staff) do not feel it (pain). Resident 3 further stated that he was in a lot of pain during the days that the facility staff failed to administer his fentanyl patch. During an interview on 6/11/2025 at 12:35 PM, Certified Nurse Assistant (CNA) 5, who had been caring for Resident 3 in the facility for the morning shifts, stated Resident 3 was always in pain. During an interview on 6/11/2025 at 4:35 PM with DON 1, DON 1 stated Nurses should check residents' medication and reorder medications before it ran out. DON 1 stated the licensed nurses should have followed up Resident 3's fentanyl patch medication order form, the next day on 6/2/2025, with the Pharmacy and Resident 3's physician and should have endorsed to the next shift to follow up. DON 1 stated if Resident 3 misses his scheduled fentanyl patch, it can lead to withdrawal from the medication, and unrelieved pain. During a review of the facility's policy and procedure (P&P) titled, Pain Management, dated 8/25/2021, the P&P indicated the purpose of pain management was to maintain the highest possible level of comfort for residents by providing a system to identify, assess, treat, and evaluate pain. The facility is responsible for pain management that is consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences is provided to residents who require such service. During a review of the facility's P&P titled, Medication Orders and Receipt Record, revised on April 2007, the P&P indicated Medications should be ordered in advance, based on the dispensing pharmacy's required lead time.

Based on interviews and record reviews, the facility failed to ensure that one of two sampled residents (Resident 1), who had a diagnosis of Diabetes Mellitus ([DM, a chronic disease where a person has high blood sugar levels because the body does not produce insulin [a hormone that regulates blood sugar levels in the body]) and history of hypoglycemia (a condition were blood sugar levels drop below normal), received treatment and services, in accordance with professional standards of practice, the care plan, and physician orders for the management of DM and hypoglycemia. The facility failed to: 1. Ensure Registered Nurse (RN) 2 reviewed Resident 1's General Acute Hospital Records (GACH 2) on [DATE], for all appropriate GACH 2 discharge orders and ensure readmission orders from GACH 2 and continuity of care for DM was verified with the facility's attending physician (MD 1) or the facility's Nurse Practitioner (NP 1), upon readmission back to the facility on [DATE]. 2. Ensure the facility's licensed staff (Registered Nurse [RN] 2 and Licensed Vocational Nurse [LVN] 3) reviewed Resident 1's medical history of DM and history of hypoglycemic episode, requiring transfer to GACH 2 on [DATE], and was previously receiving blood sugar (BS) monitoring (the process of regularly checking and measuring the levels of blood sugar), prior to readmission to the facility to ensure continuity of diabetic care and management, on [DATE] to [DATE]. 3. Ensure Resident 1's care plan for DM was implemented by monitoring Resident 1 for hypoglycemia and hyperglycemia (a condition in which a person's blood sugar level is higher than normal) while residing at the facility from [DATE] to [DATE] (5 days). 4. Inform or verify with MD 1 or NP 1 on [DATE] that Resident 1's GACH 2 Discharge Summary orders dated [DATE] for BS monitoring before meals and at bedtime, including a routine insulin injection (Insulin Glargine [a long acting insulin used to manage blood sugar levels]) at bedtime was not ordered upon the resident's readmission back to the facility on [DATE], to manage the resident's DM. Licensed Vocational Nurse (LVN) 3 failed to obtain an order from MD 1 or NP 1 prior to entering an order for 10 units of routine insulin injection to be administered at bedtime on [DATE], three days after the resident's readmission to the facility. Additionally, LVN 4 failed to check Resident 1's blood sugar before administering the newly entered order of routine insulin injection on [DATE] at bedtime to Resident 1, in accordance with Resident 1's care plan for DM and P&P on Physician Orders. 5. Ensure LVN 1 and LVN 2 performed adequate assessment of Resident 1's condition on [DATE] and notified MD 1 or NP 1 of Resident 1's altered level of consciousness, blood sugar of 27 and low blood pressure (undocumented) on [DATE] and called 911 emergency services, in accordance with professional standards of practice and recommended guidelines for residents with hypoglycemia. As a result, Resident 1 had a change in condition in the morning of [DATE], as evidenced by altered level of consciousness (a change in a patient's state of awareness [ability to relate to self and the environment]), and hypoglycemia with a blood sugar of 27 (normal blood sugar levels are between 70 to 100). Resident 1 was transferred to GACH 3 via 911 emergency services (EMS - provides emergency medical care) on [DATE] and admitted to the Intensive Care Unit (ICU - provides the critical care and life support for acutely ill and injured patients). Resident 1 died at GACH 3 on [DATE]. On [DATE] at 4:51 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the facility's failure to ensure a resident with a diagnosis of Diabetes Mellitus (DM) received treatment and services for diabetes. The team notified the Administrator (ADM) of an IJ situation on [DATE] at 4:51 PM, due to the facility's failure to ensure Resident 1 received the appropriate admission orders for diabetes care and management provided by a physician. On [DATE] at 1:48 PM, the Administrator (ADM) provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings). On [DATE] at 1:52 PM, while onsite and after the surveyor verified/confirmed the facility's full implementation of the IJ Removal Plan through observation, interview, and record review, and determined the IJ situation was no longer present, the IJ was removed onsite, in the presence of the ADM and the DON. After the IJ was removed, the surveyor verified that the facility's non-compliance remained at a lower scope and severity (refers to the seriousness of the harm to the residents) of isolated (refers to the deficiencies affecting a very limited number of resident/s), actual harm (means the resident have experienced a negative outcome or injury due to the non-compliance), that was not immediate jeopardy. The IJ Removal Plan dated [DATE], included the following: - On [DATE], the admitting licensed nurse was provided a one-to-one re-education and training by the vice president of education (VPE) on receiving diabetic treatment and services, in accordance with professional standards of practice, have care plan, and physician orders for the management of hypoglycemia. - Admitting licensed nurse will be provided re-education and training by the vice president of education on received diabetic treatment and services, in accordance with professional standards of practice, have care plan, and physician orders for the management of DM and hypoglycemia prior to her next scheduled work. - The interim director of nursing started [DATE] and was provided by the VPE with training on care plan for DM and review the resident's records to ensure the care plan is being followed, in accordance with the Director of Nursing's job description. - On [DATE], the Interdisciplinary Team (IDT - a group of healthcare professionals from various disciplines who collaborate to provide comprehensive patient care) was also provided education and training by the vice president of education regarding reviewing the residents plan of care upon admission/readmission, change of condition and as needed. - The Medical Director was informed by the administrator on [DATE] regarding the IJ findings for further corrective actions and recommendations. - Diabetic residents (91) had their care plan reviewed. Eighteen (18) residents care plans were revised and 20 new care plans were initiated on [DATE] by the interim Director of Nursing or designees, to reflect blood glucose monitoring check order and current diabetic management protocol of hypoglycemia and hyperglycemia. - On [DATE], the interim Director of Nursing initiated education to licensed nursing staff on all shift on diabetic management with emphasis on the following:- Ensure diabetic residents upon admission/re-admission have blood sugar monitoring as ordered. - Ensure diabetic residents have parameters for low and high BS and has order to give when below/high BS parameters. - Ensure physicians are notified when resident's blood sugar falls below the parameters as specified by Physician. - Licensed Nurses that are newly hired, on vacation, on leave, part time, or on call and registry staff will be given inservice by the Interim DON or designee prior to the start of their shift or hired. - The facility's policies and procedures regarding Diabetic Management of residents was reviewed on [DATE]. - On [DATE], The Interim Director of Nursing or designee audited (1) new admission on [DATE] and current residents (91) with diagnosis of Diabetes for diabetic management and ensure appropriate interventions are in place and care planned. Facility created an audit tool for residents with diagnosis of Diabetes for diabetic management - New hires will receive education on Diabetic Management, and resident safety by the Interim Director of Nursing or designee. - Registry staff (staff personnel provided by a placement service on a temporary or on a day-to-day basis, in a facility) will be provided with accelerated orientation that includes checking of blood glucose levels and care plan initiation on residents upon admission/re-admission and as needed. - A Quality Assurance Performance Improvement (QAPI - a comprehensive, data-driven approach to continuously improve the quality of care and services in long-term care facilities) Performance Improvement Project (PIP) will be implemented to review and interpret all audit findings pertaining to the new admission and current residents with diabetes from Monday to Friday by the IDT during clinical meetings and RN Supervisor on weekends. - Monthly, the Interim DON and or designee will continue to review QAPI plan to address, monitor progress and address missed opportunities by conducting root cause analysis and continuous quality improvement with collaboration with attending physician's medical director, pharmacy consultant and company management clinical resource. - New admissions/re-admissions will be reviewed from Mondays to Fridays, during clinical meeting by the IDT headed by the Interim DON and RN Supervisor on weekends to ensure that all admitted resident with Diabetes diagnosis, treatment and services with accordance with professional standard of practice which include diabetic management protocol for hypoglycemia and hyperglycemia, monitoring of blood glucose as ordered and care plan. - The RN Supervisor on weekends will review all admissions/re-admissions to ensure compliance with Diabetes treatment and services with accordance with professional standard of practice which include diabetic management protocol for hypoglycemia and hyperglycemia, monitoring of blood glucose as ordered and care plan. - The RN Supervisor during the shift will be notified by the Charge Nurse for any change of condition for coordination of care. Findings: During a review of Resident 1's Admission Record (AR), the AR documented that Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included pneumonia (an infection that inflames air sacs in one or both lungs, which may fill with fluid), sepsis (a serious condition in which the body responds improperly to an infection), respiratory failure (a serious condition that makes it difficult to breathe on your own), DM Type 2 , cerebral infarction (when a blood vessel in the brain is blocked, preventing blood and oxygen from reaching the brain tissue, leading to cell death), End Stage Renal Disease (ESRD- a condition in which the kidneys have lost most of their function and are no longer able to adequately filter waste products, excess fluids, and electrolytes from the blood). During a review of Resident 1's Physician Telephone Order (TO) dated [DATE] timed at 1:44 AM, the TO indicated, Insulin Lispro (a fast acting type of insulin) injection solution, inject as per insulin sliding scale (ISS - a chart of insulin dosages preordered for each blood sugar result): 2 units for BS of 150 - 199 [mg/dL], 4 units for BS of 200 - 249 [mg/dL], 6 units for BS of 250 - 299 [mg/dL], 8 units for BS of 300 - 349 [mg/dL], and 10 units for BS of 350 - 399 [mg/dL], Subcutaneously (SC-beneath the skin) at bedtime for Antidiabetics, before meals. During a review of Resident 1's Physician TO dated [DATE] timed at 2:01 AM, the TO indicated an order to admit Resident 1 under the care of MD 1. During a review of Resident 1's Nurses Progress Notes dated [DATE] documented at 3:08 AM, the TO indicated Resident 1 was readmitted back from GACH 1. The Note indicated Resident 1 was alert and oriented. During a review of Resident 1's Medication Administration record (MAR), the MAR indicated a start date of [DATE] and discontinued (DC) date of [DATE]. The MAR showed the licensed nurses monitored Resident 1's blood sugar with Lispro ISS injection of 2 units for BS of 150 - 199, 4 units for BS of 200 - 249 [mg/dL], 6 units for BS of 250 - 299 [mg/dL], 8 units for BS of 300 - 349 [mg/dL], and 10 units for BS of 350 - 399 [mg/dL], Subcutaneously at bedtime for Antidiabetics, before meals from [DATE] to [DATE]. The MAR indicated the code HO which indicated Resident 1 was hospitalized from [DATE] to [DATE]. During a review of Resident 1's MAR for February 2025, the MAR indicated Resident 1 was on insulin Glargine solution (long acting form of insulin), inject 10 units SC at bedtime [9 PM] for DM. The MAR indicated Resident 1 received one dose of Insulin Glargine 10 units routinely every 9 PM from [DATE] to [DATE]. The MAR indicated the code HO which indicated Resident 1 was hospitalized from [DATE] to [DATE]. During a review of Resident 1's MAR indicated a start date of [DATE] and DC date of [DATE], the MAR showed Resident 1 was on Metformin Hydrochloride (HCL) (a medicine taken by mouth to treat type 2 diabetes) oral tablet 1000 mg, one tablet by mouth two times a day for Antidiabetic. During a review of Resident 1's Nurses Progress Notes dated [DATE] documented at 10:30 AM, the Note indicated Resident 1 was observed with altered level of consciousness (ALOC) staring at the ceiling, with cold clammy skin, BS was at 60 [mg/dL] with oxygen saturation (measures the percentage blood that is carrying oxygen - with normal levels between 95 to 100%) of 80%. The Note indicated the physician was notified and ordered the licensed nurse to transfer Resident 1 to the GACH via 911 EMS. The Note indicated EMS arrived on [DATE] at 10:45 AM and transferred Resident 1 to GACH 2 for ALOC. During a review of Resident 1's Physician TO dated [DATE] timed at 10:40 AM, the TO indicated an order to transfer the resident to GACH 2 for ALOC. During a review of Resident 1's GACH 2 records titled Discharge Summary dated [DATE], the DC Summary indicated Resident 1's discharge medications that included Insulin Glargine solution, inject 10 units subcutaneously (SC-beneath the skin) at bedtime and Insulin lispro, 0 units SC before meals and at bedtime. During a review of Resident 1's History and Physical Examination (HPE) from the facility, dated [DATE] and signed by Resident 1's attending physician (MD 1), the HPE indicated the resident had the capacity to understand and make decisions. The HPE indicated a handwritten Plan for Resident 1 that included blood sugar checks before meals and at bedtime with insulin sliding scale (ISS) and low dose insulin, Hemodialysis (a treatment to filter wastes and water from the blood) Mondays, Wednesdays and Fridays, fall precautions, and medication reconciliation. During a review of Resident 1's Nurses Progress Notes dated [DATE] documented at 7:36 PM by RN 2, the Note indicated Resident 1 was readmitted back to the facility from GACH 2 due to altered mental status and metabolic acidosis (develops when too much acid is produced in the body). During a review of Resident 1's Physician TO dated [DATE] documented at 8:16 PM, the TO indicated an order to admit Resident 1 under the care of MD 1. During a review of Resident 1's Physician TO dated [DATE] documented at 8:21 PM, the TO indicated an order for: Insulin Lispro injection solution, inject as per sliding scale (ISS): 2 units for BS of 150 - 199, 4 units for BS of 200 - 249, 6 units for BS of 250 - 299, 8 units for BS of 300 - 349, and 10 units for BS of 350 - 399, Subcutaneously at bedtime for Antidiabetics, before meals. The order further indicated the BS monitoring was discontinued on [DATE] timed at 11:20 PM. During a review of Resident 1's TO dated [DATE] documented at 1:43 AM was entered by RN 2 in Resident 1's electronic records. The TO indicated Resident 1 to be readmitted back to the facility. Further review of Resident 1's TO indicated no evidence of blood sugar monitoring ordered for Resident 1, after the blood sugar monitoring order had been discontinued on [DATE]. During a review of Resident 1's Nurses Progress Notes dated [DATE] documented at 1:52 AM by RN 2, the Note indicated Resident 1's readmission orders and medications were reconciled and faxed to the facility pharmacy. During a review of Resident 1's Nurses Progress Notes dated [DATE] documented at 7:49 PM by LVN 2, the Note indicated NP 1 came to visit Resident 1 at the facility and reviewed the resident's admission orders. During a review of Resident 1's MAR for February 2025 with a start date of [DATE], indicated Resident 1 was on Metformin HCL oral tablet 1000 mg, one tablet by mouth two times a day for DM2. The MAR indicated Resident 1 received one dose of Metformin by mouth on [DATE] (9 AM and on hemodialysis appointment at 5 PM), [DATE] (9 AM and 5 PM), [DATE] (9AM and 5 PM), [DATE] (9 AM and Resident 1 was HO at 5 PM). During a review of Resident 1's TO dated [DATE] (three days after Resident 1's readmission to the facility) documented at 10:44 AM and entered by LVN 3 in Resident 1's electronic records, the TO indicated to administer Insulin Glargine SC solution injection, 10 units subcutaneously at bedtime for Diabetes Mellitus. During a review of Resident 1's MAR for February 2025, the MAR indicated Resident 1 was started on Insulin Glargine solution, inject 10 units SC at bedtime [9 PM] for DM on [DATE]. The MAR indicated Resident 1 received one dose of Insulin Glargine 10 units on [DATE] at 9 PM. The MAR indicated the code HO (hospitalized ) the next day on [DATE]. During a review of Resident 1's Nurses Progress Notes dated [DATE] documented at 9:38 PM by LVN 4, the Notes indicated Insulin Glargine SC solution injection 10 units was administered to Resident 1 at bedtime on [DATE] (9 PM) for DM 2. The Note did not indicate evidence that Resident 1's BS was checked prior to the insulin administered by LVN 4. During a review of Resident 1's Nurses Progress Notes dated [DATE] documented at 11:35 AM by LVN 2, the Note indicated that the charge nurse (LVN 1) assigned to Resident 1 checked the resident's BS on [DATE], before lunch at 11:30 AM and the BS indicated 47. The Note indicated Glucose gel (an over the counter product taken by mouth to swallow and used to treat low blood sugar levels) and orange juice given. The Note indicated Resident 1 was Awake and able to swallow. The Note indicated the physician was notified and ordered to transfer the resident to GACH 3 for management of hypoglycemia. The Note indicated at the time of the evaluation Resident 1's BP at ,d+[DATE], pulse at 68, respiration at 20. During a review of Resident 1's Physician TO dated [DATE] documented at 1:48 PM by LVN 2, the TO indicated an order to transfer Resident 1 to GACH 3 due to low blood glucose (blood sugar) level. During a review of Resident 1's Nurses Progress Notes dated [DATE] documented at 3:11 PM by LVN 2, the Note indicated the Emergency Medical Technician (EMT - provide out of hospital emergency medical care and transportation) transport arrived at 2 PM and refused to take Resident 1 to GACH 3 as ordered. The Note indicated that according to the EMT, the facility staff needed to Upgrade the call to 911. The Note indicated 911 paramedics/EMS was called by LVN 2. The Note indicated upon arrival of 911 (no time indicated) paramedics/EMS, Resident 1's BS was 37. During a review of Resident 1's Physician TO dated [DATE] documented at 3:22 PM by LVN 2, the TO indicated May transfer to GACH [3] via 911 for further evaluation of hypoglycemia. During a review of the EMTs Patient Care Report (ambulance transport) for Resident 1 with date of service [DATE], indicated the call type was Basic Life Support (BLS) Emergency (provides essential pre-hospital medical care and transportation for patients who are not in a critical condition, focusing on basic interventions and is staffed by trained EMTs]. The EMT Report indicated the EMTs time of arrival at Resident 1's room was at 2:15 PM. The EMT Report indicated the medical transport was Canceled on scene after the patient was evaluated timed at 2:40 PM. The EMT Report indicated Resident 1's vital signs timed at 2:17 PM indicated blood pressure (BP normal ranges between ,d+[DATE] to ,d+[DATE]) of ,d+[DATE], pulse was 77 weak normal range was 60 to 100), respiration was 14 (normal range was 12 to 20), oxygen saturation was 97%, and blood sugar level at 47. The EMT Report indicated the EMT requested LVN 1 to take another set of vital signs and BS and at 2:20 PM Resident 1's BP was at ,d+[DATE] with a BS of 27. During the same review of the EMT Report dated [DATE], the EMT Narrative indicated Resident 1 appeared to be altered (a change from a person's normal level of mental function) and disoriented. The EMT Narrative indicated LVN 1 stated that Resident 1 was Typically much more alert and responsive, tracking more appropriately. Patient (Resident 1) has had decreased level of alertness and altered mentation since approximately 12:30 (PM) today. The EMT report indicated At this time given severe hypoglycemia and hypotension (abnormally low blood pressure level) as well as patient's reported decreased mental status from baseline, EMTs agreed that patient needed to be upgraded to ALS (Advanced Life Support - refers to a medical service that provides advanced medical care to critically ill or injured patients during transport to a healthcare facility) call and patient was too unstable for BLS transport. The EMT Narrative indicated LVN 2 stated This was unnecessary and Resident 1 was stable enough to transfer to the acute hospital. The EMT Narrative indicated that EMT 1 spoke to NP 1 over the phone, in the presence of LVN 2 and reiterated Resident 1's instability and need for ALS transport while LVN 2 stated Resident 1 did not need 911 (ALS) transport. The EMT Narrative indicated LVN 2 was advised that LVN 1 had confirmed that Resident 1's decreased alertness was new onset for the past two hours and not Resident 1's baseline. During a review of GACH 3 Emergency Department (ED) Reports dated [DATE] timed at 3:06 PM, the Report indicated Resident 1 arrived at the GACH 3 ED for Hypoglycemia. The Report included initial vital signs taken at [DATE] timed at 3:07 PM included temperature of 97.9, heart rate of 90, respirations of 16, BP of ,d+[DATE], oxygen saturation was 99%. The Report further indicated, Patient presents with hypotension, hypoglycemia . glucose was in the 20's . Given intravenous (IV - through the vein) Dextrose 50 and 250 milliliters (solution restores blood glucose levels in hypoglycemia) bolus of D5water (an IV solution used to provide hydration and calories, often used to treat dehydration [severe fluid loss in the body] or low blood sugar). Sugars improved to the 200's . [Resident 1] does not appear to be able to take anything by mouth at this time. The GACH 3 ED Report indicated Resident 1 was admitted to the GACH 3's ICU with diagnoses that included hypoglycemia, hypotension (abnormally low blood pressure), lactic acidosis (refers to lactic acid [produced when oxygen levels become low in cells within the areas of the body] build up in the bloodstream), and pneumonia (an infection of one or both of the lungs). During a review of GACH 3 Discharge Summaries Notes, Death Summary dated [DATE], the Death Summary indicated on [DATE] to [DATE], while waiting for hospice (a home providing care for the terminally ill patient) evaluation, Resident 1's code status was changed to a DNR (Do not Resuscitate - a legal document that instructs providers not to revive if a patient's breathing stops or if the patient's heart stops beating). The GACH 3 Death Summary indicated Resident 1 expired on [DATE] with final diagnoses that included chronic kidney (a condition where the kidneys are damaged and cannot filter blood as well as they should, leading to a gradual loss of kidney function over time) disease, hypoglycemia, hypotension, lactic acidosis, pneumonia, and septic shock (a condition in which the blood pressure fail, and the organs of the body fail to receive sufficient oxygen). During an interview on [DATE] at 12:12 PM with Resident 2, Resident 2 stated on [DATE], he was Resident 1's roommate and remembered EMT 1 coming into their room to take Resident 1 to the hospital but when EMT 1 saw Resident 1 was incoherent (talking in a confused/unclear way), EMT 1 told the nurse (LVN 2) I can't take him like this you have to call 911. Resident 2 stated LVN 2 and EMT 1 began to argue back and forth for a while. Resident 2 stated Resident 1 would often yell to call out for the nurses or say he wanted to go home but on that day ([DATE]) Resident 1 was just lying in bed just making like groaning noises. Resident 2 stated Resident 1 was not acting like his normal self. During an interview on [DATE] at 4:04 PM and record review of Resident 1's telephone readmission orders dated [DATE] and GACH 2 DC Summary and discharge medications dated [DATE] with the MDS (Minimum Data Set, a federally mandated assessment tool) Nurse, the MDS Nurse stated Resident 1's [DATE] readmission orders did not include an order for Blood Sugar monitoring or hypoglycemic protocol as well. The MDS Nurse stated the licensed nurses should have had both blood sugar monitoring on Resident 1's readmission because of DM diagnosis and past history of hypoglycemic episodes at the facility so that his BS levels could be monitored. The MDS Nurse indicated the admitting nurse (RN 2) should have clarified the missing admission orders by notifying MD 1 or NP 1. During a subsequent interview on [DATE] at 4:08 PM and record review of Resident 1's Care Plans for DM with the MDS nurse, the MDS Nurse stated Resident 1's Care plan for DM was not implemented by monitoring the resident for hypoglycemia and hyperglycemia while residing in the facility from [DATE] to [DATE], because Resident 1 did not have any order for blood sugar checks. During a telephone interview on [DATE] at 12:59 PM with LVN 2, LVN 2 stated she was called by LVN 1 to Resident 1's room on [DATE] at around 11:30 AM because Resident 1's BS was 47. LVN 2 stated she rechecked Resident 1's BS but could not recall what the reading was and did not document. LVN 2 stated both LVN 1 and LVN 2 gave Resident 1 glucose gel and rechecked Resident 1's BS and read as 46. LVN 2 stated she thought Resident 1's BS was rechecked two more times and remained at 46. LVN 2 stated she called Resident 1's NP 1 and informed him of Resident 1's BS and that they had already administered glucose gel twice prior to calling him and Resident 1 was awake. LVN 2 stated she did not take Resident 1's vital signs because LVN 1 checked the vital signs but recalled the vital signs were normal. LVN 2 stated the NP 1 1 ordered a regular ambulance transport for Resident 1's transfer order to GACH 3. LVN 2 stated on [DATE] at around 2 PM, the ambulance transport arrived and the EMT's did not want to take Resident 1 to GACH 3 due to his low BS levels. LVN 2 stated she informed the EMTs their dispatch operator had said it was okay to transfer the resident because Resident 1 was awake and responsive but the EMT's refused. LVN 2 stated she called NP 1 and informed him the EMTs did not want to take Resident 1 because his BS was low, the EMT spoke to NP 1 and NP 1 decided to call 911. During a telephone interview on [DATE] at 1:50 PM with NP 1, NP 1 stated on [DATE] he remembered receiving a call from LVN 2 who informed him Resident 1 had a low blood sugar. NP 1 stated LVN 2 informed him Resident 1 was given glucose gels and was awake and alert. NP 1 stated he told LVN 2 it was okay to transfer Resident 1 to the hospital so he can be monitored for low blood sugar levels. NP 1 stated he ordered regular ambulance transport and not 911 emergency services based on the information he received from LVN 2, who informed him Resident 1 was alert and awake. NP 1 stated if he had been notified by LVN 2 that Resident 1 had ALOC with severely low BS, he would have ordered the licensed nurses to call 911 EMS. NP 1 stated Resident 1 should have had his BS checked routinely before meals and bedtime while in the facility. During an interview on [DATE] at 2:17 PM with LVN 1, LVN 1 stated that on [DATE], LVN 1 was Resident 1's assigned nurse. LVN 1 stated she remembered that around 8:30 AM to 9 AM Resident 1's CNA (CNA 1) approached her and asked to check on Resident 1 because he did not look good and did not look like himself. LVN 1 stated she went to Resident 1's bedside and immediately checked his vital signs. LVN 1 stated Resident 1's BP was ,d+[DATE] and the BS was 27. LVN 1 stated she thought the glucose machine was defective and went to get another glucose machine to recheck Resident 1's BS but received the same BS reading of 27. LVN 1 stated she did not document the BS of 27 and low BP because LVN 2 stated she would document Resident 1's change in condition. LVN 1 stated she asked for LVN 2s help. LVN 1 stated she told LVN 2 that Resident 1's BS was really low at 27 and that they should call 911 emergency services. LVN 1 stated LVN 2 gave Resident 1 three packets of glucose gel at the same time and observed LVN 2 directly squeezed the glucose gel into Resident 1's mouth because Resident 1 did not want to eat. LVN 1 stated LVN 2 prompted Resident 1 to swallow the glucose gel by tapping Resident 1's cheeks and throat so he would swallow the glucose gel. LVN 1 stated Resident 1 was just sitting and did not try help LVN 2 as she squeezed another glucose gel onto his mouth. LVN 1 stated Resident 1 appeared very weak. LVN 1 stated she told LVN 2 they should call 911 because Resident 1's BS levels were not going up but LVN 2 stated Resident 1's NP 1 wants Resident 1 to be transferred via regular ambulance transport to GACH 3. LVN 1 stated regular ambulance transport takes a long time to arrive as it is not for emergency situations. During the same interview on [DATE] at 2:17 PM, LVN 1 stated when the regular ambulance transport arrived and evaluated Resident 1, they stated they could not take Resident 1 because he was too unstable, and it was unsafe. LVN 1 stated EMT 1 informed us that Resident 1 required 911 emergency services. LVN 1 stated eventually LVN 2 called NP 1 and overheard the EMTs talking to NP 1 and informed NP 1 that either the facility calls 911 or the EMTs would call 911 to take Resident 1 to the GACH. LVN 1 stated she recalled LVN 2 getting angry and telling the EMTs to leave and then proceeded to get into an argument with the EMTs until the 911 paramedics arrived. LVN 1 stated she did not notify the facility's Registered Nurse (RN 3) Supervisor on duty, because RN 3 was from a Nursing Registry (a nurse who works on an as needed or temporary basis through an agency) and she thought LVN 2 who was a regular facility staff who knew Resident 1 better would be able to help her. LVN 1 stated when 911 paramedics arrived, she recalled the RN 3 got upset because she was not notified of Resident 1's condition. LVN 1 stated RN 3 informed them (LVN 1 and LVN 2) that Resident 1's low BS levels, hypotension, and ALOC was an emergency situation that warranted a 911 call. During a telephone interview on [DATE] at 12:11 PM with CNA 1, CNA 1 stated the morning of [DATE], Resident 1 had refused to eat breakfast in the morning. CNA 1 stated when she went to Resident 1's room around 9 AM to 10 AM, Resident 1 looked pale and was not acting like his normal self. CNA 1 stated Resident 1 did not respond to any questions and only responded with a grunt (a noise that is a byproduct of the body's struggle to compensate for the decreased muscle strength). CNA 1 stated she notified LVN 1 and LVN 1 took the resident's blood pressure and blood sugar. CNA 1 stated she remembered LVN 2 coming in Resident 1's room and LVN 1 told LVN 2 to call 911 emergency services and LVN 2 responded that the licensed nurses cannot send Resident 1 out like that becaus [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure 4 of 9 residents reviewed with pressure ulcer (Resident 186, 9, 121 and 55) received treatment and services to protect skin integrity (the state of skin being intact, healthy, and free from damage), promote healing, and prevent the development and worsening of pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) by failing to ensure: 1. Resident 186, who did not have a pressure ulcer on admission to the facility, developed a Stage 2 (partial-thickness of skin, presenting as a shallow open sore or wound) coccyx (tailbone) pressure ulcer that worsened to a Stage 3 pressure ulcer (full-thickness loss of skin, dead and black tissue may be visible). In addition, the resident developed a left heel vascular ulcer (an open sore developed due to problems with poor blood circulation) while in the facility. 2a. Resident 121's, who had a healed Stage 4 pressure ulcer (skin damage due to unrelieved pressure of all layers of the skin, reaching the underlying muscle, tendon, or bone, often with exposed tissue and a high risk of infection) on the sacral, Low Air loss Mattress (LAL, distributes the resident's body weight over a broad surface area and help prevent skin breakdown) was not set based on the resident's weight of 150 pounds (lbs.) and was not checked every shift for setting, connection, and functioning as ordered by the physician. 2b. Resident 9's, who had a healed Deep Tissue Injury (DTI, skin damage due to unrelieved pressure beneath the skin that may appear purple or maroon, or with blood-filled blister) on the ischium (lower and back part of the hip), the LAL mattress was not set based on the resident's weight of 101 lbs. and was not checked every shift for setting, connection, and functioning as ordered by the physician. 3. Resident 55, who had a Stage 4 pressure ulcer on the right ischium, the facility had no obtain records from the wound specialist regarding the resident's wound condition and treatment recommendation since 1/23/2025. In addition, there was no weekly skin and wound assessment documentation in Nursing Progress Notes and Interdisciplinary Team report of the resident's wound condition after 1/23/25. These deficient practices resulted in the development of pressure ulcer for Resident 186 and the potential to result in the recurrent development of pressure ulcers and/or worsening of pressure that could lead to pain, discomfort and infection for Residents 121, 9 and 55. Findings: 1. During a review of Resident 186's Admission Record, indicated the facility admitted Resident 186 on 1/31/2025 with diagnoses that included acute respiratory failure (ARF, when the lungs have trouble getting enough oxygen [odorless gas needed for plant and animal life] into the blood) with hypoxia (not enough oxygen in the body's tissues, muscle weakness, and peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs). During a review of Resident 186's History and Physical (H&P, a comprehensive physician's note regarding the assessment of a resident's health status), dated 1/31/2025, Resident 186 had the capacity to understand and make decisions. The H&P indicated Resident 186 had no skin breakdown and skin was intact. During a review of Resident 186's Body Check document, dated 1/31/2025, indicated Resident 186 did not have any skin breakdown. During a review of Resident 186's Braden Scale for Predicting Pressure Sore Risk Original (a standardized and evidence-based assessment tool to assess a resident's risk of developing pressure ulcers), dated 1/31/2025, indicated Resident 186 was at mild risk for developing pressure ulcer due to the resident's skin was occasionally moist, and makes small frequent movement while confined to bed. During a review of the Nursing Progress Notes, dated 2/1/2025, Treatment Nurse (TXN) 2 indicated Resident 186 had a coccyx (tailbone) Stage 2 pressure ulcer (partial-thickness loss of skin, presented as a shallow open sore or wound) sized 2 centimeters (cm, unit of measure) by 2 cm by 0.1 cm, with 100% pink wound bed. During a review of Resident 186's Order Summary Report (physician's orders), dated 2/1/2025, indicated to clean Resident 186's coccyx pressure ulcer with normal saline, pat dry, apply [NAME]-honey (sterile, medical grade honey dressing used to treat wounds), and cover with foam dressing every day, every shift. During a review of Resident 186's care plan, date initiated on 2/1/2025, the care plan indicated Resident 186 had an actual skin breakdown on her coccyx pressure. The care plans interventions, dated 2/1/2025, included to turn or reposition the resident for comfort as tolerated, observe for signs and symptoms of skin breakdown such as redness, decrease sensation, and if skin that does not blanche easily, and to observe for verbal and nonverbal signs of pain related to wound treatment. During a review of Resident 186's care plan, date initiated on 2/5/2025, the care plan indicated Resident 186 missed her treatment that included Coccyx pressure ulcer cleanse with NS, pat dry, apply thera-honey, cover with foam dressing every day shift for 30 days until finished Bilateral lower extremity apply A&D ointment x dry scaley skin every day for 30 days until finished to bilateral legs and coccyx 2/4/2025. The care plan's interventions included monitor vital signs every shift, provide treatment as ordered, and call the physician for any changes of condition. During a review of Resident 186's Minimum Data Set (MDS, a resident assessment), dated 2/6/2025, the MDS indicated Resident 186's cognition (a person's mental process of thinking, learning, remembering, and using judgement) was intact. The MDS indicated Resident 186 was dependent (helper does all the effort. Resident does none of the effort to complete the activity) for activities of daily living (ADLs, activities such as bathing, dressing, and toileting a person performs daily), and Resident 186 required substantial assistance (helper does more than half the effort) to turn from her back to the left or right side and to return to lying on her back on the bed. The MDS indicated Resident 186 was always incontinent (involuntary loss of bladder or bowel control) for urine and stool. The MDS indicated Resident 186 was at risk for developing pressure ulcers, and Resident 186 had one Stage 2 pressure ulcer present upon admission. The MDS indicated Resident 186's skin and pressure ulcer treatments included a pressure reducing device for the bed, pressure ulcer care, and the application of ointment or medication to the pressure ulcer. During a review of Resident 186's Order Summary Report, dated 2/6/2025 the physician ordered Resident 186 to be seen by wound consult (a physician specialized in wound care and pressure ulcers). During a review of Resident 186's Wound Assessment, dated 2/6/2025, evaluated by Physician Assistant (PA) 1, PA 1 indicated Resident 186 had a Stage 2 pressure ulcer on her coccyx measured 2.0 cm by 2.0 cm by 0.1 cm with light serosanguinous (thin watery fluid pink in color) drainage. PA 1 indicated Resident 186's pressure ulcer wound edges were macerated (a process where the skin becomes softened and breaks down due to prolonged exposure to moisture) and easily irritated. During a review of Resident 186's Wound Assessment, dated 2/13/2025, evaluated by PA 1, PA 1 indicated Resident 186's coccyx Stage 2 pressure ulcer measured 2.0 cm by 2.0 cm by 0.2 cm. PA 1 indicated Resident 186 had a serial surgical debridement (a medical procedure to clean a wound by removing the dead or damaged tissue). PA 1 indicated Resident 186's pressure ulcer remeasurement was 2 cm by 2 cm by 0.3 cm and reclassified as a Stage 3 pressure ulcer (full-thickness loss of skin. Dead and black tissue may be visible). PA 1 indicated Resident 186 had multiple comorbidities (two or more conditions occurring at the same time) and a high Braden score resulting in high risk for wound decline and delayed wound healing. PA 1 indicated Resident 186's coccyx pressure ulcer wound edges were macerated and easily irritated with light serosanguinous drainage noted. During a review of Resident 186's Change of Condition (CoC) document, dated 2/13/2025, the CoC indicated PA 1 examined Resident 186 and reported Resident's coccyx pressure ulcer had declined due to comorbidities. The Primary Care Physician (PCP) 1 recommendations included to continue following PA 1's treatment orders. During a review of Resident 186's care plan, date initiated 2/13/2025, the care plan indicated Resident 186 had been seen by the wound care physician for a decline of wounds related to her comorbidities. The care plan's interventions included continuing wound care treatment plan and to notify physician for any changes. During a review of Resident 186's Braden Scale document, dated 2/14/2025, the Braden Scale indicated Resident 186 was at high risk for developing pressure ulcers due to limited movement and required complete assistance with movement and skin was constantly damped with sweat or urine. During a review of Resident 186's Interdisciplinary Team (IDT, a group of health care professionals with various areas specialties who work together towards the goal of their resident) Care Conference note, dated 2/14/2025, the IDT note indicated Resident 186 had a Stage 3 coccyx pressure ulcer sized 2 cm by 2 cm by 0.3mcm, with 50% pink wound bed and 50% slough (dead tissue that is usually yellow, tan, grey, or green in color, usually moist and stringy in texture, that may be found in wounds), with light serosanguinous drainage, no odor, macerated and easily irritated wound edges. The IDT note wound status indicated Resident 186 Stage 3 pressure ulcer wound status was worsening. The IDT note indicated Resident 186's risk factors included exposure of skin to urinary and fecal incontinence. During a review of Resident 186's Order Summary Report, with an ordered date on 2/14/2025, Resident 186 had an order for a Low Air Loss (LAL, a mattress used to distribute a resident's body weight over a broad surface area and help prevent skin breakdown) mattress for pressure distribution and to monitor the LAL mattress was functioning properly. During a review of Resident 186's Nursing Progress Notes, dated 2/18/2025, TXN 3 indicated Resident 186 was seen by wound consultant on 2/17/2025 and recommended to continue current Stage 3 pressure ulcer treatment. The Nursing Progress Notes indicated a new skin breakdown on the left heel with vascular ulcer (an open sore developed due to problems with poor blood circulation). During a review of Resident 186's Order Summary Report, with an ordered date on 2/18/2025, Resident 186 had an order to cleanse the left heel vascular ulcer with normal saline, pat dry, apply betadine, and cover with dry dressing every day, every shift. During a review of Resident 186's care plan, revised on 2/20/2025, the care plan indicated Resident 186 was incontinent. The care plans interventions included, monitor for skin redness or irritation and to notify the physician and to assist Resident 186 with perineal care (cleaning and caring for the genital and anal areas to maintain hygiene and prevent infections) as needed. During a review of Resident 186's care plan, revised on 2/20/2025, the care plan indicated Resident 186 had actual skin impairment and was at risk for further skin breakdown infection, wound deterioration, and not healing wound. The care plans interventions included assisting Resident 186 with turning and repositioning for comfort and as needed, evaluate for any skin problems, to observe her skin condition daily with ADL cares and report any changes to the physician, to perform weekly skin assessments by the licensed nurse, and to perform weekly wound assessments to include measurements and descriptions of wound status. During a review of Resident 186's care plan initiated on 2/1/2025 and revised on 2/21/2025, the care plan indicated Resident 186 had a Stage 3 coccyx pressure ulcer. The care plans added the interventions to provide Resident 186 with pressure redistribution surface to her bed. The care plan's interventions included turning or repositioning the resident as tolerated, observe skin for signs and symptoms of break down which included redness, cracking, blistering, decrease sensation, and non-blanchable skin (redness that does not fade when pressed), and to provide ordered treatment and observe for signs and symptoms of infection until healed and to report changes. During a review of Resident 186's IDT note, dated 2/22/2025, the TXN 2 indicated Resident had two identified wounds. Resident 186's first wound was the Stage 3 coccyx wound was 2 cm by 2 cm by 0.3 cm with 70% pink wound bed and 30% slough with moderate serosanguinous drainage, with macerated, thinned, and irritated wound edges. Resident 186's second wound was located on the right heel sized 3 cm by 3 cm by 0.3 cm with 10% pink wound bed, 80% eschar (dead tissue that was hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like, usually firmly attached to the base, sides and/or edges of the wound and over time falls off) and 10% slough with moderate serosanguinous drainage, with macerated, irritated, and slough wound edges. During a review of Resident 186's Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer Form (Transfer Form), transfer date of 2/24/2025, the Transfer Form there was no documented evidence Resident 186 had any pressure ulcers or wounds at the time of transfer. During an interview on 2/28/2025 at 10:19AM with Registered Nurse (RN) 3, RN 3 stated, it was important to reposition the resident every two hours, place resident on a LAL mattress, and perform regular wound care treatments. RN 3 stated, it was important for the Registered Dietitian (RD) to evaluate the residents and to ensure the residents were ordered the correct supplements to encourage wound healing. During a concurrent interview and record review on 2/28/2025 at 8:30PM with Licensed Vocational Nurse (LVN) 5, Resident 186's Body Check document, dated 1/31/2025, was reviewed. There was no documented evidence Resident 186 had any skin breakdown. Resident 186 did not have any pressure ulcers or skin issues upon admission. During a concurrent interview and record review on 2/28/2025 at 8:30PM with LVN 5, Resident 186's Nursing Documentation Evaluation, dated 1/31/2025, was reviewed. The Nursing Documentation Evaluation indicated Resident 186 did not have any skin issues. LVN 5 stated, this document indicated Resident 186 did not have any skin breakdown. During a concurrent interview and record review on 2/28/2025 at 8:30PM with LVN 5, Resident 186's Weekly Summary Documentation, dated 2/4/2025, was reviewed. The Weekly Summary Documentation indicated Resident 186 did not have any skin issues. LVN 5 stated, this document indicated Resident 186 did not have any skin breakdown. During a concurrent interview and record review on 2/28/2025 at 8:30PM with LVN 5, Resident 186's CoC, dated 2/13/2025, was reviewed. The CoC indicated Resident 186 was seen by a wound consultant and noted with a decline in wound due to comorbidities. LVN 5 stated, she was unaware Resident 186 had any pressure ulcers or skin impairments prior to the PA 1's visit with Resident 186. During a concurrent interview and record review on 2/28/2025 at 8:30PM with LVN 5, Resident 186's Body Check, dated 2/21/2025, was reviewed. LVN 5 stated, there was no documented evidence Resident 186 had a Stage 3 coccyx pressure ulcer or a left heel vascular ulcer. LVN 5 stated Resident 186's skin condition should had been documented in the Body Check weekly. During a concurrent interview and record review on 2/28/2025 at 8:45PM with LVN 5, LVN 5 stated, Resident 186's Transfer form prior to transfer to General Acute Care Hospital (GACH), dated 2/24/2025, there was no indication in the Body Check form that the resident had any skin breakdown. LVN 5 stated, if there was documentation of Resident 186's pressure ulcer the skin would have been monitored, and the wound's decline could have been identified earlier. During an interview on 2/28/2025 at 9 PM with LVN 5, LVN 5 stated, Resident 186's pressure ulcer may have worsened because the resident's briefs were not being changed as often leaving Resident 186 lying in her wet and dirty briefs for a long period of time. LVN 5 also stated, Resident 186 probably was not being repositioned every two hours. LVN 5 stated she was in charge of the documentation and putting in orders and assessments for residents. During an interview on 3/1/2025 at 12 PM with TXN 2, the TXN 2 stated, Resident 186 was probably not turned and repositioned every two hours, and Resident 186's brief was probably not changed as often as it should have been, resulting in the resident lying in the same positioning and in their urine or stool filled briefs for long periods of time. During a concurrent interview and record review on 3/1/2025 at 2:55PM with CNA 9, CNS 9 stated Resident 186's Daily Skin Assessments (the skin assessment form used by the CNAs to document the residents skin condition) dated 2/12/2025, 2/13/2025, 2/14/2025, 2/18/2025, 2/19/2025, 2/20/2025, and 2/21/2025 were reviewed. CNA 9 stated she took care of Resident 186 and upon review the Daily Skin Assessments did not indicate that Resident 186 had pressure ulcers or skin breakdown. CNA 9 stated, it was never reported to her by the Licensed Nurses that Resident 186 had a pressure ulcer. 46779 2a. During a review of Resident 121's Admission Record (AR), the AR indicated the facility admitted Resident 121 on 7/23/2024 and readmitted him on 8/21/2024 with diagnoses that included diabetes mellitus (a group of diseases that result in too much sugar in the blood) and stage four pressure ulcer (the most severe stage of a pressure sore, where the wound extends through all layers of skin to the bone structure) on the sacrum (lower back and upper buttock). During a review of Resident 121's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/6/2025, indicated Resident 121 had moderately impaired memory and cognition (ability to think and reason). The MDS indicated Resident 121 required substantial/maximal assistance with rolling left and right, and was dependent from staff with toileting hygiene, personal hygiene, chair/bed-to-chair transfer. During a review of Resident 121's Order Summary Report, dated 2/28/2025, the report indicated the physician ordered for the resident to have a low air loss mattress and wound management, to check for comfort, setting and connection (functioning properly) every shift, starting on 1/4/2025. During a review of the User Manual for Low Air Loss Mattress System, dated 2018, indicated to turn the pressure adjust knob to a comfortable pressure level using the weight scale. During a concurrent observation and interview on 2/25/2025 at 9:13 AM, with Licensed Vocational Nurse (LVN) 5, Resident 121 was lying on a LAL mattress. LVN 5 stated, Resident 121's LAL mattress pump had a yellow sticker with a number 150 which indicates the resident weighs 150 pounds. LVN 5 stated, the pressure adjust knob on the LAL mattress pump was set below pounds on the weight scale display panel. LVN 5 stated the number 150 on the yellow sticker indicated the LAL mattress pressure should be set at 150 pounds and the pressure adjust knob should be pointing at 150 on the weight scale. During a concurrent interview and record review on 2/27/2025 at 10:15AM, with Treatment Nurse (TXN) 1, Resident 121's Treatment Administration Record (TAR), dated 1/2025 and 2/2025, were reviewed. TXN 1 stated, there were no documentation to indicated Resident 121's LAL mattress settings, connection, and functions were checked during the morning shift from 7AM to 3PM on 1/17/2025. The TXN 1 stated, there was no documentation to indicated Resident 121's LAL mattress setting, connection, and functions were checked during the evening shift from 3PM to 11PM on 1/8/2025, 1/11/2025, 1/15/2025, 1/17/2025, 1/23/2025, 2/4/2025, 2/23/2025, and 2/24/2025. The TXN 1 stated, there was no documentation to indicate Resident 121's LAL mattress setting, connections, and functions were checked during the night shift from 11PM to 7AM on 1/18/2025, 2/8/2025, 2/14/2025, and 2/19/2025. During an interview on 2/27/2025 at 10:15AM with TXN 1, the physician ordered was to check Resident 121's LAL mattress every shift. TXN 1 stated, the TXN should check the LAL mattress when providing wound care for the resident and document the setting, connections, and functions as completed during the morning shift. TXN 1 stated, the charge nurses were responsible to check the LAL mattress and document for the evening and night shift. During an interview on 2/27/2025 at 10:15AM with TXN 1, TXN 1 stated Resident 121's sacral wound was healed, but Resident 121 was still at high risk for skin breakdown and needed to continue skin treatments to prevent the recurrence of the of the pressure ulcer. TXN 1 stated, it was important to provide comfort and to alleviate pressure on the resident's bony parts to prevent the recurrent pressure ulcer and formation of a new pressure ulcer. During a review of Resident 9's Care Plan Report, dated 1/24/2025, the report indicated the care plan addressed Resident 9's DTI at the left ischium (lower and back part of the hip) and the interventions included pressure redistribution surface (a surface that distributes body weight across a larger area to reduce pressure on the body) to be as guideline for LAL mattress. During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9 had severely impaired memory and cognition. The MDS indicated Resident 9 required partial/moderate assistance with eating, substantial/maximal assistance with oral hygiene, toileting hygiene, shower/bathe self, and personal hygiene, and was dependent with rolling left and right. During a review of Resident 9's Order Summary Report, dated 2/28/2025, the order indicated to clean Resident 9's left ischium DTI with normal saline, pat try, and apply barrier cream for skin maintenance every day for 30 days starting on 2/23/2025. During a review of Resident 9's Order Summary Report, dated 2/28/2025, the order indicated for Resident 9's LAL mattress to check for comfort, setting, and connection every shift, starting on 1/25/2025. During a review of the undated User Manual for Low Air-Loss Mattress, the manual indicated The Pressure Control Knob on the pump should be set to a weight slightly greater than the patient's weight. During a concurrent observation and interview on 2/25/2025 at 10:07 AM, with LVN 2, Resident 9 was lying on a LAL mattress. Resident 9's LAL mattress pump had a yellow sticker written with 80-160 on it. LVN 2 stated Resident 9's recent weigh in February 2025 was 101 lbs. and the current LAL mattress setting was set at set slightly over 160 lbs. which was not the right setting. LVN 2 stated it was important to ensure the air mattress was at the right setting to redistribute the pressure and promote healing and comfort to the resident. During a concurrent observation and interview on 2/27/2025 at 10:20 AM, with TXN 1, Resident 9's TAR, dated 1/2025 and 2/2025, were reviewed. TXN 1 stated, there were no documentation that indicated the nurses checked Resident 9's LAL air mattress during the morning shift from 7 AM to 3 PM on 2/4/2024, the evening shift from 3 PM to 11 PM on 1/29/2025, 1/31/2025, 2/4/2025, 2/16/2025, 2/23/2025, 2/24/2025, and the night shift from 11 PM to 7 AM on 2/1/2025, 2/6/2025, 2/7/2025, and 2/13/2025, 2/15/2025, and 2/18/2025. TXN 1 stated, Resident 9's left ischium wound was healed, but Resident 9 was still at high risk for skin breakdown. TXN 1 stated, it was important to ensure the LAL mattress was at the right setting to provide comfort and to alleviate pressure on Resident 9's bony parts to prevent the recurrent pressure ulcer and the formation of new pressure ulcer. 3. During a review of Resident 55's AR, the AR indicated the facility admitted Resident 55 on 11/23/2019 and readmitted him on 12/16/2024 with diagnoses that included dementia (a decline in mental abilities that can include memory loss, difficulty thinking, and challenges with reasoning) and stage four pressure at right buttock. During a review of Resident 55's Care Plan Report, revised on 10/23/2024, the report indicated the care plan addressed Resident 55's stage four pressure ulcer at right ischium and the interventions included to monitor for further skin breakdown and report to physician as indicated, and weekly skin assessment to include measurements and description of redness status. During a review of Resident 55's MDS, dated [DATE], the MDS indicated Resident 55 had intact memory and cognition. The MDS indicated Resident 55 required setup or clean-up assistance with eating, partial/moderate assistance with personal hygiene, and was dependent with staff on toileting hygiene, chair/bed-to-chair transfer and rolling left and right. During a review of Resident 55's Physician Order, dated 1/23/2025, the order indicated the physician ordered to cleanse the resident's stage four pressure ulcer at right ischium with NS, pat dry, apply collagen powder (a substance applied to wounds to promote wound healing), calcium alginate (a substance used to treat wound), cover with foam dressing as needed for if soiled and every day shift for pressure ulcer at right ischium for 30 days. During a concurrent interview on 2/28/2025 at 10:35AM with TXN 1, TXN 1 stated, Resident 55 was seen by a wound care specialist in the facility every week for his right ischium pressure ulcer. TXN 1 stated, a facility TXN would accompany the wound care specialist to assess and provide wound care treatment for Resident 55 during the visit. TXN 1 stated, the TXN would document the wound assessment, current treatment, and additional wound notes in the Interdisciplinary Care Conference weekly. TXN 1 stated, the Interdisciplinary Care note was considered as the weekly wound assessment. During an interview on 2/28/2025 at 10:36 AM with TXN 1, TXN 1 stated the wound care specialist started to see Resident 55 on 1/6/2025 and the facility did not obtain any wound assessment reports, treatment recommendation and progress notes from the wound care specialist since 1/6/2025. During a concurrent interview and record review on 2/28/2025 at 11:25 AM with TXN 1, Resident 55's Interdisciplinary Care Notes, dated from 1/6/2025 to 2/14/2025, and Resident 55's Progress Notes, dated 1/2025 to 2/2025, were reviewed. TXN 1 stated there was no documentation of wound assessment for Resident 55's pressure ulcer on the right ischium after 1/23/2025. During an interview on 2/28/2025 at 11:30AM with TXN 1, TXN 1 stated, due to a lack of weekly skin/wound assessment in the Interdisciplinary Care Notes and the Nursing Progress notes, there was no indication of the communication with the wound care specialist about Resident 55's wound to indicate the condition of the wound or to evaluate if the current treatment was effective. The TXN 1 stated, it was important to obtain the progress notes from the wound care specialist because the facility staff would be aware of the wound's condition and treatment plan effectiveness. During an interview on 2/28/2025 at 7:13 PM with the Acting Director of Nursing (ADON), the ADON stated the TXNs were supposed to complete a weekly skin/wound assessment in the Interdisciplinary Care Conference note for all the residents with a skin issue or a wound, so the facility could monitor and know the healing progress of the skin and the wound, and intervene if there was a deterioration of the skin condition and the wound. The ADON stated the facility should obtain the progress notes for the residents that were seen by a wound specialist to ensure the consistent wound assessment and wound care were provided to the residents. During a review of the facility's policy and procedure (P&P) titled, Skin Integrity Management, dated 5/26/2021, indicated the facility will provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds and will perform wound observations and measurements upon initial identification of altered skin integrity, weekly, and with anticipated decline of wound. The P&P also indicated the facility will: A. Implement an individual patient's skin integrity management when it occurs within the care delivery process. B. Staff continually observes and monitors patients for changes and implements revisions to the plan of care as needed. C. Perform skin inspection on admission, readmission, weekly and document in the Treatment Administration Record and the Point Click Care (a computerized charting system at the facility). D. Nursing staff will observe for any sign of potential injury or active pressure ulcer daily while providing care. E. Develop comprehensive care plan and IDT care plan for prevention and treatments, identify risk factors and determine turning and repositioning based on resident's needs.

Based on observation, interview and record review, the facility failed to provide a hazard free environment and adequate supervision (an intervention and means of mitigating the risk for accidents) for three of five sampled (Residents 29, 128 and 491) who were assessed at high risk for falls in accordance with the facility's policy titled, Fall Management, effective 5/26/2021 by failing to: 1. Evaluate and analyze hazard and risk factors to reduce recurrent falls for Resident 29 who had multiple incidents of falls on 10/9/2024, 10/21/2024, 11/6/2024, 11/25/2024 and 11/26/2024. 2. Identify environmental hazard and risk of an accident for Resident 128 who slipped onto the floor due from Nystatin powder (medication to treat fungal or yeast infections of the skin) that was left on the ground. In addition, Resident 128 called for assistance and the resident's call light was not answered immediately after the resident fell on [DATE]. 3. Re-evaluate and provide adequate supervision for Resident 491 to prevent falls, who had been found crawling on the floor on 2/18/2025, 2/19/2025, and 2/26/2025. As a result, Resident 29 sustained a non-displaced (not out of place) acute fracture (sudden and unexpected broken bone due to traumatic event) of the left ankle on 11/27/2024. Resident 128 sustained a fracture (break in bone) of the left proximal (closer to the center of the body) humerus (shoulder bone) on 12/23/2024 resulting in pain, discomfort and decline in mobility. Resident 491 had incidents of being found on the floor that could potentially result in injuries, pain, fractures, hospitalization and a decline in mobility. Cross Reference F-657 Findings: 1. During a review of Resident 29's Admission Record (Face Sheet), indicated Resident 29 was admitted to the facility on [DATE], with diagnoses that included history of falling, muscle weakness, and dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). During a review of Resident 29's History and Physical (H&P) dated 9/13/2024, indicated Resident 29 did not have the capacity to understand and make decisions. During a review of Resident 29's care plan dated 9/14/2024 indicated Resident 29 was at risk for falls related to history of falls, The care plan goal indicated Resident 29 would have no falls with injury x (for) 90 days. The care plan interventions included reviewing past information on past falls, attempts to determine cause of falls, provide non-skid socks, place bed against the wall, assess for changes in mental status, pain status, mental status, and report to MD (medical doctor) as indicated, keep bed in low position, floor mat on the right side of the bed, non-skid floormats. During a review of Resident 29 's Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated 12/24/2024, indicated Resident 29 's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making were severely impaired. The MDS also indicated Resident 29 required substantial/maximal assistance (the helper does more than half of the effort ) with siting to lying, lying to sitting on the side of the bed, and dependent on toileting, chair/bed transferring, dressing, toileting, and personal hygiene. During a review of Resident 29 's Nursing documentation evaluation- admission, dated 9/13/2024, indicated Resident 29 was at high risk for falling. During a review of Resident 29's Change in Condition (COC) Evaluation form, dated 10/9/2024 indicated Resident 29 had a fall on 10/9/2024 at 11:12 AM but did not suffer any injuries. The form indicated that an Infection Prevention (IP) consultant saw the resident sitting in a wheelchair outside his room before the fall. The IP consultant reported that the resident fell forward onto the floor. Upon assessment, the resident was awake, responsive, and able to move both arms and legs without discomfort. A minor skin tear was found on the top of the right hand. Resident 29's family and doctor were informed, and the doctor ordered a transfer to the emergency room for further evaluation. During a Review of Resident 29's medical records showed that no Interdisciplinary Care Team (IDT) meeting was conducted after the fall on 10/9/2024. During a review of Resident 29's COC, dated 10/21/2024 indicated that Resident 29 had another fall that morning without any visible injuries. At 7:20 AM, a Certified Nursing Assistant (CNA) reported finding the resident on the floor. A Licensed Vocational Nurse (LVN) arrived and found the resident with his feet touching the wall and crouched near the bed with his head resting on it. The resident complained of back pain. The doctor was notified, and an X-ray was ordered at 8:00 AM. During a review of Resident 29's IDT meeting notes from 10/21/2024 at 10:28 AM, following the fall, indicated that safety measures would be put in place, including bed rails and a floor mat. The IDT also recommended a review of the resident's medications, continuation of the rehabilitation program, and the use of non-slip socks and a floor mat. During a review of Resident 29's COC Evaluation form dated 11/6/2024 indicated that the resident was found sleeping on a floor mattress and assisted back into bed. During a review of Resident 29 IDT dated 11/6/2024 timed at 12:01 AM, post fall incident on 11/16/24, indicated, the following will be provided to the resident: a Safety devices/Enabler, bed placed in low bed, floor pad/mat and nonskid socks. The IDT recommended continuing rehabilitation therapy five times per week, provide a hip protector, and update the resident's care plan to help prevent future falls. During a review of Resident 29's COC Evaluation form dated 11/27/2024 indicated that Resident 29 was moaning while walking and when his left ankle was moved. He was assisted back to bed, and no swelling was observed. During a review of the X-ray (a type of medical imaging that uses radiation to create pictures of the inside of your body, often used to see bones and diagnose broken bones or other injuries by showing how dense different tissues are within the body), dated 11/27/2024, at 1:45 PM, indicated Resident 29 had a non-displaced acute fracture of the left ankle. During a review of Resident 29's IDT meeting notes from 11/28/2024 indicated that the resident was experiencing pain in his left leg. The CNA reported that on 11/25/2024, just before lunchtime, the resident was found on the floor mat with both legs under the lower part of the bed. At that time, there was no noticeable change in his condition. The resident was assisted back into bed, and an additional mattress was placed next to the bed for safety. During a review of Resident 29 IDT dated 11/29/2024 at 9:59 post fall incident on 11/25/2024 indicated, Safety devices/Enabler in place: low bed, floor pad/mat and nonskid socks, bolters while on bed. IDT recommendations were to update the care plan updated to prevent reoccurrence. During a concurrent observation and interview on 2/25/2025 at 9:54 AM, Resident 29 was lying in bed, awake mumbling words and did not respond to questions appropriately. During an observation and interview on 2/26/2025 at 5:55 PM, with Family Member 1 (FM)1 in Resident 29's room. FM1 expressed concerns about Resident 29's care, stating that he has had multiple falls and that his floor mats are often not in place. During a concurrent interview and record review on 2/28/2025 at 10:46 AM with Licensed Vocational Nurse 5 (LVN) 5, Resident 29's COC was reviewed, LVN 5 stated that she was notified by a Physical Therapist that resident was complaining of pain during ambulation. LVN 5 stated that at the time she was unaware of any recent falls, she created a COC form to report about the resident's complaint of pain on 11/26/2024 and informed the doctor and FM 1. LVN 5 stated that the doctor ordered an x-ray of the left foot. She stated that results indicated the resident sustained a fracture. During a concurrent interview and record review on 2/28/2025 at 10:46 AM with LVN 5, Resident 29 care plan was reviewed. LVN 5 stated that facility did not update the resident's care plan after each fall as per policy and procedure. LVN 5 stated that the last update on the care plan was on 10/21/2024. LVN 5 stated that Resident 29 had multiple falls before the fracture occurred on 10/21/2024 and 11/6/2024 and did not complete required fall prevention measures. LVN 5 stated, The resident had a history of falls, but the care plan was not updated with new interventions before the resident sustained injury. The interventions implemented before the fall on 10/21/2024 included placing floor mats, providing non-slip socks, and physical therapy, but these measures should have been adjusted sooner. During a concurrent interview and record review of Resident 29 medical chart on 2/28/2025 at 10:46 AM with LVN 5, LVN 5 stated that after a fall it was required for the staffs to closely monitor the Resident 29 after a fall. LVN 5 stated after Resident 29 multiple falls resident was not closely monitored after the fall. LVN 5 stated that proper monitoring and supervision of Resident 29, the fall that led to the fracture could have been prevented. During a concurrent interview and record review on 2/28/2025 at 4:46 PM with Registered Nurse 1(RN) 1, RN 1 stated that Resident 29 was not properly assessed, monitored, and communicated to the staffs about the resident's risk for fall and that the resident was at high fall risk that led to preventable reoccurring falls and injury. RN 1 stated that the resident's care plan was not individualized or updated to reflect new interventions, and poor team communication further contributed to inadequate fall prevention measures. RN1 stated that there was no investigation for the root cause of the fall incidents on 10/9/2024, 11/6/2024 and 11/25/2024 and determine the appropriate intervention to implement to prevent recurrent falls. 36943 2. During a review of Resident 128's Admission Record, the facility admitted Resident 128 on 10/19/2023 with diagnoses including Type 2 Diabetes Mellitus ([DM] disorder characterized by difficulty in blood sugar control and poor wound healing), chronic (long-standing) kidney disease, presence of a right artificial shoulder joint, muscle weakness, and history of falling. During a review of Resident 128's Minimum Data Set ([MDS] a resident assessment tool), dated 11/2025/2024, the MDS indicated Resident 128 had clear speech, expressed ideas and wants, understood verbal content, and had intact cognition (ability to think, understand, learn, and remember) The MDS indicated Resident 128 was independent with eating, oral hygiene, toileting, transferring from lying in bed to the side of the bed, transferring from sitting to standing, transferring from the chair/bed-to-chair, and walking 150 feet using a walker. During a review of Resident 128's physician orders, dated 12/5/2024, the physician orders indicated to apply Nystatin External Powder (medication to treat fungal or yeast infections of the skin) to axillae (underarms) topically(means applying a medication or treatment directly to the skin one time a day for prurigo nodularis (skin condition characterized by intense itching and the formation of small, firm modules on the skin) for 30 days. During a review of Resident 128's Change in Condition Evaluation (CICE), dated 12/23/2024 and signed by Registered Nurse 1 (RN 1) on 12/26/2024, the CICE indicated Resident 128 was found lying on the floor next to the bed. The CICE indicated Resident 128 slid off the bed, landed on the left shoulder, and complained of pain to the left elbow and left shoulder. The CICE indicated Resident 128's physician ordered for Resident 128 to transfer to the General Acute Care Hospital (GACH). During a review of Resident 128's GACH X-ray (image of the inside of the body) report, dated 12/23/2024, the X-ray report indicated Resident 128 had a left proximal (closer to the center of the body) humerus (shoulder bone) fracture. During a review of Resident 128's Census List (record of residents in the facility) the Census List indicated Resident 128 returned to the facility on [DATE]. During a review of Resident 128's History and Physical (H&P) Examination, dated 12/28/2024, the H&P indicated Resident 128 had the capacity to understand and make decisions. During a review of Resident 128's IDT Care Conference, dated 12/30/2024, the IDT Care Conference indicated the IDT Care Conference did not include Resident 128 as an attendee. The IDT Care Conference indicated the root cause of Resident 128's fall was associated with the resident not asking for assistance as needed and poor balance. The IDT indicated Resident 128's care plan will be updated to prevent recurrence. During a review of Resident 128's care plan for an actual fall with (Specify: No Injury, Minor Injury, Serious Injury) Poor Balance, initiated 12/31/2024, the care plan goals and interventions were blank without any indication of goals and interventions. During a review of Resident 128's Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation, dated 12/31/2024, the OT Evaluation indicated Resident 128 was seated at the edge of the bed, slipped while standing up, and fell on [DATE]. The OT Evaluation indicated Resident 128 was referred to OT due to a decline in the ability to move without pain, ability to perform activities of daily living ([ADLs] tasks related to personal care including bathing, dressing, hygiene, eating, and mobility), range of motion ([ROM] full movement potential of a joint [where two bones meet]), and strength. During a review of Resident 128's Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation, dated 1/6/2025, the PT Evaluation indicated Resident 128 slipped on powder on the floor and fell on [DATE]. The PT Evaluation indicated Resident 128 was referred to PT due to the fall and was a fall risk, a decline in functional mobility, limitation with ambulation (the act of walking), and limited and painful movement. During a concurrent observation and interview on 2/27/2025 at 2:03 PM with Resident 128, Resident 128 was sitting on a bench located in the grass lawn next to the facility's parking lot. Resident 128 had a rollator walker next to bench (a mobility aid that features wheels, a frame, and handgrips, designed to assist individuals with walking difficulties by providing stability and balance) Resident 128 stated he slipped on powder, which was used for a body rash, on the floor, fell directly next to the bed, and broke the left arm approximately eight weeks ago. Resident 128 stated he already had a right shoulder replacement prior to living at the facility and stated the left arm did not feel the same after the shoulder fracture despite receiving therapy services. During a concurrent observation and interview on 2/28/2025 at 8:21 AM in Resident 128's room, Resident 128 was sitting at edge of the left side of the bed, facing the door. Resident 128 stated the facility staff had applied powder to Resident 128's body due to a skin rash during the time of the fall (on 12/23/2024). Resident 128 stated the powder was not visible on the floor but there were powder next to the bed. Resident 128 stated he stood up on the left side of the bed while reaching for the rollator walker, then he slipped on the powder, and he heard a crack upon falling onto the left arm. Resident 128 stated the floor was slippery to begin which became more slippery with the powder present on the floor. During an observation the floor on the left side of Resident 128's bedside was observed dry, but the surface was slippery. Resident 128's shoes slid slightly forward when Resident 128 attempted to plant both feet on the floor. During an interview with Resident 128, Certified Nursing Assistant 1 (CNA 1) walked into the room and stated she felt the floor on Resident 128's bedside was dry but felt slippery. During the same interview on 2/28/2025 at 8:21 AM in Resident 128's room, Resident 128 stated he pushed the call light after the fall, but nobody came for at least 10 minutes. Resident 128 stated he managed to kick the bedside table over, causing CNA 11 (no longer an employee) to come into the room and then called RN 1 for assistance. Resident 128 stated RN 1 came into the room after the fall and called the ambulance, which took Resident 128 to the hospital. During a concurrent interview and record review on 2/28/2025 at 12:07 PM with RN 1, RN 1 reviewed Resident 128's care plan for actual fall, initiated 12/31/2024 (after the IDT Care Conference), and stated Resident 128's care plan did not include any interventions to prevent recurrent fall that addressed preventing the resident from slipping on the floor due to the Nystatin powder. During an interview on 2/28/2024 at 12:44 PM with Resident 128 in the presence of RN 1, Resident 128 stated he slipped on powder located on the floor and could not prevent himself from falling (on 12/23/2024). Resident 128 stated the facility did not meet with Resident 128 after the fall. During a concurrent interview and record review on 2/28/2025 at 12:46 PM with RN 1, RN 1 reviewed Resident 128's MDS, dated [DATE], physician orders, dated 12/5/2024, and IDT Care Conference, dated 12/30/2024. RN 1 stated the MDS indicated Resident 128 was independent with transferring from lying in bed to the side of the bed, transferring from sitting to standing, transferring from the chair/bed-to-chair, and walking 150 feet using a walker. RN 1 stated Resident 128 did have physician orders to apply Nystatin powder at the time of the fall. RN 1 stated the IDT Care Conference indicated the root cause of Resident 128's fall was poor balance and not asking for assistance as needed. RN 1 stated the root cause was not accurate since Resident 128 was independent with sit to stand transfers and walking at the time of the fall and would not need to call for assistance. RN 1 stated the facility should have included Resident 128 in the IDT Care Conference and would have discovered the root cause was the presence of Nystatin powder on the floor. RN 1 stated the IDT should have developed interventions with Resident 128 to prevent further falls. 50203 3. During a review of Resident 491's Admission Record, indicated Resident 491 was admitted on [DATE] with diagnoses which included acute respiratory failure (ARF, when the lungs have trouble getting enough oxygen [odorless gas needed for plant and animal life] into the blood) with hypoxia (condition where the body's tissues doesn't have enough oxygen), unspecified atrial fibrillation (a heart condition that caused an irregular heart beat), and other abnormalities of gait (the pattern a person walks) and mobility. During a review of Resident 491's History and Physical (H&P, a comprehensive physician's note regarding the assessment of the resident's health status), dated 2/15/2025, indicated Resident 491 does have the capacity to understand and make decisions. During a review of Resident 491's Minimum Data Set (MDS, a federally mandated resident assessment), dated 2/20/2025, indicated Resident 491's cognition (a person's mental process of thinking, learning, remembering, and using judgement) was severely impaired. The MDS indicated Resident 491 required moderate assistance (helper does less than half the effort) when transferring from sitting to lying in bed, lying to sitting on the side of the bed and the ability to sit to stand from the chair. The MDS indicated Resident 491 was frequently incontinent (involuntary loss of bladder or bowel control) of urine and stool. The MDS indicated Resident 491 did not have any history of falls prior to admission to the facility. During a review of Resident 491's care plan, dated 2/15/2025, the care plan indicated Resident 491 was at risk for falls related to confusion, gait (the way the residents walks or moves /balance problems. The care plan goals indicated the resident will be free of falls by 5/16/2025. The care plan interventions included anticipating and meeting the residents needs and ensuring the resident's call light was within reach. During a review of Resident 491's Nursing Documentation Evaluation document, dated 2/15/2025, the document indicated Resident 491's had a risk factor of falls related to disorientation and confusion. During a review of Resident 491's Change in Condition Evaluation (CoC, a form used to document and report a significant change in a resident's health or circumstances) document, dated 2/18/2025 timed at 3:40 PM, LVN 5 indicated Resident 491 had episodes of confusion and was found crawling on the floor. During a review of Resident 491's care plan, dated 2/18/2025, the care plan indicated Resident 491 was at risk for falls due to episodes of confusion and crawling on the floor. The care plans goals indicated the resident will have no falls by 5/16/2025. The care plans interventions, included providing verbal safety reminders, placing the call light within reach, and monitoring for and assisting Resident 491 with toileting needs. During a review of Resident 491's Nursing Progress Notes, dated 2/19/2025, Licensed Vocational Nurse (LVN) 11 indicated at 3:30PM on 2/19/2025, Resident 491 was crawling on the floor. LVN 11 indicated one to one staffing was provided. During an observation on 2/26/2025 at 9:40 AM in the hallway by Resident 491's room, Resident 491 was raising his voice in foreign language asking for food as Certified Nurse Assistant (CNA) 10 was seen walking out of Resident 491 and saying to Resident 491 Let me change you. Resident 491 continued to refuse CNA 10's assistance and was asking for food. CNA 10 walked out of Resident 491's room, and Treatment Nurse (TXN) 1 asked CNA 10 to check another resident's room. CNA 10 walked away from Resident 491's room. Resident 491 could be heard raising his voice asking for help. During an observation on 2/26/2025 at 9:42 AM in Resident 491's room, Resident 491 was found lying on his left side on the floor by the foot of the bed on the right side of the bed. Resident 491 was without clothing covered with blanket and lying on a bedsheet stained with stool. Resident 491 was heard raising his voice speaking in a foreign language asking for help. During an interview on 2/26/2025 at 9:53AM with CNA 10, CNA 10 stated, she went into Resident 491's room to assist the resident with the morning care, and Resident 491 refused his linens and adult briefs to be changed. CNA 10 stated, someone (unable to identify) told her to go change another resident's linens. CNA 10 stated, she stepped out of Resident 491's room to go change another resident's linen while Resident 491 was still lying in bed. CNA 10 did not state the reason why Resident 491 was refusing to have his linens and adult brief to be changed. During an interview on 2/26/2025 at 9:53AM with CNA 10, CNA 10 stated, she was unaware Resident 491 was at risk for fall. CNA 10 stated, nobody told me. I should not have left (Resident 491) alone. CNA 10 stated, she was unaware Resident 491 needed frequent supervision, and she was not aware how the resident fell on the floor because the resident was left on the bed when she left the room to assist another resident. During an interview on 2/27/2025 at 5:36PM with CNA 12, CNA 12 stated, Resident 491 has tried to get out of bed a couple times before because he was always trying to stand up. CNA 12 stated, Resident 491 was mad because he wants to walk but he cannot. CNA 12 stated, Whenever I work with him, I end up trying to catch him. CNA 12 stated, Resident 491's room was located far away from the nursing station. CNA 12 stated, I make sure to be aware of him at all times by passing by his room and checking if he needs any assistance. CNA 12 stated, she tried to stay close to Resident 491 when she was assigned to him because Resident 491 was always trying to get up. During an interview on 2/28/2025 at 3PM with LVN 10, LVN 10 stated, Resident 491 was considered a fall risk. LVN 10 stated, Resident 491 has a yellow star outside his door, which indicated Resident 491 was a fall risk. LVN 10 stated, Resident 491 needed frequent monitoring and supervision because Resident 491 has a history of putting himself on the floor. During a concurrent record review and interview on 2/28/2025 at 5:38PM with RN 1, Resident 491's Nursing Documentation Evaluation, dated 2/15/2025 and CoC, dated 2/18/2025 were reviewed. The Nursing Documentation Evaluation, dated 2/15/2025, indicated Resident 491 was a fall risk. Resident 491's CoC, dated 2/18/2025, indicated Resident 491 was found crawling on the floor. RN 1 stated, Resident 491's fall risk indicators indicated he was disorientated and confused. RN stated, Resident 491 had a history of being found on the floor and crawling three different episodes since his admission on 2/15/2025. RN 1 stated, Resident 491 required more frequent staff supervision and a re-evaluation of fall precaution interventions because Resident 491 had a history of being found on the floor on 2/18/2025, 2/19/2025, and 2/26/2025. During a review of the facility policy and procedure (P&P) titled, Fall Management, effective on 5/26/2021, the P&P's purpose included to reduce risk for falls and minimize he actual occurrence of falls. The P&P indicated residents experiencing a fall will receive appropriate care and investigation of the cause. The P&P also indicated the IDT reviewed the incidence after the fall and updated the care plan to reflect new interventions if a resident falls in the facility. During a review of the facility's policy and procedure (P&P) titled, Fall Prevention and Management, effective date 5/26/2021, indicated: 1. Residents at risk for falls as part of the nursing process. 2. Document accident/incident in the clinical record 3. Residents determined to be at risk will receive appropriate intervention to reduce risk and minimize injury. 4. Communicate resident's fall risk to the caregivers. 5. Develop individualized plan of care and review and revise as indicate. 6. Update care plan to reflect new interventions. 7. Interdisciplinary to review post Fall.

Based on observation, interview, and record review, the facility failed to provide care and services to prevent new and recurrent urinary tract infection (UTI an infection in any part of the urinary system, the kidneys, bladder, or urethra)) infection, blockage (an obstruction or flow which makes movement or flow difficult or impossible) or bleeding for five of five sampled residents Resident 180,10, 57, 14 and 25) by failing to: 1. Ensure no delay in informing Resident 180's primary physician of Resident 180's critical lab values of white blood cell count (WBC, a type of blood cell that helps fight infection and disease) and low blood glucose (BG, the main sugar found in the blood), which were reported by the laboratory on 2/23/2025 at 11:48 PM as evidenced by the critical lab results were followed up on 2/24/2025 at 2:36 PM (approximately 14.5 hours when the critical lab results were reported). 2. Ensure the Licensed Nurses assessed and documented their daily nursing assessment related to Resident 180's indwelling catheter (a tube inserted into the bladder to drain urine) and urine output characteristics from 2/15/2025 to 2/25/2025. 3. Ensure the Licensed Nurses continued to monitor, document the vital signs, (measurements of the body's most basic functions, such as breathing rate, BP, HR, and temperature),change in mental status and food intake from 2/24/2025 to 2/25/2025 when Resident 180 started to become more lethargic (weak), responsive only to sternal rub (rubbing the middle of the chest to elicit pain and response) and immediately called the physician for the resident's worsening change in condition. 4. Ensure Residents 10 and 57 with suprapubic catheter (a device surgically inserted into the bladder to empty urine from the bladder) and history of recurrent UTIs were kept and dry when incontinent (no control) of urine and stool. 5. Ensure Residents 14 with indwelling urinary catheter and 25 suprapubic catheters, the facility failed was assessed and monitored the signs and symptoms of UTI such the presence sediment (presence of crystals, bacteria, or blood exit through the urine in the urine, blood in the urine, back/flank pain with urination and fever as ordered by the physician. As a result of these deficiencies Resident 180 was transferred to General Acute Care Hospital (GACH) 1 and arrived at the Emergency Department (ED) by ambulance on 2/25/2025 at 3:19 PM with admitting blood pressure (BP, the measurement of the pressure or force of blood inside the blood vessels) 64/44 mm Hg (Millimeters of mercury, a unit of measurement for pressure), and heart rate (HR) of 115 per minute (unit of time). Subsequently, Resident 180 was admitted to the Intensive Care Unit (ICU, a hospital ward that provides specialized care for patients who are very ill or injured) where the resident was diagnosed with septic shock (a life-threatening condition that occurs when an infection causes dangerously low BP and organ failure) with obstructive uropathy (a condition in which the flow of urine is blocked). While in the ICU, 700 milliliters (unit of volume) of purulent urine (urine that contains pus, a thick, yellowish fluid which indicates a sign of infection) was drained out from the indwelling catheter (a tube inserted into the bladder to drain urine). In addition, for Residents 10, 14, 57 and 25 the residents were at risk for recurrent UTIs that could lead to pain and hospitalization and decline in the wellbeing. Findings: 1. During a review of Resident 180's Admission Record (AR), the AR indicated the facility admitted Resident 180 on 1/29/2025 with diagnoses that included pneumonia (a severe an infection of the lungs that may be caused by bacteria, viruses, or fungi), sepsis (a life threatening infection in the blood which could lead to decreased in BP, increased HR, shortness of breath and altered level of consciousness, that can damage the body organs). During a review of Resident 180's Minimal Data Set (MDS-a federally mandated resident assessment), dated 2/4/2025, indicated Resident 180's cognition (ability to think, remember, and reason with no difficulty) was intact and needed partial assistance (helper does less than half the effort) in eating and personal hygiene. During a review of Resident 180's Plan of Care Progress Notes for Physical Medicine and Rehabilitation, dated 2/4/2025, indicated Resident 180 was identified to have diagnoses and/or comorbidities which were impacting functional status. The notes indicated the diagnoses included sepsis, with a high risk of complication. The notes indicated Resident 180's multiple medical issues necessitate frequent clinical evaluations, placing him at high risk for readmission without proper care. Neglecting regular monitoring and management may result in symptom exacerbation and complications, possibly requiring hospitalization . The notes indicated Resident 180 would require close monitoring for altered mental status, fever and or leukocytosis (an abnormally high number of white blood cells in the bloodstream) that would indicate recurrent or worsening state of sepsis. During a review of Resident 180's Order Summary Report (OSR), indicated on 2/5/2025, Resident 180 had a physician order for Indwelling Catheter for BPH [Benign Prostatic Hyperplasia, a benign (not cancer) condition in which the prostate gland (a gland in the male reproductive system) is larger than normal] and obstructive uropathy. The order indicated to change the indwelling catheter for blockage, leaking, pulled out, excessive sedimentation; change catheter drainage bag as needed and with every change of indwelling catheter. Further review of Resident 180's OSR lacked orders or other documentation for catheter care. During a review of Resident 180's care plans, indicated that facility staff failed to develop a care plan for interventions and monitoring of Resident 180's indwelling catheter use. During a review of Resident 180's Daily Documentation [Nursing assessment on overall health of the resident including vital signs (measurements of the body's most basic functions, such as breathing rate, BP, HR, and temperature), mental status, and activity of daily living], dated 2/14/2025, indicated Resident 180 was alert and oriented to time, place, and person. The assessment indicated Resident 180's indwelling catheter was in place with yellow urine output. During a review of Resident 180's Daily Documentation for the month of February 2025, indicated that facility staff failed to complete daily nursing assessments from 2/15/2025 to 2/25/2025 related to indwelling catheter and urine output characteristics. During a review of Resident 180's Order Summary Report (OSR), indicated on 2/15/2025 (10 days after the physician order indwelling catheter on 2/5/2025), Resident 180 had a physician order for indwelling catheter care every shift. The order failed to specify how facility staff were to care for the indwelling catheter. During a review of Resident 180's Treatment Administration Record (TAR) for the month of February 2025, the TAR indicated Resident 180 was given indwelling catheter care as ordered from 2/15/2025 to 2/25/2025. The TAR did not specify how the care was given and if the characteristic of the urine was assessed. During a review of Resident 180's phone orders, dated 2/22/2025, indicated Resident 180 had a physician order on 2/22/2025 at 7:39 PM for CBC (complete blood count, a blood test that measures the number and size of different types of blood cells), CMP (a routine blood test that measures 14 different substances in a sample of the blood), and UA with C&S (urinalysis with culture and sensitivity). During a review of Resident 180's Laboratory Results Report, dated 2/23/2025 timed at 11:48 PM, indicated Resident 180 had critical lab values for BG level of 60 milligrams (unit of weight) per deciliter (a metric unit of capacity) (mg/dL- reference range 65-99 mg/dL) and WBC count of 39.59 cells per microliter (unit of volume) of blood (normal reference range was 4-11 cells per microliter of blood). During a review of Resident 180's Change in Condition (CIC) Evaluation, dated 2/24/2025, indicated Resident 180 had critical lab results with low BG of 60, high WBC of 39.59 with no fever, clear breath sounds, and vital signs within normal range. The CIC indicated, on 2/24/2025 at 2:48 AM, LVN 5 notified Resident 180's Nurse Practitioner (NP) 1 about critical lab results of low blood glucose and high WBC and received a physician order for antibiotics (medication given to treat infection), however, further review of the CIC indicated that facility staff failed to document the antibiotic order. During a review of Resident 180's care plans since admitted [DATE], indicated a care plan was not developed to indicate interventions and monitoring of Resident 180 with critical lab results of low BG and high WBC on 2/23/2025. During a review of Resident 180's Follow-up Documentation for the CIC of critical lab results of low BG and high WBC, dated 2/24/2025, timed at 2:36 PM, the document indicated Licensed Vocational Nurse (LVN) 10 followed up with NP 1 for abnormal labs with no new order and to continue to monitor Resident 180. During a review of Resident 180's phone orders, dated 2/25/2025, Resident 180 had a physician order on 2/25/2025 at 10:14 AM for Zosyn (medication to treat infection) intravenously (into the vein/bloodstream) three times a day for Leukocytosis for 10 Days. During an observation on 2/25/2025 at 10:05 AM in Resident 180's room, Resident 180 was lying with a towel on his head and eyes closed. During a concurrent observation and interview on 2/25/2025 at 10:07 AM with Resident 180's Family Member (FAM) 1, FAM 1 was shaking Resident 180's arms then both legs and was calling Resident 180 to wake up, Resident 180 did not respond, and his eyes remained closed. FAM 1 stated, Resident 180 always called him every day, but on 2/24/2025, Resident 180 did not call him on the phone. FAM 1 stated, Resident 180 had not eaten anything since 2/24/2025 morning. During a concurrent observation and interview on 2/25/2025 at 11:05 AM with Certified Nurse Assistant (CNA) 4 in Resident 180's room with the presence of FAM 1, Resident 180 was lying in bed with his eyes closed. CNA 4 stated, she needed to change Resident 180 because he was wet due to his indwelling catheter was leaking. While CNA 4 was cleaning Resident 180, the resident was observed with an indwelling catheter and a sheet wet with urine. Resident 180 did not wake up while being changed. During a review of the facility's Charting Guidelines, indicated Resident 180 was to be monitored from 2/24/2025 to 2/27/2025 for vital signs, pain, change in behavior, level of consciousness and mental status due to abnormal labs, and generalized weakness. During a review of Resident 180's Weight and Vitals Summary, there was no documented evidence that Resident 180's BP, HR, oxygen saturation level, body temperature and level of consciousness were monitored from 2/24/2025 at 2:36 PM to 2/25/2025 at 1:54 PM (approximately for 24 hours, the resident's vital signs were not assessed). During a review of Resident 180's CIC Evaluation, dated 2/25/2025, indicated Resident 180 was noted with no intake for breakfast and lunch, vomiting, and overall weakness. The CIC indicated NP 1 was made aware of the resident's worsen condition at 1:30 PM on 2/25/2025. The CIC indicated NP 1 recommended to transfer Resident 180 to GACH for further evaluation. The CIC indicated Resident 180's BP was at 90/62 with HR of 110 at 1:54 PM on 2/25/2025. During a review of Resident 180's Order Summary Report (OSR), indicated on 2/25/2025, NP 1 ordered Resident 180 to transfer to acute hospital for further evaluation. During a concurrent record review and interview on 2/25/2025 at 1:05 PM with LVN 5, Resident 180's CIC Evaluation, dated 2/24/2025, timed at 3:31 AM was reviewed. LVN 5 stated, she worked as a Desk Nurse during the day, who was responsible to assist the Charge Nurses in communicating with the doctors. LVN 5 stated, she only worked dayshift and was not working at nighttime on 2/23/2025 and 2/24/2025. LVN 5 stated, in the morning of 2/25/2025, she noticed that there was an incomplete CIC which was created on 2/24/2025 at 3:31 AM for critical lab results of low glucose and high WBC. LVN 5 stated, the CIC indicated that on 2/24/2025 at 2:48 AM, Resident 180's physician was messaged and was still waiting for response, so she called Resident 180's covering physician (NP 1) to report the critical lab results and received a physician order for antibiotics around 9:30 AM. LVN 5 stated, on 2/25/2025, after she received order for antibiotics, she revised the physician recommendations on 2/24/2025 at 2:48 AM from waiting for response to NP 1 made aware with new orders for IV antibiotic. LVN 5 stated, she forgot to change the physician notification time from 2/24/2025 at 2:48 AM to 2/25/2025 at 9:30 AM. LVN 5 stated, she should have documented her physician notification in Resident 180's progress notes or a follow up assessment for the CIC. During an interview on 2/25/2025 at 1:13 PM with LVN 7, LVN 7 stated, she was taking care of Resident 180 from 11 PM on 2/24/2025 until 7 AM on 2/25/2025. LVN 7 stated, did not receive any report from LVN 9 (3-11 PM shift LVN) that Resident 180 was to be monitored for critical lab results. LVN 7 stated during the shift from 11 PM on 2/24/2025 until 7 AM on 2/25/2025, Resident 180 was observed asleep throughout the shift, and she did not check or ensure Resident 180's vital signs were taken during night shift when she took care of Resident 180. During an interview on 2/25/2025 at 1:17 PM with LVN 8, LVN 8 stated, he was the charge nurse for Resident 180 since 7 AM on 2/25/2025. LVN 8 stated, he was not aware and did not receive any report from previous nurse on the night shift (LVN 7) that Resident 180 was to be monitored for critical lab results of low blood glucose, high WBC, and generalized weakness. LVN 8 stated, he took care of Resident 180 for the first time today (2/25/2025), he did not know that Resident 180's baseline mental status as more awake and alert before, so he did not notify the physician. LVN 8 stated, Resident 180 was asleep during his shift on 2/25/2025 prior to transfer to GACH 1. During an interview on 2/25/2025 at 3:40 PM with LVN 9, LVN 9 stated, she was the Charge Nurse who took care of Resident 180 from 3-11 PM on 2/23/2025 and 2/24/2025. LVN 9 stated, she saw a significant change in Resident 180's mental status. LVN 9 stated, on 2/23/2025, Resident 180 was awake, alert, and able to eat, but on 2/24/2025, during 3-11 PM shift, Resident 180 was lethargic, sleeping, did not respond when spoken to, and did not eat his dinner. LVN 9 stated, she did not notify the Resident 180's physician because she was informed by LVN 10 (7-3 PM LVN on 2/24/2025) that the physician was already aware of the situation with no new order but to continue to monitor the resident. During a review of Resident 180's GACH 1's ED (Emergency Department) Triage, dated 2/25/2025, indicated Resident 180 arrived at the ED by ambulance on 2/25/2025 at 3:19 PM with admitting BP of 64/44 mm Hg, and HR of 115 per minute. During a review of Resident 180's GACH 1's History and Physical (H&P) Notes, dated 2/25/2025, timed at 7:15 PM, indicated Resident 180 was admitted to GACH 1 with altered mental status and drowsiness. The H&P indicated Resident 180's CT (computed tomography, scan is a non-invasive medical imaging procedure that uses X-rays to create detailed pictures of the inside of the body) of abdomen/pelvis revealed distended bladder. The physician's assessment indicated Resident 180 had septic shock with obstructive uropathy. The H&P indicated Resident 180 had an indwelling catheter and purulent urine was drained out from the bladder with 700 milliliter was removed. During a review of Resident 180's GACH 1's Progress Notes-Nursing, dated 2/25/2025, timed at 11:56 PM, indicated Resident 180 was admitted to GACH 1's ICU at 10:30 PM with an indwelling mixed of pus and blood output. During a phone interview on 2/26/2025 at 5:23 PM with Resident 180's FAM 1, FAM 1 stated, on 2/24/2025, he brought food to Resident 180 around noon time but Resident 180 was sleeping so after waiting for an hour, FAM 1 left his food at the bedside and left the facility. FAM 1 stated, he came back to the facility around 6 PM on the same day, he tried to touch and shake Resident 180 to wake him up but Resident 180 would not wake up, so he notified LVN 9. FAM 1 stated, LVN 9 and Registered Nurse (RN) 2 came to comfort him and told him that Resident 180's BP was low, and that Resident 180 was running a fever, so they had a towel over Residents 180's head. FAM 1 stated, RN 2 and LVN 9 told him that they would monitor Resident 180 but did not explain to him how they would monitor Resident 180. FAM 1 stated, he thought Resident 180 was already dead. FAM 1 stated, he stayed for 2.5 hours and did not see any staff come back to check the resident's vital signs. During an interview on 2/27/2025 at 4:20 PM with NP 1, NP 1 stated, on 2/20/2025 he ordered laboratory tests for blood and urinary analysis (a series of test on the urine) for a general checkup to make sure Resident 180 was stable with no infection related to his Foley catheter, in preparation for discharging Resident 180 home with his family. NP 1 stated, he did not receive any call or messages from the nurses regarding Resident 180's condition from the facility before he ended his shift at 7 PM on 2/24/2025. NP 1 stated, he only received text messages from the nurses reporting that Resident 180's HR was fast and was running a fever, so he ordered to monitor the resident. NP 1 stated, monitor means frequent assessment during each shift for change in mental status, abnormal vital signs, any decrease in baseline condition and that he expected the LVNs to report their findings to the physician. NP 1 stated, if he was aware of the lab results and the mental status changes when Resident 180 was not responsive and not eating on the night of 2/24/2025, he would have recommended to transfer Resident 180 to an acute hospital because, NP 1 stated, it was a 9/10 urosepsis [a life-threatening condition that occurs when a urinary tract infection (a bacterial infection that occurs in the urinary tract) spreads to the kidneys and causes sepsis], and for BG at 60, the BG should also be monitored as well as sign and symptoms of hypoglycemia. During an interview on 2/27/2025 at 5:12 PM with LVN 10, LVN 10 stated, he took care of Resident 180 from 7 AM to 3 PM on 2/24/2025. LVN 10 stated during the first or second hour of his shift, the RN supervisor gave him lab results and asked him to wait for the physician to respond so he did not call NP 1 in the morning of 2/24/2025. LVN 10 stated, Resident 180 was alert and responded to verbal command at the start of his shift. LVN 10 stated, around 2 PM, Resident 180 was slightly lethargic with generalized weakness, and elevated temperature so he notified NP 1 and received order to monitor. During an interview on 2/28/2025 at 10:30 AM with LVN 5 (Desk Nurse), LVN 5 stated, she was helping on 2/25/2025. LVN 5 stated, around 1:15 PM, when she came in Resident 180's room to notify Resident 180's FAM 1 that Resident 180 had a physician order for antibiotics, FAM 1 told her that Resident 180 had not eaten anything since 2/24/2025. LVN 5 stated, LVN 5 asked CNA 4 and was informed that Resident 180 did not have breakfast and lunch. LVN 5 stated, she notified NP 1 and received an order around 2 PM to transfer Resident 180 to an acute hospital for further evaluation. LVN 5 stated, LVN 8 was responsible to monitor, assess, and follow up with the physician when Resident 180 continued to not able to eat breakfast and drowsy. During a concurrent record review and interview on 2/28/2025 at 10:45 AM with LVN 5, Resident 180's Daily Documentation, for the month of February 2025, were reviewed. LVN 5 stated, per facility's protocol, the dayshift LVNs were responsible for Resident 180's assessment and document them daily. LVN 5 stated, based on the record, there was no daily assessment since 2/14/2025, which indicated Resident 180 was alert and oriented to time, place, and person. During a concurrent record review and interview on 2/28/2025 at 11:15 AM with LVN 10, Nursing Station 1's CIC book with Charting Guidelines, for the month of February 2025, was reviewed. LVN 10 stated, when a resident had any CIC, the LVN who created the CIC was responsible to list the resident's name, reason for CIC, with the start date and end date to monitor the resident. LVN 10 stated, Resident 180 was listed on 2/24/2025 with abnormal labs, generalized weakness and to be monitored for all shifts from 2/24/2025 to 2/27/2025. LVN 10 stated, the Charting Guidelines indicated Resident 180 to be monitored for vital sings, pain, change in behavior, level of consciousness and mental status. There no documented evidence the Resident 180 was monitored for the change in vital signs, pain, change in behavior and change in level of consciousness. During an interview on 2/28/2025 at 12:30 PM with CNA 4, CNA 4 stated, she took care of Resident 180 from 7AM to 3 PM on 2/24/2025 and 2/25/2025. CNA 4 stated, on 2/24/2025, Resident 180 ate very little of his breakfast, and was not able to eat anything for lunch. CNA 4 stated, around 1-2 PM on 2/24/2025 she tried to wake Resident 180, but he would not respond and was very drowsy. CNA 4 stated, she reported Resident 180's condition to LVN 10 and was told by LVN 10 that the doctor was already aware and to continue to monitor Resident 180. CNA 4 stated, when she started her shift on 2/25/2025 at 7 AM, Resident 180 was very drowsy with a towel over his head. CNA 4 stated, Resident 180 did not eat breakfast and did not wake up when she tried to wake Resident 180 up for at least 2 times prior to his transfer to GACH 1. CNA 4 stated, Resident 180 had an indwelling catheter, but Resident 180 was frequently wet with urine. During an interview on 2/28/2025 at 4:44 PM with the Acting Director of Nursing (ADON), the ADON stated, critical lab results must be reported to the physician promptly to avoid delay in treatment and Resident 180 was supposed to be monitored for his mental status, vital signs for at least 72 hours. The ADON stated, all shift LVNs were responsible to monitor and document their findings in the Progress notes or the CIC-Follow up assessment so the LVNs could see the changes in Resident 180's condition to report to the physician. The ADON stated, if Resident 180 was awake and alert on 2/23/2025 but was lethargic, responding only to sternal rub with poor intake, she expected RN 2 and LVN 9 to immediately notify Resident 180's physician for a transfer out for higher level of care. ADON stated, LVN 8 was supposed to follow up with the physician right away when Resident 180 continued to be drowsy and not able to eat breakfast, not waiting until after lunch time. The ADON stated, a delay in physician notification could result in a delay in care and worsen resident's condition. During an interview on 2/28/2025 at 5:40 PM with CNA 5, CNA 5 stated, she took care of Resident 180 from 3-11 PM on 2/24/2025. CNA 5 stated, Resident 180 was very drowsy and would not wake up and did not have dinner. During an interview on 2/28/2025 at 7:15 PM with RN 2, RN 2 stated, he was in charge of Resident 180's care from 3-11 PM on 2/24/2025. RN 2 stated, he received report from the previous shift that Resident 180 was under monitoring for critical labs and lethargy. RN 2 stated, toward the nighttime, he heard crying sounds from Resident 180's FAM 1 with concern for Resident 180's lethargy, unresponsiveness, and not able to eat anything. RN 2 stated, Resident 180 would not respond to voice or touch, and would only respond to sternal rub (rubbing the mid chest to elicit a response). RN 2 stated, he did not call Resident 180's physician about what he observed on Resident 180's condition because he was informed by LVN 9 that a CIC was already created and that LVN 9 would monitor Resident 180. During a review of the facility's Policy and Procedure (P&P) titled, Urinary Tract Infections/Bacteriuria-Clinical Protocol, revised 2018, indicated: -The physician and staff will identify individuals with history of symptomatic UTIs, (such as noticeable symptoms like pain or burning during urination, strong urge to urinate, cloudy or bloody urine, etc.) and those who have risk factors (for example, an indwelling catheter, urinary outflow obstruction) for UTIs. -The staff and practitioner will identify individuals with possible signs and symptoms of a UTI, nurses should observe, document and report signs and symptoms in detail. During a review of the facility's P&P titled, Change in Condition: Notification of, dated 8/25/2021, indicated Facility must immediately inform the resident, consult with the Resident's physician and/or NP, and notify, consistent with his/her authority, Resident Representative where there is a significant change in the resident's physical, mental, or psychosocial status (such as a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications). During a review of the facility's P&P titled, Guidelines for Charting and Documentations, revised 2012, indicated the purpose of charting and documentation is to provide: a. A complete account of the resident's care, treatment, response to care, signs, symptoms, etc., and the progress of the resident's care. b. The facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident. c. Nursing service personnel with a record of the physical and mental status of the resident. -Chart all pertinent changes in the resident's condition, reaction to treatments, medication, etc., as well as routine observation. -For Medicare residents: chart daily, all three shifts must chart (e.g., vital signs, eating, condition of the resident, etc.) -Document assessments, interventions, treatments, outcomes, etc. 50012 2. During a review of Resident 10's Admission Record, the facility admitted Resident 10 on 3/20/2018 and readmitted on [DATE] with diagnoses including UTI, and muscle weakness. During a review of Resident 10's History and Physical (H&P), dated 1/15/2025 indicated, Resident 10 did not have the mental capacity to make medical decisions. During a review of Resident 10's MDS, dated [DATE], indicated the cognitive skills for daily decisions making of the resident was severely impaired, and the resident was dependent on staff for toileting hygiene, that required supervision to extensive assistance from the staff for the activities of daily living. The MDS indicated Resident 10 was frequently incontinent of bladder and bowel. During a review of Resident 10's Change in Condition (COC) Evaluation form, dated 5/22/2024 indicated Resident 10 had pain when urinating on 5/22/2024 and MD (Medical doctor) notified. During a review of Resident 10's urinalysis (UA- checking the appearance, concentration and content of urine) results dated 5/27/2024, indicated Resident 10's urine appearance was cloudy, with presence of white blood cell (WBC), small bacteria, and few mucus threads (thin, stringy particles that can be visible in the urine), and Klebsiella pneumonia in the urine (a bacterium commonly found in the intestines of humans and other animals, where it usually causes no harm. If entering the urinary system, this can cause UTI). During a review of Resident 10's COC Evaluation form, dated 8/13/2024 indicated Resident 10 had burning (sensation) with urination on 8/13/2024 and the MD was notified and ordered UA. During a review of Resident 10's UA results dated 8/19/2024, indicated Resident 10's urine appearance was cloudy, with presence of WBC, small bacteria, and few mucus threads, and with Escherichia coli in the urine (E. coli, a bacterium commonly found in the intestines of humans and other animals that can cause UTI). During a review of Resident 10's COC Evaluation form, dated 1/3/2025 indicated Resident 10 had a change of condition resulting in the left side weakness, slurred speech (difficult to speak clearly), and elevated blood pressure and was transferred to the hospital. During a review of Resident 10's GACH Progress Note dated 1/3/2025, indicated the Resident 10 had severe sepsis (infection in the blood) likely secondary to UTI. During a review of Resident 10's GACH medication administration dated 1/3/2025, indicated the Resident 10 received Meropenem (medication use to treat infection)1000mg (milligram) every 12 hours for UTI. During an observation on 2/26/2026 at 12:32 PM, in Resident 10's room, Resident 10 was observed sitting in a wheelchair. During an interview on 2/26/205 at 6:45 PM with Family Member 2(FM) 2, FM 2 stated, she has found Resident 10 soiled or wet when she visits Resident 10 and was concern that Resident 10 has had recurrent UTIs while at the facility. FM 2 stated that Resident 10 was transferred to the hospital in January 2025 due to UTI. During a concurrent record review and interview conducted on 2/28/2025 at 1:45 PM with Certified Nurse Assistant (CNA)13, indicated the Documentation Survey Reports Personal Hygiene: toileting Resident 10 was dependent on staff for incontinence care and brief changes. CNA 13 stated that residents who are incontinent required to be checked at least every two hours or as needed. CNA 13 stated due to staffing shortages, Resident 10 was sometimes left in a wet or soiled diaper for longer periods. CNA 13 stated that documentation of incontinence care was sometimes incomplete, making it unclear whether the resident received timely incontinent care. CNA 13 stated that prolonged exposure to urine and stool can cause bacterial growth and increase the risk of UTIs. During a concurrent interview and record review on 2/28/2025 at 2:45 PM with the Registered Nurse 1 (RN) 1, Resident 10's care plans were reviewed. RN1 stated there were no care plan to monitor or prevent the reoccurrence of UTIs for Resident 10. RN1 stated that Resident 10 had multiple UTIs this last one requiring hospitalization but stated that no additional infection prevention measures were implemented beyond routine care. RN 1 stated that with appropriate care and monitoring Resident 10 should not have had recurrent UTIs. 3. During a review of Resident 57 's Admission Record (Face Sheet), the facility admitted Resident 57 on 1/17/2018 and readmitted on [DATE] with diagnoses including UTIs an infection in any and hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated). During a review of Resident 57's History and Physical (H&P), dated 9/25/2024 indicated, Resident 57 did not have the mental capacity to make medical decisions. During a review of Resident 57's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 1/31/2025, indicated the cognitive (the ability to think and process information) severely impaired and was totally dependent on two persons for bed mobility, transfer, dressing, eating, and toileting. The MDS indicated the resident had an indwelling catheter and was incontinent of bowel. During a review of Resident 57's COC Evaluation form, dated 9/14/2024 indicated Resident 57 had hematuria (presence of blood in the urine) on 9/14/2024 MD notified and ordered GAGH transfer. During a review of Resident 57's GACH record indicated a UA obtained on 9/19/2024, result was Resident 57's urine appearance was turbid (unclear and murky appearance), had the presence of white blood cell, bacteria. UA also indicated Staphylococcus SPP in the urine (a bacteria commonly found in the in humans' skin, nose, mouth, lungs, and stomach if entering the urinary system, this can cause UTI). During a review of Resident 57's GACH History and Physical dated 9/19/2024, indi [TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide necessary care, treatment and interventions to prevent the development and worsening of pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure) and moisture associated skin damage (MASD- skin irritation and damage caused by prolonged exposure to moisture like urine, sweat, stool, wound fluid) to one (1) of two (2) sampled residents (Resident 1), who was admitted to the facility on [DATE] without pressure ulcer and MASD. The facility failed to: 1. Provide Pressure Ulcer Prevention Measures, in accordance with Resident 1's initial admission assessments on [DATE]. Resident 1 was assessed with skin issues in the groin (the area between the abdomen and the thigh on either side of the body area due to the Foley catheter (a type of indwelling catheter - a thin, flexible tube inserted into the bladder to drain urine), as indicated in the resident's Body Check, and was assessed of moderate risk to develop pressure ulcers as documented in the facility's Braden Scale for Predicting Pressure Sore Risk record. 2. Implement Facility 1's (Skilled Nursing Facility) assessment to provide Resident 1 with pressure ulcer prevention measures on [DATE], that included a low air loss mattress for pressure injury management and frequent turning and positioning. 3. Apply barrier cream (a topical product that creates a physical barrier between the skin and irritants) and turn/reposition Resident 1 every two hours, for skin redness on the resident's groin (the area between the abdomen and the thigh on either side of the body) area and Stage 1 pressure ulcer (a localized area of intact skin that has been altered by pressure and appears red, blue, or purple) on the left buttock/upper thigh under buttocks on [DATE], in accordance with Hospice 1's skin assessment and plan of care dated [DATE]. 4. Perform wound observations, daily monitoring of wounds in accordance with the facility's policy and procedures (P&P) on Skin Integrity Management, Wound Prevention, and Care Plan Comprehensive, upon identification of Resident 1's altered skin integrity on [DATE], [DATE], [DATE], and on [DATE]. As a result of these deficient practices, Resident 1's skin breakdown worsened, resulting in two Stage 3 pressure ulcers (a full-thickness skin loss where subcutaneous fat [deepest layer of the skin] is visible within the wound bed) to the right and left posterior buttocks requiring wound debridement (a wound care procedure that uses mechanical force to remove dead or infected tissue from a wound) on [DATE]. Findings: During a review of Facility 1's P&P titled Skin Integrity Management dated [DATE], the P&P indicated the facility must perform wound observations and measurements upon initial identification of altered skin integrity, weekly, and with anticipated decline of wound, perform daily monitoring of wounds or dressings for presence of complications or declines and document if indicated, and develop comprehensive, interdisciplinary plan of care including prevention and wound treatments, as indicated: implement pressure ulcer prevention for identified risk factors, turning and repositioning based on resident care needs, and review care plan and revise as indicated. During a review of Facility 1's P&P titled Wound Prevention dated 2025, the P&P indicated when a significant change in the resident's status occurs, the resident's skin will be evaluated head-to-toe by the licensed nurse utilizing a Braden Scale Observation and weekly skin checks will be conducted and documented in the resident's Electronic Medical Record (EMR). The P&P indicated daily, during routine care, the CNA will observe the resident's skin and when abnormalities are noted this will be communicated to the licensed nurse and the licensed nurse would complete a Wound Event. During a review of Facility 1's policy and procedure (P&P) titled Pressure Injuries Overview and Wound Staging dated [DATE], the P&P indicated an unavoidable wound meant the resident developed a pressure ulcer/injury and that one or more of the following was not completed: evaluation of the resident's clinical condition and risk factors; definition or implementation of interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitoring or evaluation of the impact of the interventions; and revision of the interventions as appropriate. The P&P indicated a Stage 3 pressure injury was a full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. During a review of Facility 1's P&P titled Care Plan Comprehensive dated [DATE], the P&P indicated the facility must develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, physical, mental, and psychosocial needs that are identified in the comprehensive assessment. The P&P indicated each resident's comprehensive care plan is designed to: incorporate identified problem areas, and aid in preventing or reducing declines in the resident's functional status and/or functional levels. The P&P indicated the facility must identify problem areas and their causes and develop interventions that were targeted and meaningful to the resident. The P&P indicated assessments of residents were ongoing and care plans are reviewed and revised as information about the resident and the resident's condition change. The P&P indicated the Interdisciplinary Team was responsible for evaluation and updating of care plans: when there had been a significant change in the resident's condition. During a review of Resident 1's General Acute Care Hospital (GACH 1) History and Physical (H&P) dated [DATE], prior to Resident 1's admission to Facility 1, the GACH 1 H&P documented that Resident 1's skin was intact with no identified issues. During a review of Resident 1's GACH 1 Wound Pressure Injury (pressure ulcer) Photo Note dated [DATE], the GACH 1 record documented that Resident 1 was at risk for pressure ulcers on the backs of the ears, the heels, the sacrum, and the buttocks. The GACH 1 Note indicated Resident 1's skin was intact During a review of Resident 1's Facility 1 records titled Admission Record (AR), the AR indicated Facility 1 admitted Resident 1 from GACH 1 on [DATE], with diagnoses including malignant neoplasm of unspecified ovary (cancer [abnormal cell growth] of the ovary a female reproductive system), epilepsy (disorder of the brain characterized by repeated seizures), obstructive and reflux uropathy (a condition that affect the urinary tract and could cause urine to back up into the kidneys), sepsis (a life-threatening blood infection), obstructive and reflux uropathy (when urine cannot drain through the urinary tract) and chronic kidney disease (when the kidneys are damaged and could not filter blood the way they should). The AR indicated Resident 1 was under hospice care with Hospice 1, while residing at Facility 1. During a review of Hospice 1 records, titled Physician's Certification for Hospice Benefit dated [DATE], indicated Resident 1 started Hospice Care Services upon Facility 1 admission on [DATE]. During a review of Facility 1 records, titled Body Check dated [DATE] at 10:12 PM, the record documented Body check completed with skin issues. The record indicated a premade questionnaire to Identify and describe skin issues with a body map illustration of different sites (an area, place or point in the body) of the body. The record indicated one site, the groin and indicated under description was foley catheter and bruising on the back. The record further indicated Pressure Ulcer Prevention Measures, check all that apply. The record lacked documentation that any Pressure Ulcer Prevention Measures were implemented. During a review of Facility 1 records titled Braden Scale (a tool used to predict a patient's risk of developing pressure ulcers) for Predicting Pressure Sore Risk dated [DATE] at 10:41 PM, the Braden Scale indicated Resident 1's score was a 13, indicating that R1 was at moderate risk of developing pressure sores. The Braden Scale indicated the resident's sensory perception (the ability to use the senses of sight, smell, hearing, taste, and touch to understand and interact with the environment) was slightly limited, skin was occasionally moist, activity was bedfast, mobility was very limited, nutrition was probably inadequate, and friction and shear (mechanical forces that contribute to skin and tissue damage, often leading to the development of pressure injuries) was a potential problem. During a review of Hospice 1 records titled Hospice Comprehensive Nursing assessment dated [DATE] timed at 10:15 PM, the hospice record documented that Resident 1's skin was warm, dry, with fair skin turgor. The hospice record documented that Resident 1 had redness noted to the left hip, but no open wounds were noted. During a review of Facility 1 records titled Body Check dated [DATE], the Body Check indicated to put a check mark for pressure ulcer prevention measures that apply to Resident 1. The Body Check included a check mark was placed next to a pressure reducing mattress, including turning and positioning. During a review of Hospice 1 records titled RN (Registered Nurse) Visit Note dated [DATE] (one day after admission at Facility 1) timed at 12:40 PM, authored by Hospice Registered Nurse 1 (HRN 1), the hospice record indicated Resident 1 did not have any rash, wounds, ulcer/bed sores (injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time). The hospice record indicated HRN 1's skin assessment of Resident 1 indicated the resident did not have redness or open wounds noted on the skin or body during this visit. During a review of Facility 1 records titled Minimum Data Set (MDS - a federally mandated [a law or court ruling that the federal government imposes on state and local governments] resident assessment tool) with an assessment reference date (timeframe of MDS assessment) of [DATE], the MDS documented that Resident 1 had moderate cognitive impairment (a person experiencing noticeable and significant difficulties with thinking, learning, remembering, and other skills that impact daily life). The MDS documented that the resident was dependent (helper did all the effort and the resident did none of the effort to complete the activity) upon facility staff with all functional abilities (the skill and capacity that allowed people to perform daily tasks and work). The MDS documented that the resident had an indwelling catheter. The MDS further documented that Resident 1 was always incontinent (the inability to control the release of urine or feces) of bowel (the long, tube-shaped organ in the abdomen that completes the process of digestion) movements. During the same review of the MDS dated [DATE], the MDS documented that Resident 1 was free of pressure ulcers but was at risk of developing pressure ulcers/injuries. The MDS documented that Resident 1 did not have any other skin issues at the time of the assessment. During a review of Facility 1 records titled Physician Order dated [DATE] at 6:45 PM, documented that Resident 1 was to have an indwelling catheter as needed for urinary cancer (a type of cancer that develops in the bladder). During a review of Facility 1 records titled Resident requires indwelling foley catheter due to urinary cancer indicated a care plan was developed for Resident 1 on [DATE], with interventions that included facility staff would monitor the residents for signs and symptoms of infection. During a review of Hospice 1's records titled RN Visit Note dated [DATE] timed at 4 PM, the hospice record documented redness was noted to Resident 1's groin area and the buttocks/upper thigh areas under the buttock region. The Visit Note indicated the facility staff were to apply barrier cream and turn and reposition the patient every two hours to maintain skin integrity and prevent pressure ulcers. The Visit Note documented to keep Resident 1's skin dry and clean by limiting exposure to sweat, urine, and stool. The Visit Note documented that facility staff were to inspect Resident 1's skin for signs of redness, discoloration, or breakdown and that the facility staff verbalized understanding. During a review of Hospice 1 records titled Plan of Care dated [DATE] timed at 10:13 AM, the hospice record indicated Resident 1 had Stage 1 (pressure ulcer) on the groin area and Stage 1 (pressure ulcer) on the left buttock/upper thigh under buttock. The Plan of Care indicated a goal for the resident not to have any worsening of wounds within the next 14 days, prevent potential skin problems within the next 21 days, and the resident to verbalize/express understanding of treatment and side effects within the next 30 days. The Plan of Care indicated interventions to assess alteration in skin integrity every visit, assess changes in wound status, and monitor/assess effectiveness of current and new medication/treatment. Further review of Resident 1's medical record lacked evidence that facility staff implemented the care plan interventions developed by Hospice 1 to prevent R1's further skin breakdown. During another review of Hospice 1's records titled RN Visit Note, dated [DATE] timed at 10:45 AM, three days after redness was documented for Resident 1's groin area and under buttocks/upper thigh areas on [DATE] on the Hospice's RN Visit Note, the Hospice 1 records indicated Resident 1 was noted to have IAD (incontinence-associated dermatitis - a skin condition that develops when the skin is exposed to urine or feces for prolonged periods) on the inner thighs and buttocks due to moisture. The Visit Note documented new orders to apply Calmoseptine Topical Cream (an over-the-counter ointment that protects and heals skin irritations) and Zinc Oxide 20% Topical ointment (a topical medication used to treat and prevent minor skin irritations and diaper rash). The Visit Note did not indicate the frequency and location of the treatment orders. During a review of Hospice 1's records titled Physician's Order dated [DATE], the hospice record indicated for Resident 1 to have Zinc Oxide 20% Topical Ointment, 1 application topical, mix a thin layer application with Calmoseptine cream and apply to the area as directed for IAD. During a review of Hospice 1's records titled Physician's Order dated [DATE], the hospice record indicated for Resident 1 to have Calmoseptine Topical 0.44% Cream, 1 application topical, mix a thin layer with Zinc Oxide and apply to the affected area for IAD. During a review of Facility 1 records titled Change of Condition (COC) dated [DATE] timed at 6:57 PM, the COC documented that HRN1 notified facility staff that Resident 1 developed scattered skin openings to the bilateral buttocks and coccyx area. The COC documented that the physician was notified, and recommendations included the Hospice RN to return on [DATE] with orders on wound treatment. During a review of the same Facility 1 record titled COC dated [DATE] but timed at 8:22 PM, the COC documented that the Hospice RN notified facility staff that Resident 1 developed moisture associated skin damage (MASD) to bilateral (both) groin extending to the medial thighs. The COC documented that facility staff were awaiting orders from the physician. During a review of Facility 1 records, the record documented that a care plan was developed on [DATE] for Resident 1's noted skin breakdown. The care plan indicated interventions that included to pat skin when drying, turn/reposition to resident comfort, observe for signs/symptoms of skin breakdown, evaluate for any localized skin problems, observe skin daily during ADL (activities of daily living - daily tasks people perform to care for themselves) care and report abnormalities. Further reviews of Resident 1's medical records lacked evidence Facility 1 developed and implemented Resident 1's care plan for skin breakdown dated [DATE]. During a review of Facility 1 records titled Resident has Actual Skin Breakdown indicated a care plan was developed on [DATE], three days after R1 first developed skin breakdown. The care plan documented interventions to provide treatment to skin tear per physician order and observe for signs of infection, turn and/or reposition as tolerated, and observe skin for signs and symptoms of skin breakdown, and evaluate for any localized skin problems. During a review of Facility 1 records titled Progress Note dated [DATE], the Progress Note documented that facility staff re-inserted R1 a new indwelling catheter due to the leaking foley catheter. . During a review of Facility 1 records, the records indicated the following skin treatment orders ordered by the hospice physician on [DATE] for Resident 1: 1. Cleanse R1's IAD with normal saline (NS - a mixture of water and salt with a salt concentration of 0.9%), pat dry, apply a mixture of zinc oxide and Calmoseptine, leave open to air every day and evening shift for 30 days, until finished and as needed for 30 days. 2. Cleanse R1's bilateral groin (the junctional area between the torso and the thigh) extending to medial (toward the middle or center) thighs IAD with NS, pat dry, apply mixture of zinc oxide and Calmoseptine and leave open to air every day and evening shift for 30 days until finished and as needed for 30 days. 3. A referral for Resident 1 to have a wound consult (a wound specialist to assess a wound and create a treatment plan) with Hospice 1 wound consultant. During a review of Facility 1 records, titled Treatment Administration Record (TAR) dated [DATE] to [DATE], the TAR indicated the following physician orders for skin treatments: -On [DATE], a treatment order was placed for Resident 1's Bilateral buttocks extending to coccyx IAD cleanse with NS, pat dry apply mixture of zinc oxide and Calmoseptine and leave open to air, every day shift (7 AM to 3 PM) and evening shift (3 PM to 11 PM) for 30 days until finished. The treatment order lacked documentation that facility staff completed Resident 1's treatment during the day shift of [DATE] and during the evening shifts of [DATE], [DATE], [DATE], and [DATE]. - On [DATE], a treatment order was placed for Resident 1's Bilateral groin extending to medial thighs IAD cleanse with NS, pat dry, apply mixture of zinc oxide and Calmoseptine, and leave open to air every day shift and evening shift for 30 days until finished. The treatment order lacked documentation that facility staff completed R1's treatment during the day shift of [DATE] and during the evening shifts of [DATE], [DATE], [DATE], and [DATE]. Further review of R1's medical record documented that hospice ordered a wound care evaluation on [DATE]. During a review of Facility 1 records titled Interdisciplinary Care Conference (ICC) dated [DATE] timed at 7:31 PM, the ICC further indicated that aside from Resident 1's existing IAD to the bilateral groin areas extending to the medial thighs, an additional IAD was identified on [DATE] to Resident 1's bilateral buttocks extending to the coccyx area. The ICC indicated Resident 1 was at risk for skin breakdown related to the use of foley catheter, decreased activity, frail fragile skin, impaired cognition, impaired sensation, incontinence, limited mobility, moisture/excessive perspiration, and shear/friction risks. During a review of Hospice 1 records titled RN Visit Note dated [DATE] timed at 3:15 PM, the hospice record documented that R1's Family reports patient's wound is worsening. Further review of R1's hospice documentation revealed that facility staff failed to identify that R1's wound was worsening. The hospice record documented that the hospice nurse notified facility staff that R1 needed to be turned and repositioned every two hours for 7 days to prevent further skin breakdown. The hospice record indicated that Hospice 1 referred Resident 1 to a wound consult on [DATE], and the wound physician is scheduled to visit Resident 1 on [DATE]. During a review of Facility 1 records titled Wound Consult Progress Report dated [DATE], authored by Hospice 1 Wound Nurse Practitioner (NP - a nurse who is qualified to treat certain medical conditions without the direct supervision of a doctor), indicated Resident 1 had a new, right posterior (the back right side of the body) buttocks pressure ulcer at Stage 3. The Progress Report indicated the length (longest dimension of the wound) of the wound was 6.77 centimeters (cm - unit of measurement), the width (widest part of the wound) was 9.55 cm, the depth (measurement of how far a wound penetrates into the tissues) was 0.1 cm, the area (multiplying the greatest length and width of the wound) was 64.65 square cm, and the volume (the amount of tissue lost) was 6.47 cubic cm. The Progress Report indicated moderate amount of exudate (fluid that leaks out of blood vessels into surrounding tissues), 50% granulation tissue (a new connective tissue that forms in the body as part of the healing process), and 50% necrotic tissue (tissue in the body that has died due to lack of blood flow). The Progress Report documented that the wound was Not an unavoidable wound (a skin injury that develops despite proper care and evaluation). The Progress Report indicated Resident 1 had a wound debridement on [DATE] and recommendations for a family conference, off-loading (a treatment that reduces pressure on a wound to help it heal, turning and repositioning, and an air mattress (a type of pressure reducing mattress that help avoid skin breakdown by promoting blood flow and stimulating circulation in the body). During a review of Facility 1 records titled Wound Consult Progress Report dated [DATE], authored by Hospice 1 Wound Physician, indicated Resident 1 had a new left posterior buttocks pressure ulceration Stage 3. The Progress Report indicated the length of the wound was 2.74 cm, the width was 3.71 cm, the depth was 0.1 cm, the area was 10.17 square cm, and the volume was 1.02 cubic cm. The Progress Report indicated moderate amount of exudate, 20% granulation tissue, and 80% necrotic tissue. The Progress Report documented that the wound was not an unavoidable wound. The Progress Report indicated the resident had a mechanical debridement on [DATE] and recommendations for a family conference, off-loading, turning and repositioning, and an air mattress. During a review of Hospice 1's records titled Physician's Order dated [DATE], the hospice record indicated orders for Resident 1's left posterior buttocks: cleanse with saline solution (a mixture of salt and water) and pat dry with gauze (a thin translucent fabric of silk, linen, or cotton), apply Tetracyte (a topical antibiotic ointment that treats bacterial infections of the skin) and medical grade honey (sterile honey that has been processed to treat wounds) to the wound bed, cover with foam with silicone bordered dressing (a sterile, absorbent foam dressing with a silicone adhesive border used to treat wounds) three (3) times weekly and as needed (PRN). The hospice record indicated to clean the wound with wound cleanser, pat dry with gauze, apply Tetracyte, apply Therahoney (a sterile wound dressing made of Manuka honey used to treat wounds) followed by alginate (a natural water-soluble polysaccharide [a long-chain carbohydrate used by the body for energy or to help with cellular structure] extracted from brown algae-cell walls and bacteria), cover with foam dressing. During a review of Hospice 1's records titled Physician's Order dated [DATE], the hospice record indicated orders for Resident 1's right posterior buttocks: cleanse with saline solution and pat dry with gauze, apply Tetracyte and medical grade honey to the wound bed, cover with foam dressing with silicone bordered dressing 3 times weekly and PRN for soiled or loose dressing. The Physician's Order indicated to use bordered gauze between scheduled dressing changes and PRN for soiled or loose dressing. The Physician's Order indicated to secure dressing with tape as needed. During another review of Facility 1 records, titled Treatment Administration Record (TAR) dated [DATE] to [DATE], the TAR indicated additional physician orders for skin treatments for the month of [DATE]: -On [DATE], a treatment order was placed for Resident 1's Left posterior buttocks pressure injury, cleanse with NS, pat dry, apply Tetracyte and Therahoney, cover with foam with silicone border dressing . everyday during Tuesdays, Thursdays and Fridays for 30 days until finished. The treatment order indicated; Resident 1 received the first treatment on [DATE] (no time). -On [DATE], a treatment order was placed for Resident 1's Right posterior buttocks pressure injury, cleanse with NS, pat dry, apply Tetracyte and Therahoney, cover with foam with silicone border dressing . every day shift during Tuesdays, Thursdays and Fridays for 30 days until finished. The treatment order indicated; Resident 1 received the first treatment on [DATE] (no time). During a review of Facility 1 records, titled Progress Notes dated [DATE] at 1:20 PM, Documented that R1 had passed away. During an interview on [DATE] at 12:12 PM, Resident 1's FM 1 and FM 2 stated Resident 1 informed them that Resident 1 would call the facility staff to reposition her, but the facility staff would not come. FM 1 stated after the Resident 1 was admitted to the facility, Resident 1 was placed on diapers and the resident started to develop diaper rash (a skin irritation that occurs when skin is exposed to moisture from urine and stool for too long) a few days later around [DATE]. FM 1 stated that Facility 1 staff asked FM 1 to bring a cream to put on Resident 1. FM 1 stated today ([DATE]), FM 1 stated she arrived at the facility around 11 AM and the facility staff have not checked on Resident 1 to see if she was soiled and needed to be changed. FM 1 stated the staff informed her the facility changed the resident in the morning. During the same interview on [DATE] at 12:12 PM, FM 2 stated that sometime around [DATE] or [DATE], facility staff informed her that Resident 1's diaper rash was getting really bad and looked like a bleeding baby rash with little cuts. FM 2 stated the facility staff asked FM 2 to bring a cream that would work better. FM 2 stated every day when she arrived at the facility around 2 PM, staff would inform FM 2 that Resident 1 was cleaned (incontinence care) around 11 AM. FM 2 stated that she would not see another facility staff member come in the room to check on Resident 1, until the next evening shift around 4 PM. FM 2 stated if the family was not with the resident every day, the resident would have been in the same position all day without being changed. During an observation on [DATE] at 2:40 PM in Resident 1's room, Resident 1 was observed in bed, with an indwelling catheter present with open wounds noted in between the legs around the perineal area, and the left/right buttocks. The resident was noted with a pink xeroform dressing (a sterile, non-adherent gauze dressing that was used to treat wounds) on the sacrum and a bordered dressing (a wound dressing with an adhesive border used to treat wounds, ulcers, and pressure injuries) by the buttocks area. Resident 1 was unresponsive. During an interview on [DATE] at 3:15 PM, the facility's Treatment Nurse (TN) 1 stated the wound care physician determined Resident 1's buttocks wounds were a Stage 3 pressure ulcer during his resident visit on [DATE]. During an observation on [DATE] at 12:15 PM in Resident 1's room, Treatment Nurse (TN) 2 was providing wound care to Resident 1. Two round Stage 3 pressure injuries/wounds were observed in the sacrum area, that included the resident's left and right buttocks. Resident 1's wound beds in the left/right buttocks and sacrum area were red in color with areas of yellow slough (a layer of dead tissue, often yellow or white, that can form on a wound bed) and moderate moisture. Resident 1's surrounding skin showed signs of erythema (reddening of the skin or mucous membranes). During the observation, Resident 1's perineal (the area of the body between the anus and the vulva [the external female genital organs] in females) area was observed to be red in color with areas of peeling skin and open sores (damaged or broken area of skin or tissue that was often painful, red, and could be infected) scattered in different areas. During an interview on [DATE] at 12:30 PM, the facility's second treatment nurse (TN 2) stated Resident 1's wounds are difficult to measure because the resident had scattered openings in different areas with different open skin lesions (an abnormal area of tissue or skin that looks or feels different from the surrounding tissue or skin) in varying sizes. TN 2 stated if a wound developed at the facility, the resident would need a wound consult right away to get immediate physician treatment orders to manage the resident's pressure injuries. TN 2 stated if the wound was a Stage 3 or higher, the resident would need a low air loss mattress (a medical device that helps prevent and treat pressure ulcers by circulating air through the mattress). TN 2 stated Resident 1 was not provided a low air loss mattress for pressure injury management. TN 2 stated pressure injury prevention required repositioning and the Certified Nursing Assistants (CNA) at the bare minimum should have been checking Resident 1's skin at least twice a shift. TN 2 stated there was no documented evidence that Resident 1 was being turned and repositioned every two hours since being admitted to the facility on [DATE]. TN 2 stated residents who acquire IAD or MASD do so because they were left in their own stool or been wet for too long. TN 2 stated residents with pressure ulcers were either left in their own stool for too long, not repositioned, not eating or drinking, and are very compromised (impaired or diminished in function). During an interview on [DATE] at 3:15 PM, CNA 1 stated for residents with pressure ulcers, the facility staff were expected to reposition them every 2 hours and apply Vitamin A and D ointment (A&D ointment - a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations) on the buttocks with each incontinence brief. CNA 1 stated for residents with indwelling catheters, the facility staff were to check at least twice a shift to see if there was urine in the incontinence brief and make sure the indwelling catheter was working. During a concurrent observation and interview on [DATE] at 2:40 PM, inside Resident 1's room with Licensed Vocational Nurse (LVN) 1 R1 was observed lying flat in bed. The resident was turned to the right side, a pink xeroform dressing was noted on the sacrum, and a bordered dressing was observed near the buttocks. LVN 1 stated, sometime last week, (unable to recall exact date) Hospice Nurse 1 noted Resident 1's wound to the buttocks and informed the Facility 1 Treatment Nurses. LVN 1 stated it was the TNs responsibility to conduct skin assessments and wound monitoring. During an interview on [DATE] at 4:15 PM, the Assistant Director of Nursing (ADON)stated the facility was supposed to have facility care plans in placed to prevent skin breakdown and Resident 1 should not have developed a skin breakdown despite her health condition. The ADON stated facility staff were expected to complete weekly skin assessments as well as on an as-needed basis, and if a CNA identified potential skin breakdown, they must report it to the LVN. The ADON stated upon admission if a resident had skin breakdown or a change o [TRUNCATED]

Based on interview and record review the facility failed to assess, monitor, evaluate the wound and notify the physician and wound consultant physician's assistant (WCPA) of a significant change in condition for one (1) of four (4) sampled residents (Resident 1) by failing to: 1. Notify Resident 1's physician (Physician 1) when Resident 1's posterior neck incision (surgical cut made in the skin) was noted to have dehisced (something that had split open or come apart along a seam or line) and the wound size increased from 0.5 cm by 0.5 cm (unit of measurement) on 12/19/2024 to 4 cm by 4 cm on 12/21/2024, in accordance with the resident's care plan titled Posterior Neck Incision Dehiscence Care Plan. 2. Notify Resident 1's WCPA and obtain new orders when Resident 1's posterior neck incision was noted to have dehisced on 12/21/2024. 3. Implement the facility's policy & procedure (P&P) titled Skin Integrity Management by not notifying the physician to obtain orders for Resident 1's wound dehiscence ([wound separation] when a surgical incision separates after it has been stitched or stapled closed). 4. Implement the facility's P&P titled Wound Care by ensuring all assessment data (wound bed color, size, drainage) were obtained when inspecting Resident 1's wound. 5. Ensure the Physician Order, Physician's and Nursing Progress notes indicated the reason for discontinuing a foam dressing (a thick foam designed to absorb fluid [exudate] that comes from the wound to maintain a moist environment and help wound to heal) to the neck incision with wound drainage on 12/15/2024. These deficient practices resulted in Resident 1's transfer to the General Acute Care Hospital (GACH) on 12/23/2024 with noted enlarging, purulent (a wound that was infected and produces a thick, milky fluid called pus [liquid produced in an infected tissue]) neck wound and an increased wound separation of about three (3) to five (5) cm. Resident 1 received irrigation and debridement ([I&D] - a medical procedure that involves flushing a wound with a liquid and removing infected or diseased tissue) to the neck wound, application of a wound vacuum (wound vac - a medical device that uses gentle suction to pull excess fluid and debris from a wound helping the wound heal faster by creating a clean environment and bringing the edges of the wound closer together), and surgical procedure to close the neck wound. Findings: During a review of Resident 1's Admission Record (AR), the AR indicated the facility admitted the resident on 12/2/2024, with diagnoses including encounter for orthopedic (a branch of medicine that focuses on the care of the skeletal system and the interconnecting parts: bones, muscles, and joints) aftercare (care a patient receives after an orthopedic procedure or injury), fusion of spine (a surgical procedure that permanently joins two or more vertebrae in the spine to prevent movement and relieve pain), and spinal stenosis (a chronic condition that occurs when the spaces in the spine narrow, putting pressure on the spinal cord and nerves). During a review of Resident 1's Body Check dated 12/3/2024, the Body Check indicated the resident had a left upper arm peripherally inserted central catheter (PICC - a long thing tube that was inserted through a vein in the arm and near the heart to give IV medications) and neck post-surgery. During a review of Resident 1's Right Anterior Neck Incision Care Plan dated 12/3/2025, the Care Plan indicated a goal for the wound to remain free from signs and symptoms of infection (the invasion and growth of germs in an area of the body) and for 30 days. The Care Plan interventions included to monitor for pain, monitor for signs and symptoms of infection, and to provide wound treatment as ordered. During a review of the Resident 1's physician's order, dated 12/3/2024 indicated, to apply NS and pat dry cover with dry dressing every day for 30 days on the anterior right side of neck and posterior neck wound. During a review of Resident 1's History and Physical (H&P) dated 12/5/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of the Resident 1's physician's order, dated 12/6/2024 indicated, to apply NS and pat dry cover with dry dressing every dayshift and every nine days for 30 days on the anterior right side of neck and posterior neck wound. During a review of Resident 1's Nurses Progress Note dated 12/8/2024 at 1:35 PM, the Nurses Progress Note indicated the resident reported drainage to her posterior neck incision. The Nurses Progress Note indicated Resident 1 verbalized scratching that area and the wound might have opened because of the scratching. The Nurses Progress Note indicated the wound had moderate serosanguinous drainage (a thin, watery fluid that leaks from a wound, usually appearing slightly pink or red due to a small amount of blood mixed with the body's natural fluid) noted, no odor, erythema (a skin condition that causes redness, inflammation, or a rash) to surrounding area. During a review of Resident 1's Change in Condition (COC) evaluation dated 12/8/2024 at 4:18 PM, the COC indicated the resident had posterior neck incision with drainage. The COC indicated the resident was not in pain and the physician was notified and the facility was awaiting a response. The COC posterior neck wound was assessed for the size, the appearance and amount of drainage and if the wound had a foul odor. During a review of the Resident 1's physician's order, dated 12/8/2024 indicated, to apply Calcium Alginate, cleans with NS, pat dry cover with dry dressing every dayshift for 30 days on the posterior neck wound. During a review of Resident 1's Minimum Data Set (MDS - a federally mandated [a law or court ruling that the federal government imposes on state and local governments to address issues that affect the United States] resident assessment tool) dated 12/9/2024, the MDS indicated the resident's cognition (thought process) was intact (sufficient judgement and self-control to manage the normal demands of the environment). The MDS indicated the resident had spinal surgery and received surgical wound care treatments. The MDS indicated the resident had an intravenous (IV - a method of delivering fluids, drugs, blood products, or nutrition directly into the bloodstream through a vein) access and was receiving IV medications. During a review of the Resident 1's physician's order, dated 12/11/2024 indicated, to apply Calcium Alginate, cleans with NS, pat dry cover with foam dressing every dayshift for 14 days on the posterior neck wound. A review of the Nursing Progress Notes on 12/11/2024 timed at 11:11 AM, indicated Resident 1 was observed with open skin in the left shoulder measured at 0.5 cm x 0.5 cm x 0.1 cm, without drainage with 100% pink. During a review of Resident 1's COC evaluation dated 12/13/2024 timed at 3:50 AM, the COC indicated the resident had light yellow color fluid coming out of the resident's neck incision. The COC indicated the resident was not in pain and the physician was notified and stated to continue the resident's IV antibiotic order. During a review of Resident 1's Light Yellow fluid Neck Incision Drainage Care Plan revised 12/13/2024, the Care Plan indicated a goal for the resident to have no further complications for 30 days. The Care Plan interventions included to provide wound care as ordered, monitor for signs and symptoms of infection, and notify the physician for any significant changes. During a review of Resident 1's Wound assessment dated [DATE], authored by the WCPA, indicated Resident 1 was seen by the Wound Physician on 12/19/2024, the Wound Assessment indicated the resident had a posterior neck wound measured 0.5 cm x 0.5 cm. The Wound Assessment indicated the wound had light serosanguinous drainage, no odor, and the resident's wound bed (the open, exposed area at the base of a wound) was 100 % pink. The Wound Assessment indicated treatment for the wound included Calcium Alginate (a substance with many uses, including in food, wound dressings, and plant tissue culture). During a review of Resident 1's Interdisciplinary Care Conference (ICC, a meeting where different healthcare professionals involved in a resident's care, come together to discuss the resident's needs, share information, and coordinate the treatment plan) dated 12/20/2024 at 8:50 PM, indicated the resident had a posterior neck wound measuring 0.5 cm by 0.5 cm. The ICC indicated the resident's wound status/progress was stable and to continue the current plan of care with weekly follow up with the wound consultant. During a review of Resident 1's COC evaluation dated 12/21/2024 at 11:03 PM, authored by Licensed Vocational Nurse (LVN) 1, indicated while providing wound care, the posterior neck incision was noted to have dehisced measuring four (4) by four (4) cm with no odor, moderate drainage, and was 100% pink. The COC indicated the resident was not in pain and the physician (Physician 1) was notified and the facility was awaiting a response. During a review of Resident 1's Posterior Neck Incision Dehiscence Care Plan revised 12/21/2024, the care plan indicated a goal for the resident's wound to remain free from signs and symptoms of infection for 30 days. The care plan interventions included to monitor for pain, to refer to wound consult, and to provide treatment to skin tear (a wound that occurs when the skin is separated from the underlying tissue) per physician order for signs of infection until healed and report changes. During a review of Resident 1's TAR dated 12/16/2024 and 12/22/2024, the TAR indicated Resident 1's received treatment on the posterior neck incision, with NS, pat dried, applied Calcium Alginate and covered with dry dressing without the foam dressing every dayshift for 14 days. During a review of a physician order indicate to discontinue Resident 1's foam dressing on the posterior neck incision on 12/15/2024. A review of the Nursing Progress Notes and Physician's Progress Notes and Physician order on 12/15/2024 had no documented evidence the reason for discontinuing the foam dressing on the posterior neck. During a review of Resident 1's Treatment Administration Record (TAR) dated 12/21/2024, the TAR indicated Resident 1's received treatment on the anterior right side of neck and was cleansed with normal saline (NS), pat dry, cover with dry dressing and cleanse with NS, pat dry, apply calcium alginate, cover with dry dressing as provided. During a review of Resident 1's TAR dated 12/21/2024 and 12/22/2025, the TAR indicated Resident 1's received treatment on the posterior neck incision and was cleansed with NS, pat dry, apply calcium alginate, cover with dry dressing as provided. During a review of Resident 1's Skilled Nursing Facility (SNF) to Hospital Transfer Form dated 12/23/2024, the SNF to Hospital Transfer Form indicated the resident was transferred to the GACH on 12/23/2024. The SNF to Hospital Transfer Form indicated the reason for transfer was for the resident's neck surgical incision. During a review of Resident 1's General Acute Care Hospital (GACH) Plastic Surgery (a surgical specialty involved with both the improvement in a person's appearance and the reconstruction of facial and body tissue defects due to illness or trauma) Infection Prevention (IP) Consult Note dated 12/23/2024, the Note indicated Resident 1 was at a neurosurgery (a medical specialty that involves the diagnosis and treatment of conditions affecting the brain, spinal cord, and peripheral nerves) clinic follow-up appointment on 12/23/2024, when the neurosurgery physician noted Resident 1 with an enlarging, purulent wound. The Consult Note indicated the resident reports moderate pain at the surgical site. The Consult Note indicated upon evaluation, the wound separation was about three (3) to five (5) cm around, fascia (a thin layer of connective tissue that surrounds and supports the body's organs, muscles, bones, nerves, and blood vessels) intact without purulence (the state of containing or producing pus) or drainage but skin flaps (a piece of healthy skin and tissue that had moved to cover a wound) have elevated off of the paraspinal flaps (an extensive set of muscles, that run all the way along the back of the spine). The Consult Note indicated there is No exposure of hardware (pins, plates, or screws to help fix a broken bone). She (Resident 1) states that on 12/12/24, she felt that her shirt was wet and that something came out of her wound, but there was no [NAME] skin separation at that time. The timing of when the separation occurred is unclear. She (Resident 1) reports that she has had a headache for the past 4 (four) days around her temples but otherwise has been feeling normal without any new symptoms. The Consult Note indicated recommendations to pack the neck wound, irrigate and debride, possible wound vac placement, and possible local flap (a piece of skin or tissue taken from an area directly next to a wound or defect, which was then moved and positioned to cover the area that needs repair) with Plastic and Reconstructive Surgery (PRS - a broad field that includes surgical procedures to improve the appearance and function of the body). During a review of Resident 1's GACH Plastic Surgery IP Consult Note dated 1/6/2025, the Consult Note indicated on 12/26/2024, Resident 1 underwent debridement (the process of cleaning a wound by removing dead or infected tissue) of cervical wound (an injury or cut located in the neck area, specifically on the part of the body containing the cervical vertebrae [neck bones]) and wound vac application. The Consult Note indicated on 1/3/2025, the wound vac was taken down at the resident's bedside and replaced with a new wound vac. The Consult Note indicated on 1/6/2025, the wound vac did not have any output (the amount of fluid that was collected and drained from a surgical wound) and planned for the GACH operating room (OR) tomorrow (1/7/2025) for closure. During a review of Resident 1's GACH Surgical/Procedure Documentation dated 1/7/2025, the Documentation indicated the resident had a repeat I&D and closure of the cervical wound. During an interview on 1/8/2025 at 11:09 AM, Resident 1 stated the wound was oozing (the act of flowing slowly through a small opening or producing a thick, sticky liquid) a lot and the facility bandaged the wound up and a couple days afterward the wound was the size of a golf ball. Resident 1 stated while at a follow-up appointment the surgeon looked at the wound and decided to admit the resident to the GACH right away where Resident 1 was still admitted . Resident 1 stated she had surgery yesterday to close the wound. During an interview on 1/8/2025 at 11:50 AM, LVN 1 stated she was the Charge Nurse on 12/21/2024 for Resident 1 and when the Treatment Nurse (TN) noticed Resident 1's wound dehiscence, the TN described the neck wound and asked LVN 1 to document her observations to Resident 1's records (COC Evaluation form) and contact the physician (Physician 1). LVN 1 stated she went home after her shift on 12/21/2024 and did not work the next day (12/22/2024) and was unaware if there was any follow up made by the TN to any of Resident 1's physicians (Physician 1 and WCPA). During an interview on 1/8/2025 at 12:14 PM, the TN stated upon admission to the facility on [DATE], Resident 1's neck wound incision was healed and a week later the incision started opening up (unable to state exact date), started draining, and continued to get bigger. The TN stated she informed another LVN (LVN 1) to contact the physician (Physician 1) to obtain orders for the neck wound. The TN stated the physician did not follow up [call back] and the TN stated she continued to treat the resident's wound with the original treatment order and did not reach out to Physician 1 a second time to follow up. During an interview on 1/8/2025 at 12:40 PM, the Assistant Director of Nursing (ADON) stated if the physician did not call back and the licensed nurse's shift was over, the nurse must endorse the information to the incoming shift (next licensed nurse working). The ADON stated the facility staff should have followed up and called the physician again because there was no response on the first call. The ADON stated if the licensed nurse did not follow up, the resident would not receive the proper treatment and was at risk for deterioration. The ADON stated this incident that happened with Resident 1 could have been prevented if the licensed nurses (TN and LVN 1) obtained another treatment recommendation from the physicians (WCPA and Physician 1) to avoid further wound dehiscence. During an interview on 1/8/2025 at 1 PM, the Registered Nurse Supervisor (RNS) stated Resident 1's physician did not call back and no facility staff followed up with the physician. The RNS stated the physician should have been notified. The RNS stated if the physician was not notified Resident 1 could have an infection and the wound could reopen which could be debilitating for the resident. The RNS stated this incident could have been prevented if the facility staff followed up with Physician 1 or the WCPA to get the necessary measures or treatment for the neck wound. During an interview on 1/8/2025 at 1:35 PM, the TN stated she found the neck wound dehisced while providing wound care on 12/21/2024 at 4 PM. The TN stated documentation was not done to indicate what treatment was provided or how Resident 1's neck wound looked like on 12/21/2024 or the days following before the resident was transferred to the GACH on 12/23/24. The TN stated she did not endorse her observation of Resident 1's neck wound because she did not want to expose the wound to the environment because the treatment for Resident 1's wound was only once a day. The TN stated she should have endorsed Resident 1's neck wound dehiscence to other licensed nurses to follow up with the physicians, otherwise the resident's wound could get worse which could affect the resident's health and possibly require more surgery or be on antibiotics longer. During an interview on 1/8/2025 at 3:05 PM, the Director of Nursing (DON) stated the expectation of the facility staff when a resident's wound dehisces was to inform the physician and follow what the physician ordered. The DON stated the facility staff would let the primary physician know too but the wound physician was the one that should have been informed, and the TN should have done that [inform the WCPA]. The DON stated the TN should not have treated the dehisced wound with the original treatment order because the wound was worse and meant the original treatment order was not working. The DON stated if the right treatment was not provided the wound would be declining and affect the resident's overall health. The DON stated this incident could have been prevented if the facility staff followed the process and the wound consultant assessed Resident 1's neck wound, and new orders were obtained. During another interview on 1/8/2025 at 3:14 PM, the TN stated she could not find documented evidence of a physician order to treat Resident 1's dehisced neck wound. The TN stated she had no documented evidence that the WCPA was notified about the neck wound that dehiscence. During a telephone interview on 1/13/2025 at 10:58 AM, the WCPA stated the TN messaged her to follow up with Resident 1 on the following Monday (12/23/2024) because Resident 1's neck wound was worse. The WCPA stated she was not made aware or informed by the TN on 12/21/2024 of the wound that dehisced on the posterior neck, so she did not order to treat the dehisced wound. The WCPA stated the TN should have notified the physician, the wound consultant, or the surgeon when Resident 1's wound dehisces. The WCPA stated depending on how bad the wound dehiscence status was, she would transfer Resident 1 to the acute hospital or have the physician see the resident to assess the wound. The WCPA stated if the wound was not assessed the wound could get infected and the patient could decline. During a review of the facility's P&P titled, Change in Condition: Notification of, dated 8/25/2021, indicated the purpose was to ensure residents, family, and physicians were informed of changes in the resident's condition. The P&P indicated, a facility must immediately inform the resident, consult with the Resident's physician and/or nurse practitioner (NP), and notify, consistent with his/her authority, Resident Representative where there was: a significant change in the Resident's physical, mental, or psychosocial status (that was, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). The P&P indicated, when making notification, the facility must ensure that all pertinent information was available and provided upon request to the physician and/or NP. During a review of the facility's undated P&P titled, Wound Care, indicated preparation included verifying there was a physician's order for the procedure. The P&P indicated, the following information should have been recorded in the resident's medical record: the type of wound care given, the date and time the wound care was given, any change in the resident's condition, all assessment data (wound bed color, size, drainage) obtained when inspecting the wound, how the resident tolerated the procedure, and the signature and title of the person recording the data. During a review of the facility's P&P titled, Skin Integrity Management, dated 5/26/2021, the P&P indicated, to perform skin inspection on admission/re-admission and weekly. Document on Treatment Administration Record (TAR) or in Point Click Care (PCC); perform wound observations and measurements upon initial identification of altered skin integrity, weekly, and with anticipated decline of wound; and perform daily monitoring of wounds or dressings for presence of complications or declines and document if indicated. The P&P indicated, to implement special wound care treatments/techniques, as indicated and ordered. The P&P indicated to notify the physician to obtain orders and review care plan and revise as indicated. During a review of the facility's Wound Care/Treatment Nurse Job Description dated July 2022, the P&P indicated resident care functions include completing regular skin assessments on residents and documenting the findings and providing skin and wound care and treatments, as ordered. The Job Description indicated, the Wound Care/Treatment Nurse agrees to perform the tasks outline in this job description in a safe manner and in accordance with the facility's established procedures.

Based on observation, interview, and record review the facility failed to ensure 3 of three sampled residents (Residents 3, 4, and 5) were free from neglect (the failure of the facility, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress) and mistreatment (inappropriate treatment or exploitation of a resident) by facility staff failing to assist Residents 3, 4 and 5 with activities of daily living (ADLs, routine tasks, activities such as bathing, dressing, and toileting a person performs daily to care for themselves) and not respond to their call lights (also known as a call bell or nurse call button; a device typically found near a patient's bed or within reach. It consists of a button that, when pressed, sends a signal to the nursing station or a centralized system, alerting healthcare providers that assistance is required in the patient's room) leaving residents in bed with soiled undergarments. This failure resulted in Resident 3, 4 and 5 feeling neglected and depressed due to the lack of care and services from not having enough staff to provide the needed care and services that could potentially cause psychosocial decline and worsening medical condition such as skin breakdown and urinary tract infection (UTI- a common infection that occurs when bacteria enter the urinary tract and multiply). Findings: 1. During a review of Resident 4's Admission Records (Face sheet) indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included cervical radiculopathy (pinched nerve in the neck area), hemiplegia (paralysis of the dominant side - right), and post (after) laminectomy (post-spinal surgery). During a review of Resident 4's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/25/2024, indicated the resident was moderately impaired in cognition (problems with a person ' s ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 4 was assessed requiring maximal assistance (helper does more than half the effort) with toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after urination, or having a bowel movement), and bathing self. The MDS indicated Resident 4 was dependent (helper does all the effort) on assistance for lower body dressing and maximal assistance with mobility such turning side to side, transferring from lying to sitting on the side of the bed, moving from sitting to standing, and transferring from bed to chair. During a review of Resident 4's History and Physical (H&P, a comprehensive physician ' s note regarding the assessment of the resident ' s health status), dated 9/19/2024, indicated Resident 4 does have the capacity to understand and make decisions. During a review of Resident 4's Care Plan (a document that outlines the facility ' s plan to provide personalized care to a resident based on the resident ' s needs), dated 9/20/2024, indicated Resident 4 had MASD [Moisture-associated skin damage caused from prolonged exposure to moisture] on the buttocks with interventions that included to keep Resident 4 clean and dry at all times. During an interview on 10/3/2024 at 2:51 PM with Resident 4, Resident 4 stated, 9/21/2024 during her first night in the facility, she used the call light at 11PM to request the staff to change her urine-soaked undergarment. Resident 4 stated, no nurse came to change her until 2:45AM (a total of 3 hours and 45 minutes wait). Resident 4 stated, she asked the Certified Nursing Assistant (CNA)(unable to identify by the resident) why it took a long time to answer the call light, but the CNA did not respond. Resident 4 stated, she felt depressed and neglected when her undergarment was not changed for a long period of time. Resident 4 stated, the same incident happened for two consecutive nights after she was admitted when her undergarment was soiled with urine and feces/stool (a stool is the solid waste that passes out of the body during a bowel movement. It's also known as feces). Resident 4 stated, the last time her undergarment was soiled with urine and feces was last Sunday, 9/27/2024. Resident 4 stated, when she asked the CNA (unable to identify by the resident) why it took so long for her undergarment to be changed, the CNA stated they are short staffed. During an interview on 10/4/2024 at 12:56 PM, with family member (FM) 1, FM 1 stated, that Resident 1 ' s undergarment was not being changed at night. FM 1 stated, Resident 4 told her The nurses do not check on her at night and leaves her [Resident 4] in her urine-filled undergarment. FM 1 stated, it really affected her (Resident 4) mental health, and she is depressed. FM 1 stated, on 9/25/2025, the Infection Preventionist (IP) told them to push the call light, and someone would come. FM 1 stated, that was the problem, no CNA would come. During a concurrent observation and interview on 10/7/2024 at 8:43AM in Resident 4 ' s room, Resident 4 was observed lying in bed with FM 2 by her bedside. Resident 4 stated she pressed the call light for a nurse to help change her urine-soaked and stool filled undergarment on 9/21/2024, and she had to wait from 11PM to 2:45AM, 9/22/2024 and 9/23/2024 from 12:00AM to 2:00AM for a nurse to come and change her undergarment but the staff did not come. 2. During a review of Resident 3's Admission Record indicated that the facility admitted the resident on 9/12/24 with diagnoses that included aftercare following joint replacement surgery (surgical procedure to replace the damage joint with an artificial one) and osteoarthritis of the right hip (a progressive disorder of the joints, caused by a gradual loss of cartilage). A review of Resident 3's MDS, dated [DATE], indicated that the resident ' s cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and senses) was intact, and the resident needed substantial/maximal assistance from a person when she must perform daily living activities such as toileting and showering. During a review of Resident 3's Care Plan, created on 9/13/24, indicated that the resident was at risk for decreased ability to perform ADLs in personal hygiene and toileting related to right hip osteoarthritis and postoperative (post [after]-surgery) right total hip replacement. During an interview on 10/3/24 at 2:05 PM, Resident 3 stated, that she used the call light to ask a CNA (unknown identity) to change her undergarment when it becomes soiled with urine, and it usually takes 30-45 minutes before a CNA answers the call. She stated, she felt neglected whenever she waits that long for a CNA to change her undergarment. Resident 3 stated, that the CNAs usually respond late when she presses the call light after 7 PM. 3. A review of Resident 5 's Admission Record indicated that the facility admitted the resident on 3/13/24 and readmitted the resident on 9/24/24 with diagnoses that included urinary tract infection (UTI, an infection in the bladder/urinary tract) and calculus of the kidney (hard deposits that form in the kidneys and can cause pain and other symptoms). A review of Resident 5's MDS, dated [DATE], indicated that the resident ' s cognition was intact. The MDS indicated that Resident 5 was incontinent of the urine and bowel. A review of Resident 5's Care Plan created on 8/16/23, indicated that the resident required assistance and was dependent for ADL care related to admission diagnosis and history of UTI cystitis (a type of urinary tract infection (UTI) that causes inflammation of the bladder). During an interview on 10/3/24 at 3:15 PM, Resident 5 stated the call light response during the day is acceptable but becomes slower after 7 PM. She stated she waits at least 30 minutes for a staff to answer the call light. During an interview on 10/4/2024 at 10:40AM with LVN 4, LVN 4 stated, on 9/20/2024 there was only 1 LVN (unidentified LVN) scheduled for the 3-11PM shift who called off. LVN 4 stated that all the LVN charge nurses on the 7AM to 3PM shift stayed at the facility to cover the 3PM to 11PM shift. During an interview on 10/4/2024 at 11:33AM with LVN 3, LVN 3 stated the licensed nurses were short staffed on the weekends. LVN 3 stated sometimes there were only four LVN nurses and each LVN had 45 patients. LVN 3 stated there cannot be any distraction when passing medications or she would be late. LVN 3 stated the resident knows when their medications were late. During an interview on 10/3/2024 at 3:44 PM, CNA 1 stated, sometimes the CNAs have a large workload because of staffing shortages. CNA 1 stated, she noticed more workload during the 11PM to 7AM shift. CNA 1 stated staffing shortages affected the care of the resident because it caused many residents to sit in their urine and stool for long periods of time. CNA 1 stated, if the residents were not changed timely, this may cause a break down in the resident ' s skin integrity leading to problems such as wounds or infections. CNA 1 stated the management team was aware of the nursing shortage. During an interview on 10/4/2024 at 3:48 PM, CNA 3 stated, if she was in the hallway, she would answer call lights right away. CNA 3 stated, if she was changing a resident ' s undergarment and heard a call light, the resident who pressed the call light would have to wait until she was done changing the resident ' s undergarment. CNA 3 stated, when the CNAs were short staffed and had a heavy workload, CNA 3 need to prioritize her residents. During an interview on 10/3/2024 at 12:51 PM with the Assistant Director of Nursing (ADON), the ADON stated there were 4 or 5 licensed nurses who resigned (voluntarily leave their job) immediately in the last two weeks. The ADON stated, the facility was not hiring nurses from the registry agency (a business that provides nursing staff to provide nursing services to a healthcare facilities) at this time because the Infection Preventionist (IP) and the MDS nurses were assisting with resident ' s care by passing medication, resident assessments while performing the duties of IP and MDS nurse. The ADON stated she was aware that there was a shortage of staff including the CNAs especially during the night shift but they are not hiring CNAs from the registry agency rather they are just hiring from the community. During an interview on 10/3/2024 at 1:15 PM with the Assistant Director of Staff Development (DSD), the Assistant DSD stated, because of the shortage of staffs, the nurses that works 7AM to 3 PM shift continues to work from 3PM to 11PM), the LVNs works 12 to 16 hours shift and by the night shift [11PM to 7AM] LVNs would come in early to work part of the 3PM to 11PM shift. During an interview on 10/7/2024 at 3:29PM with the Assistant Director of Nursing (ADON), the ADON stated, the staff must answer call lights right away. The ADON stated, it was important to find out how to address the resident ' s needs. During a review of the Facility Assessment Tool dated 8/7/2024, Staff Plan indicated that based on the facility ' s resident population and their needs for care and support, the facility ' s approach to staffing was to ensure there were sufficient staff members with the appropriate skill set to meet the needs of the resident at any given time included the following: Skilled Nursing Facility (SNF) = 7AM to 3PM shift with 1 RN and 5-7 LVN (depending on census and wound care case load) & 8-10 residents per CNA, 3PM to 11PM shift with 1 RN and 4-5 LVN (depending on census) & 10-12 residents per CNA, and 11PM to 7AM shift with 1 RN and 4 LVN & 15-17 residents per CNA. Subacute Unit = 7AM to 7PM with 1 RN and 3 LVN (depending on census and treatment) and 7PM to 7AM with 1 RN and 2 LVN. 7AM to 3PM shift with 8-10 residents per CNA (depending on census), 3PM to 11PM with 10-12 residents per CNA (depending on census), and 11PM to 7AM with 10-12 residents per CNA (depending on census). During a review of the facility ' s Job description for Certified Nursing Assistants, indicated the CNA will provide nursing residents with routine daily nursing care and services in accordance with the residents assessments and care plan as directed by supervisors, by assisting the residents ranging from minimal assistance to total dependent care on activities of daily living (ADL). During a review of the facility ' s P&P, titled Abuse Prohibition Policy and Procedure dated 2/23/21, the facility will prohibit abuse, mistreatment, and neglect of the residents by identifying, correcting, and intervening in situations in which abuse, neglect, is more likely to occur; and establishing a safe environment that supports, to the extent possible, the residents. During a review of the facility ' s policies and procedures (P&P) titled, Answering the Call Light, dated 9/2022, indicated the purpose was to ensure timely responses to the residents request and needs. This P&P indicated the staff to answer the resident call system immediately. During a review of the facility ' s titled Activities of Daily (ADLs), Supporting, dated March 2018, indicated the appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) b. Mobility (transfer and ambulation, including walking) c. Elimination (toileting); Staff will do rounds prior to all meals t ensure that ADL are met. During a review of the facility ' s P&P titled, Staffing dated October 2017, indicated, the facility provided sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment.

Based on observation, interview, and record review, the facility failed to provide pain management (the process of alleviating pain) for one of two sampled residents (Resident 2), by failing to: 1. Notify Resident 2 ' s physician when Resident 2 repeatedly complained of neck and head pain with a pain level above a 4 out of 10 (mild pain) and obtain alternate pain medication to manage and relieve the resident ' s excruciating (intense or agonizing) and uncontrolled pain. 2. Implement the facility ' s policy & procedure (P&P) titled Pain Management by not alleviating Resident 2 ' s pain to a level that is acceptable to the resident while minimizing negative effects on the resident to the extent possible. As a result, Resident 2 experienced excruciating and unrelieved pain resulting in the resident being transferred to the General Acute Hospital (GACH). The resident ' s discharge summary from the GACH indicated the resident had a diagnosis of compression fracture (a break in a bone that occurs when pressure causes the bone to collapse) of L1 vertebra (the topmost vertebra in the lumbar spine, which is the section of the spine that supports the upper body). Findings: During a review of Resident 2 ' s Admission Record indicated the facility initially admitted the resident on 9/1/2021 and readmitted the resident on 9/18/2024, with diagnoses including spondylolysis (a stress fracture in the vertebra, or bone in the spine), wedge compression fracture of first lumbar vertebra (a type of spinal fracture that occurs when the front of a vertebra collapses, giving the vertebrae wedge shape), and abnormal posture (a chronic, involuntary, or rigid body position or movement that was different from normal). During a review of Resident 2 ' s Care Plan for Neck Pain and Headaches, initiated 9/4/2021, indicated a goal that Resident 2 would not experience pain for three days. The Care Plan interventions included Tylenol (Acetaminophen) as ordered, send resident to the GACH to locate the source of the pain, and evaluate pain characteristics: quality, severity, location, precipitating/relieving factors. During a review of Resident 2 ' s Physician ' s Order dated 4/13/2024, indicated to give the resident Acetaminophen (a drug that reduces pain and fever but not inflammation) tablet 325 mg (milligram, unit of measurement), give two (2) tablets by mouth every four hours as needed (PRN) for mild pain one (1) to four (4) on a pain scale of 1 to ten (10) [pain scale- pain level from 1 to 3 (mild). The Order also indicated more than three doses in 48 hours, notify the physician/advanced practice provider, and to not exceed three g (grams, metric unit of mass equal to on thousandth of a kilogram) per day. During a review of Resident 2 ' s Quarterly Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 5/7/2024, indicated the resident ' s cognition was intact (sufficient judgement and self-control to manage the normal demands of the environment). The MDS indicated Resident 2 was not receiving scheduled pain medication and did not have any presence of pain during the assessment. During a review of Resident 2 ' s Annual Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/1/2024, indicated the resident ' s cognition was intact (sufficient judgement and self-control to manage the normal demands of the environment). The MDS indicated Resident 2 was not receiving scheduled pain medication and did not have any presence of pain during the assessment. During a review of Resident 2 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/18/2024, indicated the resident ' s cognition was intact (sufficient judgement and self-control to manage the normal demands of the environment). The MDS indicated Resident 2 did not have any presence of pain during the assessment. During a review of Resident 2 ' s Medication Administration Record (MAR) for the month September 2024, indicated the pain medication available for the resident was Acetaminophen tablet 325 mg, give two (2) tablets by mouth every four hours PRN for mild pain one (1) to four (4) on a pain scale of 1 to ten (10). The MAR also indicated more than three doses in 48 hours, notify the physician/advanced practice provider, and to not exceed three g (grams, metric unit of mass equal to on thousandth of a kilogram) per day. During a review of Resident 2 ' s Change of Condition (COC) dated 9/4/2024 at 2:53 AM, indicated Resident 2 had uncontrolled pain in her neck and head, and reported a pain level of 10 out of 10 on the pain scale. The COC indicated the physician was notified and Resident 2 was transferred to the General Acute Care Hospital (GACH) for further evaluation. The COC did not indicate any new pain medication was obtained from the physician due to the resident ' s increase in pain level. During a review of Resident 2 ' s Electronic Medication Administration Record (eMAR) Progress Note dated 9/4/2024 at 4:20 AM, indicated Resident 2 was administered 2 tablets of Acetaminophen 325mg for complaints of 6 out of 10 neck pain. During a review of Resident 2 ' s Progress Note dated 9/4/2024 at 5:15 AM, indicated the resident requested to be transferred to the GACH for further evaluation and the MD was notified. The Progress Note indicated the ambulance was scheduled to pick up the resident at 8 AM. During a review of Resident 2 ' s Progress Note dated 9/4/2024 at 7:30 AM, indicated the resident complained of uncontrollable pain all over her body and could not wait for the scheduled ambulance to come at 8 AM. The Progress Note indicated emergency services (911) was initiated to pick up Resident 2 and bring her to the GACH for evaluation. The Progress Note did not indicate pain medication was given to the resident or that the physician was notified to obtain alternative pain medication to manage the resident ' s pain. During a review of Resident 2 ' s Progress Note dated 9/4/2024 at 7:50 AM, indicated emergency services arrived at the facility at 7:38 AM and the resident was transferred to the GACH. During a review of Resident 2 ' s Order Summary Report dated 9/9/2024, indicated an order to readmit Resident 2 to the facility under the care of Physician 2. During areview of Resident 2 ' s Progress Note dated 9/10/2024 at 8:54 PM, indicated the resident complained of pain to the back of her neck. The Progress Note indicated the physician was notified with a new order for Diclofenac Sodium External Gel 1% (blocks substances that cause inflammation and pain), apply to back of neck topically two times a day for pain management. During a review of Resident 2 ' s eMAR Progress Note dated 9/12/2024 at 1:55 PM, indicated Resident 2 was administered 2 tablets of Acetaminophen 325mg for complaints of body pain and reporting a 9 out of 10 pain level. The eMAR Progress Note indicated Acetaminophen (Tylenol) was administered to Resident 2. The Progress Note did not indicate Physician 2 was notified to obtain alternative pain medication to manage the resident ' s pain. During a review of Resident 2 ' s eMAR Progress Note dated 9/12/2024 at 2:30 PM, indicated the Acetaminophen administered to Resident 2 was ineffective and Resident 2 reported pain of 9 out of 10 was and pain was unrelieved. The Progress Note did not indicate pain medication was administered to the resident or tht Physician 2 was notified to obtain alternative pain medication to manage the resident ' s pain. During a review of Resident 2 ' s COC dated 9/12/2024 at 3:38 PM, indicated the resident had neck pain not relieved by pain medication (Acetaminophen). The COC indicated the residents pain level was a six out of 10 on the pain scale. The COC indicated Acetaminophen (Tylenol) was given, Diclofenac cream was applied, and the Medical Director was notified. The Medical Director ordered emergency services to pick up the resident, but Resident 2 refused to be transferred to the GACH on 9/12/24. The COC indicated the residents FM (family member) was notified. The COC did not indicate any new pain medication was ordered by the physician (Medical Director) or that Physician 2 was informed to obtain alternative pain medication to manage the resident ' s pain. During a review of Resident 2 ' s eMAR Progress Note dated 9/12/2024 at 5:55 PM, indicated Resident 2 was administered 2 tablets of Acetaminophen 325 mg for complaints of 9 out of 10 neck pain. During a review of Resident 2 ' s eMAR Progress Note dated 9/12/2024 at 6:25 PM, indicated the 2 tablets of Acetaminophen 325mg, administered to Resident 2 was ineffective, and Resident 2 ' s pain was unrelieved and remained at a 9 out of 10 pain level. There is no documented evidence the physician was notified regarding the resident ' s complaint of unrelieved pain. During a review of Resident 2 ' s eMAR Progress Note dated 9/12/2024 at 9:58 PM, indicated Resident 2 was administered 2 tablets of Acetaminophen 325 mg for complaints 9 out of 10 neck pain. During a review of Resident 2 ' s eMAR Progress Note dated 9/12/2024 at 10:28 PM, indicated the 2 tablets of Acetaminophen 325mg, administered to Resident 2 was ineffective, and Resident 2 ' s pain was unrelieved and remained at a 9 out of 10 pain level. During a review of Resident 2 ' s Progress Note dated 9/13/2024 at 12:46 AM, indicated Resident 2 was complaining of excruciating neck pain that was unrelieved by pain medications. The Progress Note indicated Resident 2 ' s primary physician could not be reached, therefore facility staff called emergency services. The Note indicated emergency services could not transfer Resident 2, since Resident 2 ' s pain was not emergent. The Note indicated Resident 2 did not go to the GACH with emergency services. The Note indicated Medical Director was contacted regarding Residents 2 ' s complaints of excruciating neck pain, however the Note indicated the Medical Director ordered for Resident 2 to be transferred to the GACH. The Note did not indicate any additional or new pain medications ordered for Resident 2. During a review of Resident 2 ' s MAR dated 9/13/2024, indicated Resident 2 was not administered any pain medications for complaints of excruciating pain on 9/13/24 at 12:46 AM. During a review of Resident 2 ' s Progress Notes on 9/13/2024, indicated no documented evidence facility staff provided pain management or treatment for the resident from 12:46 AM to 8:37 AM. During a review of Resident 2 ' s Physician ' s order, dated 9/14/24 indicated an order for Baclofen (skeletal muscle relaxant) 10 mg tablet, one tablet every eight hours as needed (PRN) for muscle spasm/neck pain. During a review of Resident 2 ' s Physician ' s order, dated 9/14/24 indicated an order for Ibuprofen (a drug used to treat fever, swelling, pain, and redness by preventing the body from making a substance that causes inflammation), 600 mg, 1 tablet every 12 hours as needed for pain management/neck pain During a review of Resident 2 ' s eMAR Progress Note date 9/14/2024 at 2:30 PM, indicated the resident received Ibuprofen (a drug used to treat fever, swelling, pain, and redness by preventing the body from making a substance that causes inflammation) due to pain in back of neck. During a review of Resident 2 ' s Lab Result Note dated 9/14/2024 at 2:36 PM, indicated the physician was notified the resident was still complaining of pain to her neck and was informed of the resident ' s spinal x-ray results. The Lab Result Note indicated the Physician stated the results were arthritic (a condition that causes inflammation or degeneration in one or more joints) and ordered Baclofen (skeletal muscle relaxant) 10 mg tablet, one tablet every eight hours PRN for muscle spasm/neck pain; Ibuprofen 600 mg, one tablet every 12 hours as needed for pain management/neck pain; and physical therapy services. During a review of Resident 2 ' s eMAR Progress Note dated 9/14/2024 at 5:30 PM, indicated the resident received Acetaminophen two 325 mg tablets because the resident complained of neck pain. The eMAR did not indicate if the pain medication was effective. A review of Resident 2 ' s MAR dated 9/14/2024 at 5:30 PM, indicated Resident 2 was administered 2 tablets of Acetaminophen 325 mg for complaints of 7 out of 10 neck pain. A review of Resident 2 ' s MAR dated 9/14/2024 at 9:30 PM, indicated Resident 2 was administered 2 tablets of Acetaminophen 325 mg for complaints of 8 out of 10 neck pain. A review of Resident 2 ' s eMAR Progress Note dated 9/15/2024 at 12 PM, indicated the resident received Baclofen one 10 mg tablet. During review of Resident 2 ' s COC dated 9/15/2024 at 1:15 PM, indicated the resident had excruciating pain to her neck unrelieved by pain medication and had two vomiting episodes. The COC indicated the Physician gave new orders to transfer the resident to the GACH. The COC indicated transportation arrived at 2:20 PM and because the resident ' s vitals were not stable, they were unable to provide transport. The facility contacted emergency services and at 2:30 PM t when the resident was transferred to the GACH. During a review of Resident 2 ' s GACH record dated 9/15/2024, the GACH record indicated Resident 2 was admitted to the GACH for complaint of pain. During review of Resident 2 ' s Discharge Summary GACH record dated 9/19/2024 at 5:49 AM, indicated the resident's final diagnosis included compression fracture (a break in a bone that occurs when pressure causes the bone to collapse) of L1 vertebra (the topmost vertebra in the lumbar spine, which is the section of the spine that supports the upper body). The Discharge Summary indicated the resident's history of present illness included mild compression fracture of L1 vertebral body. During a concurrent observation and interview in Resident 2 ' s room on 10/7/2024 at 3:20 PM, Resident 2 was sitting on the right side of her bed in her wheelchair watching television and had her left hand on the left side of her neck. Resident 2 stated her neck was sore. Resident 2 stated she would not receive pain medication until the evening shift (3PM-11PM) and Resident 2 must request for pain medication since facility staff did not provide pain medications unless Resident 2 requested. After Resident 2 called for assistance using her call light, an unnamed facility staff entered Resident 2 ' s room, and Resident 2 told the unnamed staff that her left ear hurt. The unknown facility staff was observed telling Resident 2 that they would inform the licensed nurse to provide Resident 2 with pain medication. During a review of Resident 2 ' s MAR dated 10/7/2024, indicated no pain medication were administered to Resident 2, after Resident 2 complained of left ear pain. During a concurrent interview and record review on 10/7/2024 at 4:30 PM with the Director of Nursing (DON), Resident 2 ' s MAR was reviewed. The DON stated medications administered to Residents were documented on the MAR. The DON stated if the MAR was blank and a facility staff did not sign their name, then the MAR indicated the medication was not given. The DON stated Resident 2 did not have an order for pain medications for complaints of moderate to severe pain level. The DON stated Resident 2 should have pain medications ordered for moderate to severe pain, and not just mild pain, due to Resident 2 ' s history and diagnosis. During a concurrent interview and record review of Resident 2 ' s COC dated 9/4/2024 at 2:53 AM on 10/10/2024 at 10:24 AM, the DON stated the medication provided to Resident 2 was inappropriate since Resident 2 reported a pain level of 10, and only 2 tablets of Acetaminophen 325mg was administered to Resident 2, which was for mild pain (1-4). The DON stated no other pain medications were ordered for Resident 2, and that facility staff have followed up with the physician and documents the physician's response regarding Resident 2 ' s need for pain relieve. During a concurrent interview and record review on 10/10/24 at 10:28 AM, with the DON, Resident 2 ' s Progress Note, dated 9/4/2024 at 7:30 AM was reviewed. The DON stated licensed nurses should have informed the physician immediately when Resident 2 reported unrelieved, excruciating neck pain. The DON state contacting the physician was important so the resident would not be in pain. During a concurrent interview and record review on 10/10/24 at 10:32 AM, with the DON, Resident 2 ' s eMAR Progress Note dated 9/12/2024 at 1:55 PM was reviewed. The DON stated Resident 2 did not have pain medications ordered for the relieve of moderate to severe pain (or pain level about a 4 ou for Resident 2, and administering Resident 2 Acetaminophen (ordered for mild pain) was inappropriate, since Resident 2 reported a pain of 9 out of 10 (severe pain). The DON stated there was no documentation indicating the physician was notified, what was discussed with the physician, nor were their any new orders for Resident 2 to address and relieve her severe pain. During a concurrent interview and record review on 10/10/24 at 10:36 AM, with the DON, Resident 2 ' s eMAR Progress Note dated 9/12/2024 at 2:30 PM was reviewed. The DON stated there was no documentation indicating any follow ups to the physician regarding Resident 2 ' s unrelieved pain. During a concurrent interview and record review on 10/10/24 at 10:41 AM, with the DON, Resident 2 ' s Progress Notes dated 9/13/2024 was reviewed. The DON stated there was no documentation indicating interventions done for Resident 2 ' s complaints of excruciating neck pain on 9/13/24 at 12:46 AM until 9/13/24 at 8:37 AM. During a concurrent interview and record review on 10/10/24 at 10:46 AM, with the DON, Resident 2 ' s MAR dated 9/14/2024 at 5:30 PM and 9:30 PM was reviewed. The DON stated the Acetaminophen administered to Resident 2 was inappropriate since Acetaminophen was ordered for mild pain, and Resident 2 complained of severe pain. The DON stated there was no documentation indicating the Physician was notified regarding Resident 2 ' s unrelieved, severe pain. During a concurrent interview and record review on 10/10/24 at 10:51 AM, with the DON, Resident 2 ' s Progress Notes dated 9/15/2024 at 1:15 PM was reviewed. The DON stated the Physician came to the facility and assessed Resident 2 and concluded the pain Resident 2 was exhibiting was arthritic (joint inflammation) therefore was not sent to the hospital. The DON stated, the facility staff should have asked for a different medication that was stronger to help the resident since the medications on hand were not working. A review of the facility ' s P&P titled Pain Management dated 8/25/2021, indicated to maintain the highest possible level of comfort for residents by providing a system to identify, assess, treat, and evaluate pain. The nurse would notify the physician/advanced practice provider (APP) as appropriate and obtain treatment orders as indicated. An individualized, interdisciplinary care plan would be developed and include using specific strategies for preventing or minimizing different levels of sources of pain or pain related symptoms. Residents receiving interventions for pain would be monitored for the effectiveness and side effects in providing pain relief and document ineffectiveness of as needed medications including interventions, follow-up, and physician/APP notification. The care plan would be evaluated for effectiveness until satisfactory pain management was achieved by contacting the physician/APP to report findings and obtain revised treatment orders, review the non-pharmacological approaches for effectiveness, and revise the care plan as indicated.

Based on interview and record review, the facility failed to identify the provision of monitoring and supervision to prevent abuse and intoxication of illicit drugs ([street drugs] refers to the use and misuse of illegal and controlled drugs) for one of two sampled residents (Resident 119) with a recent history of polysubstance abuse ([Drug Abuse] when an individual develops the habit of using multiple substances and becomes dependent on them) and an existing intravenous (IV- through the vein) line, in accordance with the facility ' s policies and procedures on Behavioral Management and Out on Pass, by failing to: 1. Identify and assess the risks of Resident 119 leaving the facility without notification for the potential of obtaining illicit drugs. 2. Monitor the use of Resident 119 ' s intravenous (IV-through the vein) line to prevent use for self-administration of illicit drugs. 3. Develop care plan interventions to provide additional monitoring and ensure the safety of Resident 119 who had a history of leaving the facility without notification and illicit drug use. As a result, on [DATE], Resident 119 was found unresponsive in his room on [DATE] and was transferred to the general acute care hospital (GACH 2) via 911 emergency services. Resident 119 was readmitted back to the facility, the same day, on [DATE] with diagnoses that included diagnosed acute methamphetamine (a powerful highly addictive stimulant) intoxication (the condition of having lost some control of one ' s actions or behaviour under the influence of a drug) and abuse. On [DATE], Resident 119 was transferred to GACH 1 via 911 emergency services due to vomiting and stomach pain. Resident 119 refused all care upon arriving to emergency services and signed a Leaving Hospital Against Medical Advice form. Resident 119 was readmitted back to the facility on the same day, on [DATE] with diagnosis of abdominal pain. On [DATE] at 12:20 AM, Resident 119 was transferred back to GACH 2 via 911 emergency services for low blood pressure [BP] (normal adult BP ranges between ,d+[DATE] to ,d+[DATE]) and low oxygen saturation (amount of oxygen in the blood) of 58% (normal oxygen saturation ranges between 95 % to 100%). Resident 119 was pronounced dead on [DATE] at 8:09 AM for worsening respiratory distress (a condition that causes fluid to build up in a person ' s lungs so oxygen cannot get to the organs) with a history of cardiomyopathy (disease of the heart muscle) endocarditis (bacteria or other germs get into the bloodstream and attach to damaged areas in the heart) due to intravenous (IV - through the vein) drug abuse. Resident 119 ' s final diagnoses included acute septic shock (a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection) due to acute endocarditis. On [DATE] at 8:01 PM, during the facility ' s Annual Recertification Survey in the presence of the Administrator (ADM) and Director of Nursing (DON), an Immediate Jeopardy (IJ, a situation in which the facility ' s noncompliance with one of more requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to a resident) was identified regarding the facility ' s failure to address and implement interventions for a resident with history of polysubstance abuse and was found with illicit drugs and paraphernalia in his room while residing in the facility. On [DATE] at 4:35 PM, the IJ was removed after the surveyor verified and confirmed the facility implemented the facility ' s IJ Removal Plan (a detailed plan to address the IJ findings) while onsite by observation, interview, and record review. The IJ was removed in the presence of the ADM and the DON. The acceptable IJ Removal Plan included the following: The Social Services Director (SSD) performed an audit on [DATE] to identify residents that has a history of substance abuse, behavioral issues and had the potential to leave the facility without notification and had the potential to obtain illicit drugs. A Resident Council was conducted on [DATE] by Recreational Director to discuss that the facility does not allow illegal/illicit substance to be brought to the facility. On [DATE], the Director of Nurses initiated an in-service to licensed nurses to obtain an order for discontinuation and removal of intravenous lines one IV medication has been completed. On [DATE], the Director of Nurses initiated an in-service to the licensed nurses, and Interdisciplinary Team (IDT) that upon admission, the clinical team will review resident ' s history to identify if there is any diagnosis of substance abuse, behavioral issues and with intravenous line and the importance of initiating person-centered care plan including proper referral for psychiatric and psychological consultation. On [DATE], the Director of Nurses initiated an in-service to the licensed nurses to obtain an order to go out on pass for resident who desire to go out on pass. If anytime the licensed nurse evaluates that the out on pass jeopardizes the safety of the resident, the nurse will hold the out on pass order until the physician is notified for further orders. The licensed nurse will inform the resident and/or responsible party of the discontinuation of the out on pass order. On [DATE], the Director of Nurses initiated an in-service to the facility staff on the out on pass policy. An out-on-pass binder will be available to each station. The licensed nurse will complete the out on pass log. The receptionist will have a list of residents with current out on pass order and will verify with the charge nurse if the order is current. The Health Information Management/Designee will print a list of residents with an out-on-pass order daily (Monday to Friday) and distribute list to the station and receptionist. The licensed nurse will endorse residents that are out on pass and expected to come back to the incoming shift. Upon return from out on pass, the licensed nurses will perform a voluntary inspection for residents with a history of drug abuse. If the facility suspects signs and symptoms of possible illegal substance use, and if the resident refuses to be inspected, the physician will be notified, and the suspected resident will be referred to the local law enforcement. Upon admission, the IDT will conduct a post admission conference with resident ' s/responsibility party to discuss resident plan of care including out on pass policy and prohibition of illegal substances in the facility. A behavior contract will be discussed with residents having a diagnosis of substance abuse. A verbal consent will be obtained and documented to inspect the resident and his/her belongings for illegal substance. Any illegal substance in plain view will be confiscated and/or referred to local enforcement. Residents will be monitored for signs and symptoms of substance abuse. The IDT will discuss with the resident/responsible party for discharge plan for rehabilitation during the post admission conference. The IDT will continuously meet with the resident/responsible party if there are barriers in discharge planning. On [DATE], the facility will initiate collaboration with the Committee for Policies and Procedures to develop policy and procedures for resident with diagnosis of substance abuse based on State and Federal Guidelines. On [DATE], the facility assessment will be reviewed and revised to reflect the capability of the facility to admit residents with history of substance abuse. Any resident identified to have an intravenous line and is at high risk to self-administer illegal drugs will be reported to the physician for further recommendations. Residents with diagnosis of substance abuse will be referred to Psychology (the scientific study of the mind and behavior) and Psychiatry (a branch of medicine focused on diagnosing and treating mental health disorders). The DON/Designee will include education on new hires during onboarding, upon return from leave of absence/vacation prior to the beginning of their shift. Findings: A review of Resident 119 ' s GACH 1 Consultation Note dated [DATE] timed at 7:03 PM, indicated Resident 119 was admitted to GACH 1 with history of intravenous (IV) substance abuse developed the endocarditis and congestive heart failure (a condition that develops when your heart does not pump enough blood for your body's needs). A review of Resident 119 ' s GACH 1 record titled Progress Note dated [DATE] timed at 8:40 AM, indicated under Internal Medicine documented Resident 119 with medical history including drug abuse presented in the GACH 1 after having syncopal episode (pass out) due to resident may have aspirated and started vomiting. The GACH 1 Note indicated Resident 119 present in the GACH after passing out after using drugs in the street. The GACH 1 Note indicated Resident 119 acknowledges drug use. The GACH 1 Note indicated a primary diagnosis of syncope after drug use. A review of Resident 119 ' s Admission Record indicated the resident was admitted to the facility from GACH 1, on [DATE] with diagnoses that included congestive heart failure and drug abuse counseling and surveillance of drug abuser. A review of Resident 119 ' s History and Physical (H&P) dated [DATE], indicated the resident had the capacity to understand and make decisions. The H&P indicated a handwritten history from Physician 1 that indicated Resident 119 ' s present illness and pertinent past history included syncopal (fainting) episode and possible pending street drugs test. The H&P indicated under Diagnoses included polysubstance abuse ([Drug Abuse] when an individual develops the habit of using multiple substances and becomes dependent on them). A review of a facility document titled PICC [Peripherally Inserted Central Catheter - a type of catheter used to access the large veins in the chest] to administer medication directly in the bloodstream Insertion Record dated [DATE], indicated the central catheter insertion was performed on Resident 119 ' s left upper arm, for intravenous antibiotic infusion due to wound infection. A review of Resident 119's Order Summary Report with a physician order dated: [DATE], indicating the resident's Out on Pass Order was on hold while Resident 119's PICC line was in place [DATE], indicating one to one sitter upon readmission. A review of a facility document titled Midline [a long, flexible tube inserted into a large vein to administer a medication directly into the bloodstream] Insertion Record dated [DATE], indicated another central catheter insertion was performed on Resident 119 ' s left upper arm, for intravenous antibiotic infusion due to cellulitis. A review of Resident 119 ' s care plans included the following resident issues: 1. Patient left facility without notifying staff, dated [DATE]. The care plan interventions included educating the resident on the importance of following the physician ' s order and facility protocol. 2. Non-adherence to physician orders which included refusing blood draws, dated [DATE]. The care plan interventions included explaining the importance of following the physician's orders and respecting the resident ' s rights to refuse. 3. Non-compliance with out-on-pass order, dated [DATE]. The care plan interventions included informing and reminding the resident to sign out before leaving the facility and monitor compliance. 4. Resident 119 on IV antibiotic therapy for cellulitis dated [DATE]. The interventions indicated monitoring the IV site for complications/infections. 5. Resident non-compliant of leaving the facility without an order dated [DATE]. The care plan interventions included frequently check for safety. A review of Resident 119 ' s Change in Condition (COC) Evaluation dated [DATE] timed at 10 AM, indicated that nurses observed Resident [119] with drug paraphernalia. The COC indicated Physician 1 ordered to discontinue Resident 119 ' s midline catheter and to discharge the resident home. The COC indicated the local law enforcement were notified and came to the facility to talk to Resident 119. A review of Resident 119 ' s Progress Notes dated [DATE] timed at 3:54 PM, indicated the resident was leaving for the day and refused for the midline catheter to be removed that day. At 9 PM, the Progress Note indicated that Resident 119 ' s PICC line was infiltrated (when fluid leaks out of the vein into surrounding soft tissue) and the resident continued to refuse for the PICC line to be removed with No reason given. A review of Resident 119 ' s Change in Condition (COC) Evaluation dated [DATE] timed at 10:16 AM, the COC indicated Resident 119 had behavioral symptoms. The COC indicated that the charge nurse heard Resident 119 on the phone stating he was on his way to the Bus Stop. Charge nurse reported to the Supervisor but Resident 119 already left. The COC indicated the facility ' s administrator called the resident on the phone. The COC indicated the physician was notified. The COC did not indicate any new orders ordered by the physician. A review of Resident 119 ' s Progress Notes dated [DATE] timed at 1:28 PM, indicated the resident had been gone for three hours after going out of the facility without a physician ' s order. The Progress Notes indicated Resident 119 returned to the facility at 1:35 PM. The Progress Notes did not indicate when Resident 119 ' s midline catheter was removed as ordered by Physician 1 on [DATE]. A review of Resident 119 ' s Progress Notes dated [DATE] timed at 12:06 PM, indicating the Social Services Designee [SSD] attempted to offer support but the resident refused and became verbally aggressive. On [DATE], timed at 2:19 PM, the SSD attempted to discuss resident ' s potential discharge and Resident 119 became verbally aggressive. The Progress Note indicated Resident 119 refused to talk about discharge plans. On [DATE] timed at 11:15 AM, the SSD note indicated another attempt to have a meeting with the resident, and Resident 119 requested to reschedule. A review of Resident 119 ' s Minimum Data Set (MDS, a care area assessment and screening tool) dated [DATE], indicated the resident had intact cognition (thought process) and able to independently make own decisions. The MDS indicated Resident 119 had verbal behavioral symptoms directed toward others such as threatening and screaming toward others. The MDS indicated Resident 119 uses the wheelchair independently and able to wheel self independently once seated in the wheelchair. The MDS indicated Resident 119 was independent with eating, personal hygiene and toilet hygiene. A review of Resident 119 ' s Change in Condition (COC) Evaluation dated [DATE] timed at 1:24 PM, the COC indicated that the wound doctor (Physician 2) recommended IV antibiotics (medicines that fight bacterial infections in people and animals) due to Resident 119 ' s recurrent lower leg cellulitis. The COC indicated that Physician 1 was made aware of Physician 2 ' s recommendation for IV antibiotics and agreed with the order. A review of Resident 119 ' s Late Entry Progress Notes dated [DATE] timed at 12:33 PM, indicated an interdisciplinary team (IDT - involves team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meeting attended by the SSD, Activity Director (AD), and the MDS Nurse (MDSN) with the resident to discuss discharge planning in two months. The IDT meeting indicated there were no other issues noted with Nursing and Activity. A review of Resident 119 ' s Progress Notes dated [DATE] timed at 1 PM, indicated the resident was seen leaving the facility premises around 2:40 PM, without a physician ' s order to go out on pass. The Progress Notes indicated Resident 119 had been educated several times on going out of facility premises without a physician ' s order. The Progress Notes indicated Awaiting return. The Progress Notes did not indicate a nursing assessment of Resident 119 for possible signs and symptoms of illegal drug use or drug abuse. A review of Resident 119 ' s Progress Notes dated [DATE] timed at 9:33 AM, indicated the resident could not be found in the facility and did not notify any facility staff before leaving the facility premises. The Progress Note indicated Resident 119 did not have an order to go out on pass. The Progress Note indicated the facility staff was waiting for Resident 119 ' s return. A review of Resident 119 ' s Progress Notes dated [DATE] timed at 10:16 AM, indicated Resident 119 was unresponsive and difficult to arouse. The Progress Note indicated Resident 119 was shivering and uncooperative and had a fast heart rate of 136 (a normal resting heart rate for adult ranges from 60 to 100 beats per minute). The Progress Note indicated Resident 119 was transferred to the general acute care hospital (GACH 2) via 911 emergency services. A review of Resident 119 ' s Progress Notes dated [DATE] timed at 10:22 AM, indicated the licensed nurses found syringes and different types of drugs, including pills and liquid substances in syringes, and other items such as lighters, pipes, container to burn the substances . in the resident ' s personal drawer. The Progress Notes indicated the local law enforcement was notified. A review of Resident 119 ' s Hospital Transfer Form dated [DATE] timed at 10:35 AM, indicated the resident was transferred to the acute hospital via 911 (emergency services). The Form indicated the reason for transfer was altered mental status. A review of Resident 119 ' s Progress Notes dated [DATE] timed at 10:54 AM, indicated local law enforcement arrived at the facility and informed the facility that some of the items found in the resident ' s possession was crystal methamphetamine, heroin (highly addictive and rapidly acting substance), and marijuana (contains active chemicals that cause drug-like effects all through the body, including the central nervous system), fentanyl (a narcotic (controlled) medication used to treat pain that is up to 50 times stronger than heroin and 100 times stronger than morphine (narcotic pain medication) pills. A review of Resident 119 ' s Progress Notes dated [DATE] timed at 12:21 PM, indicated an Interdisciplinary Note attended by the DON, Assistant DON, AD, ADM, and registered nurses. The IDT Note indicated a recount of Resident 119 ' s history of behavioral issues that included history of going out on pass without physician orders, the incident on [DATE] when the resident was found with drug paraphernalia in his room. The IDT Note indicated Resident 119 was not arrested by local law enforcement because the resident resides in a nursing home, for safety. The IDT note indicated that Resident 119 ' s friends and families visit the resident and privacy was provide during these visits. The IDT Note indicated Resident 119 out on pass order was reinstated on [DATE] and the resident went out on pass on [DATE], a day prior to Resident 119 ' s COC on [DATE]. The IDT Note indicated Resident 119 was not observed taking illicit drugs using the syringes while in the facility. The IDT Note indicated the IDT will reevaluate the resident once back in the facility. At 10:45 PM, the Progress Note indicated Resident 119 arrived back at the facility with no new orders. A review of GACH 2 ' s records titled Arrival dated [DATE] timed at 8:07 AM, with a chief complaint of altered level of consciousness indicated the resident arrived at GACH 2 with past medical history of extensive methamphetamine abuse with recurring cellulitis and getting IV antibiotics was found at the skilled nursing facility confused with a meth pipe (methamphetamine pipe- a crystal meth pipe is a small, handheld pipe that is used to smoke methamphetamine) next to his bed. The GACH 2 record indicated a diagnosis of acute methamphetamine intoxication and active drug abuse leading to the patient refusing to participate in his care. A review of the GACH 2 record titled Therapeutic Drug Monitoring dated [DATE] timed at 4:35 PM, that indicated Resident 119 ' s laboratory result as follows: -Cocaine (an addictive drug) [positive] -Opiates (a class of drugs that work to relieve pain) [positive] -Amphetamines (addictive, mood-altering drug, used illegally as a stimulant) [positive] -Fentanyl [positive] A review of Resident 119 ' s Change in Condition (COC) Evaluation documentation dated [DATE] timed at 1:56 PM, indicated that at around 2 AM, resident screaming for help and started vomiting (for three times), stated that he ' s having pain on his middle stomach. The COC indicated the resident had altered level of consciousness and refused to have his vital signs (blood pressure, pulse rate, temperature) taken. The COC indicated Resident 119 was transferred to GACH 1 via 911 emergency services. A review of Resident 119 ' s Hospital Transfer Form dated [DATE] timed at 3 AM, indicated the resident was transferred to GACH 1 via 911. The Form indicated the reason for transfer was stomach pain. A review of Resident 119 ' s Progress Notes dated [DATE] timed at 9:26 AM, indicated the resident returned to the facility from GACH 1. The Progress Note indicated that Physician 1 ordered to continue same prescribed medications. A review of Resident 119 ' s record titled Follow up Documentation dated [DATE] timed at 10:39 AM, indicated Resident 119 returned from GACH 1 Emergency Department (ED) for vomiting and abdominal pain. The follow up documentation indicated Resident 119 had a one-to-one sitter, when the sitter took his break. The follow up documentation indicated Resident 119 managed to wheel himself out of the facility and was seen outside the facility, by the ramp, headed towards the riverbank. A review of Resident 119 ' s handwritten sitter log dated [DATE] to [DATE], indicated that on [DATE] timed at 10:45 AM, Resident 119 managed to get out. A review of Resident 119 ' s Late Entry Progress Notes dated [DATE] timed at 2:42 PM, indicated the IDT met inside resident ' s room to discuss the resident ' s behavior, behavior contract, and non-compliance. The IDT meeting was attended by the ADM, SSD, MDSN, and Nursing. The IDT note indicated the following topics were discussed: placement, smoking, out on pass, and behavior contract to address current situation. A review of a facility document titled Behavioral Contract signed and dated [DATE], by the facility ' s interdisciplinary team (social services director, MDS coordinator, and three unknown facility representatives). The Behavioral Contract showed a contract indicating The IDT is proposing a behavioral contract with you to facilitate compliance with facility rules, care plan adherence, and/or to promote optimal health, safety, and well-being for yourself and others. The Behavioral Contract indicated Resident 119 ' s Specific Safety Issues Behavioral Problems were Follow smoking policy, out on pass order compliance with medication. The Behavioral Contract indicated The Specific Things the Resident Will Not Do Indicated Will not smoke outside of scheduled location times. A review of Resident 119 ' s Hospital Transfer Form dated [DATE] timed at 12:20 AM, indicated the resident was transferred to GACH 2 via 911 emergency services. The Form indicated the reason for transfer was Abnormal Vital Signs [low/high BP, high respiratory rate]. The Form indicated the resident ' s blood pressure was ,d+[DATE] and respiratory rate of 22. A review of the GACH 2 records titled History of Present Illness dated [DATE] timed at 12:31 AM, indicated Resident 119 arrived at the GACH 2 Emergency Department (ED) with a history of methamphetamine induced cardiomyopathy or cardiomyopathy secondary to intravenous (IV-through the vein) drug abuse, and severe sepsis .who presented with altered level of consciousness and hypotension (low blood pressure). A review of the GACH 2 record titled ER (emergency room ) Physician Inpatient Consult with service date [DATE] and electronically signed by the GACH 2 physician on [DATE] timed at 11:36 AM, indicated that a Code Blue was called, and cardiopulmonary resuscitation (CPR) was performed on Resident 119. The GACH 2 record indicated Resident 119 was pronounced dead on [DATE] at 8:09 AM. During an interview with the Social Services Director (SSD) on [DATE] at 12:15 PM, the SSD stated she just recently started her employment at the facility during her first encounter with Resident 119, and it was on [DATE]. The SSD stated she was informed by the previous SSD that Resident 119 leaves the facility multiple times because he liked going to the store. The SSD stated Resident 119 was non-compliant when he did not have an out on pass physician order. The SSD stated Resident 119 would go out of the facility at different times of the day. The SSD stated Resident 119 would sometimes inform and not inform facility staff when going out of the facility. The SSD stated the licensed nurses would normally address Resident 119 ' s behavior since the resident does not leave the facility when she (SSD) was present at the facility. On [DATE] at 12:28 PM, during a concurrent interview and record review of Resident 119 ' s Behavioral Contract dated [DATE], the SSD stated that on [DATE], a behavioral interdisciplinary team meeting was held to discuss the resident ' s behavior. The SSD stated there was no other behavior contracts developed with Resident 119 prior to [DATE]. The SSD stated Resident 119 signed the behavioral contract dated [DATE], which included following the smoking policy, compliance with medications, and discussion of an out on pass order. The SSD stated it did not indicate Resident 119 ' s issues with use of illicit drugs and paraphernalia. During a concurrent interview and record review of Resident 119 ' s non-compliance of leaving the facility without a physician's order care plans and progress notes from [DATE] to [DATE], on [DATE] at 1:06 PM, the Assistant Director of Nursing (ADON) stated Resident 119 went out of facility multiple times without notifying facility staff. The ADON stated the care plans developed for non-compliance of leaving the facility ([DATE], [DATE], [DATE]) indicated that Resident 119 have been reminded of the importance of following physician orders, educated on facility protocol and offered assistance. The ADON stated there was no other evidence found that additional interventions were developed to address the resident ' s continued non-compliance with going out of the facility, according to the facility policy and care plans. During an interview on [DATE] at 1:30 PM, Licensed Vocational Nurse (LVN) 1 stated Resident 119 was able to propel himself independently on the wheelchair. LVN 1 stated Resident 119 had a peripheral (a thin plastic tube inserted into a vein using a needle) IV line and PICC line due to cellulitis and was receiving antibiotic medications. LVN 1 stated Resident 119 would get upset about not going out on pass and would refuse the antibiotics. LVN 1 stated Resident 119 ' s personal belongings were not checked by facility staff routinely. LVN 1 stated that even when Resident 119 was on monitoring, there were times Resident 119 would leave the facility without a physician ' s order. LVN 1 stated that facility staff should know Resident 119's whereabouts and should have monitored the resident ' s activities every shift. During a concurrent interview and record review of Resident 119 ' s Follow up Documentation for [DATE] on [DATE] at 3:56 PM, the ADON stated the follow up documentation dated [DATE] timed at 10:39 AM, indicated Resident 119 was supposed to have a one to one supervision (sitter) but when the sitter took his break, Resident 119 managed to wheel himself out of the facility and was seen outside the facility, by the ramp headed towards the riverbank. The ADON stated monitoring for one-to-one supervision of the sitter is documented on paper. The ADON stated the one-to one sitter monitoring log indicated what the resident was doing during that time, if the resident was in his room or going out of his room. The ADON stated the one-to one sitter log is kept at the Nurse ' s Station. On [DATE] at 4:02 PM, during a concurrent interview and record review of Resident 119 ' s care plans from [DATE] to [DATE], the ADON stated there was no documented evidence that the facility had developed a care plan when Resident 119 required a one-to-one supervision (sitter). During a concurrent interview and record review of Resident 119 ' s progress notes, COCs and medication administration records on [DATE] at 7:32 PM, the ADON stated there was no documented evidence when the licensed nurses removed the midline central catheter as ordered by Physician 1 on [DATE]. The ADON could not find documented evidence of monitoring and care for the midline central catheter when Resident 119 leaves the facility. During an interview with the Director of Nursing (DON) on [DATE] at 3:22 PM, the DON stated if the resident is not compliant with physician orders for going out on pass or continued use of illicit drugs and keeps refusing care, there should be an IDT meeting conducted to explain the risks and benefits to Resident 119, and involved the physician. The DON stated there should be a revised care plan if the resident continued not to comply with physician orders for going out on pass. The DON stated that because Resident 119 had a PICC/IV line, it was for the safety of the resident for him not to have out on pass. The DON stated Resident 119 wanted to go out on pass all the time but during the Behavioral IDT Resident 119 promised he would not leave the facility anymore and signed a behavioral contract on [DATE]. The DON stated Resident 119 would have benefited with a one-to-one sitter earlier when the resident was first admitted to the facility on [DATE]. A review of a facility document titled Midline [a long, flexible tube inserted into a large vein to administer a medication directly into the bloodstream] Insertion Record dated [DATE], indicated another central catheter insertion was performed on Resident 119 ' s left upper arm, for intravenous antibiotic infusion due to cellulitis (a serious bacterial skin infection). A review of the facility ' s policy and procedure titled Out on Pass revised on [DATE], indicated that if at any time the licensed nursing staff believe the resident ' s use of the out on pass order conflicts with the resident ' s plan of care or jeopardizes the resident ' s health or safety, the nursing staff will hold the out on pass order until the attending physician or psychiatrist are notified. The policy indicated Depending on circumstance, and the attending physician or psychiatrist evaluation, the resident may need to be discharged to a more appropriate level of care. The policy indicated the licensed nurse would assess the resident prior to leaving out on pass and reassess the resident to determine the resident ' s condition .after going out on pass. A review of the facility ' s policy and procedure titled Behavioral Management, dated [DATE], indicated a resident who is exhibiting behavioral symptoms including history or current diagnosis of substance abuse will be individually evaluated to determine the behavior. The policy indicated that behaviors and interventions of residents will be addressed in the care plan. The policy indicated that the facility would monitor residents who exhibit behavioral symptoms which included examples like socially/inappropriate/disruptive and drug seeking behaviors .The policy indicated the facility will implement the following: (1) social services evaluation will be completed on admi [TRUNCATED]

Based on interview and record review, the facility failed to address, obtain necessary services (drug counseling and surveillance) and develop person centered care plans for the behavioral healthcare needs of one of two sampled residents (Resident 119) diagnosed with polysubstance abuse ([Drug Abuse] when an individual develops the habit of using multiple substances and becomes dependent on them), in accordance with the facility ' s policy and procedure titled Behavioral Management, by failing to: 1. Develop and implement behavior health care plans upon admission to the facility on [DATE] to meet the needs of Resident 119 for the diagnoses of polysubstance abuse and drug abuse counseling and surveillance of drug abuser. 2. Attempt to perform voluntary inspections when facility staff had reasonable suspicion of possession of illicit drugs and refer to local law enforcement. 3. Develop individualized interventions when Resident 119 was found with illicit ([street drugs] refers to the use and misuse of illegal and controlled drugs) drugs and paraphernalia (any collection of articles used for illicit drug activity) in the resident's room and personal belongings. On [DATE] and [DATE], a combination of multiple syringes, pipes, lighters, crystal methamphetamine, heroin (highly addictive and rapidly acting substance), and marijuana (contains active chemicals that cause drug-like effects all through the body, including the central nervous system), and fentanyl (a narcotic [controlled] medication used to treat pain that is up to 50 times stronger than heroin and 100 times stronger than morphine (narcotic pain medication) pills. 4. Ensure facility staff which included licensed nurses, had knowledge of the signs/symptoms and triggers of residents with possible illicit drug abuse which included changes in behavior, lack of coordination, unexplained drowsiness, mood changes and slurred speech. As a result, on [DATE], Resident 119 was found unresponsive in his room and on the same day, was transferred to the general acute care hospital (GACH 2) via 911 emergency services. Resident 119 was readmitted back to the facility, the same day, on [DATE] with diagnoses that included acute methamphetamine (a powerful highly addictive stimulant) intoxication (the condition of having lost some control of one ' s actions or behavior under the influence of a drug) and abuse. On [DATE] at 12:20 AM, Resident 119 was transferred back to GACH 2 via 911 emergency services for low blood pressure and low oxygen saturation (amount of oxygen circulating in the blood) (58%). Resident 119 was pronounced dead on [DATE] at 8:09 AM for worsening respiratory distress (a condition that causes fluid to build up in a person ' s lungs so oxygen cannot get to the organs) with a history of cardiomyopathy (disease of the heart muscle) endocarditis (bacteria or other germs get into the bloodstream and attach to damaged areas in the heart) due to intravenous (IV - through the vein) drug abuse. Resident 119 ' s final diagnoses included acute septic shock (a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection) due to acute endocarditis. On [DATE] at 7:53 PM, during the facility ' s Annual Recertification Survey in the presence of the Administrator (ADM) and Director of Nursing (DON), an Immediate Jeopardy (IJ, a situation in which the facility ' s noncompliance with one of more requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to a resident) was identified regarding the facility ' s failure to address and implement interventions for a resident with history of polysubstance abuse and was found with illicit drugs and paraphernalia in his room while residing in the facility. On [DATE] at 4:35 PM, the IJ was removed after the surveyor verified and confirmed the facility implemented the facility ' s IJ Removal Plan (a detailed plan to address the IJ findings) while onsite by observation, interview, and record review. The IJ was removed in the presence of the ADM and the DON. The acceptable IJ Removal Plan included the following: The Social Services Director (SSD) performed an audit on [DATE] to identify residents that has a history of substance abuse, behavioral issues and had the potential to leave the facility without notification and had the potential to obtain illicit drugs. The DON initiated an in-service to licensed staff on identifying signs and symptoms and triggers with possible illegal drug abuse such as changes in behavior, lack of coordination, unexplained drowsiness, mood changes and slurred speech (a symptom characterized by the poor pronunciation of words, mumbling, or a change in speed or rhythm) with emphasis on the importance of initiating person-centered care plan including proper referral for psychiatric and psychological consultation. On [DATE], the DON initiated an in-service to the facility staff on the out on pass policy. An out-on-pass binder will be available at each station. The licensed nurse will complete the out on pass log. The receptionist will have a list of residents with current out on pass order and will verify with the charge nurse if the order is current. The Health Information Management/Designee will print a list of residents with an out-on-pass order daily (Monday to Friday) and will distribute list to the station and receptionist. The licensed nurse will endorse residents that are out on pass and expected to come back to the incoming shift. Upon return from out on pass, the licensed nurses will perform a voluntary inspection for residents with a history of drug abuse. If the facility suspects signs and symptoms of possible illegal substance use, and if the resident refuses to be inspected, the physician will be notified, and the suspected resident will be referred to the local law enforcement. Upon admission, the Interdisciplinary Team (IDT) will conduct a post admission conference with resident ' s/responsible party to discuss resident plan of care including out on pass policy and prohibition of illegal substances in the facility. A behavior contract will be discussed with resident having a diagnosis of substance abuse. A verbal consent will be obtained and documented to inspect the resident and his/her belongings for illegal substance. Any illegal substance in plain view will be confiscated and/or referred to local enforcement. Residents will be monitored for signs and symptoms of substance abuse. The IDT will discuss with the resident/responsible party for discharge plan for rehabilitation during the post admission conference. The IDT will continuously meet with the resident/responsible party if there are barriers in discharge planning. On [DATE], the facility will initiate collaboration with the Committee for Policies and Procedures to develop policy and procedures for resident with diagnosis of substance abuse based on State and Federal Guidelines. On [DATE], the Facility Assessment will be reviewed and revised to reflect the capability of the facility to admit residents with history with substance abuse. Any resident identified to have an intravenous line and is at high risk to self-administer illegal drugs will be reported to the physician for further recommendations. Residents with diagnosis of substance abuse will be referred to Psychology (the scientific study of the mind and behavior) and Psychiatry (a branch of medicine focused on diagnosing and treating mental health disorders). The DON/Designee will include education on new hires during onboarding, upon return from leave of absence/vacation prior to the beginning of their shift. Findings: A review of Resident 119's GACH 1 Consultation Note dated [DATE] timed at 7:03 PM, indicated the resident was admitted to GACH 1 with history of intravenous (IV) substance abuse developed the endocarditis and congestive heart failure (a condition that develops when your heart does not pump enough blood for your body's needs). A review of Resident 119 ' s GACH 1 record titled Progress Note dated [DATE] timed at 8:40 AM, indicated under Internal Medicine documented Resident 119 with medical history including drug abuse presented in the GACH 1 after having syncopal episode (pass out) due to resident may have aspirated and started vomiting. The GACH 1 Note indicated Resident 119 present in the GACH after passing out after using drugs in the street. The GACH 1 Note indicated Resident 119 acknowledges drug use. The GACH 1 Note indicated a primary diagnosis of syncope after drug use. A review of Resident 119 ' s Admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included congestive heart failure and drug abuse counseling and surveillance of drug abuser. A review of Resident 119 ' s History and Physical (H&P) dated [DATE], indicated the resident had the capacity to understand and make decisions. The H&P indicated a handwritten history from Physician 1 that indicated Resident 119's present illness and pertinent past history which included syncopal (fainting) episode, possible pending street drugs test. The H&P indicated under Diagnoses included polysubstance abuse ([Drug Abuse] when an individual develops the habit of using multiple substances and becomes dependent on them). A review of Resident 119's Change in Condition (COC) Evaluation dated [DATE] timed at 10:56 PM, indicated Resident 119 had new/worsened delusions (false belief or judgment of reality) or hallucinations (perception of having seen, heard, touched, tasted, or smelled something that wasn't actually there). The COC indicated the licensed nurses had observed Resident 119 mumbling and talking to himself many times and it was unusual. The COC indicated the physician (Physician 1) was notified and ordered blood tests and transfer to the acute hospital. The COC indicated Resident 119 refused blood tests, urine test, and refused to be transferred to the acute hospital. A review of Resident 119 ' s Progress Notes dated [DATE] timed at 2:07 PM and 2:54 PM, indicated the licensed nurse informed Physician 1 of the resident ' s continued to have inappropriate behavior, talking to himself, yelling for no reason and continued to refuse for blood tests and urine test ordered. A review of Resident 119 ' s Change in Condition (COC) Evaluation dated [DATE] timed at 2:57 PM, indicated Resident 119 had a change in behavioral symptoms. The COC indicated Resident 119 was yelling and talking to himself. The COC indicated the physician was notified. The COC did not indicate any new physician orders. A review of Resident 119 ' s Change in Condition (COC) Evaluation dated [DATE] timed at 10 AM, indicated that nurses observed Resident [119] with drug paraphernalia. The COC indicated the local law enforcement were notified and came to the facility to talk to Resident 119. A review of Resident 119 ' s Change in Condition (COC) Evaluation dated [DATE] timed at 10:16 AM, the COC indicated Resident 119 had behavioral symptoms. The COC indicated that the charge nurse heard Resident 119 on the phone stating he was on his way to the Bus Stop. Charge nurse reported to the Supervisor but Resident 119 already left. The COC indicated the facility ' s administrator called the resident on the phone. The COC indicated the physician was notified. The COC did not indicate any new orders ordered by the physician. A review of Resident 119 ' s Progress Notes dated [DATE] timed at 1:28 PM, indicated the resident had been gone for three hours after going out of the facility without a physician ' s order. The Progress Notes indicated Resident 119 returned to the facility at 1:35 PM. A review of Resident 119 ' s Progress Notes dated [DATE] timed at 12:06 PM, indicating the Social Services Designee [SSD] attempted to offer support but the resident refused and became verbally aggressive. On [DATE], timed at 2:19 PM, the SSD attempted to discuss resident ' s potential discharge and Resident 119 became verbally aggressive. The Progress Note indicated Resident 119 refused to talk about discharge plans. On [DATE] timed at 11:15 AM, the SSD note indicated another attempt to have a meeting with the resident, and Resident 119 requested to reschedule. A review of Resident 119 ' s Minimum Data Set (MDS, a care area assessment and screening tool) dated [DATE], indicated the resident had intact cognition (thought process) and able to independently make own decisions. The MDS indicated Resident 119 had verbal behavioral symptoms directed toward others such as threatening and screaming toward others. The MDS indicated Resident 119 uses the wheelchair independently and able to wheel self independently once seated in the wheelchair. The MDS indicated Resident 119 was independent with eating, personal hygiene and toilet hygiene. A review of Resident 119 ' s Change in Condition (COC) Evaluation dated [DATE] timed at 1:24 PM, the COC indicated that the wound doctor (Physician 2) recommended IV antibiotics (medicines that fight bacterial infections in people and animals) due to Resident 119 ' s recurrent lower leg cellulitis. The COC indicated that Physician 1 was made aware of Physician 2 ' s recommendation for IV antibiotics and agreed with the order. A review of Resident 119 ' s Late Entry Progress Notes dated [DATE] timed at 12:33 PM, indicated an interdisciplinary team (IDT - involves team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meeting attended by the SSD, Activity Director (AD), and the MDS Nurse (MDSN) with the resident to discuss discharge planning in two months. The IDT meeting indicated there were no other issues noted with Nursing and Activity. A review of Resident 119 ' s Progress Notes dated [DATE] timed at 1 PM, indicated the resident was seen leaving the facility premises around 2:40 PM, without a physician ' s order to go out on pass. The Progress Notes indicated Resident 119 had been educated several times on going out of facility premises without a physician ' s order. The Progress Notes indicated Awaiting return. The Progress Notes did not indicate a nursing assessment of Resident 119 for possible signs and symptoms of illegal drug use or drug abuse. A review of Resident 119 ' s Progress Notes dated [DATE] timed at 9:33 AM, indicated the resident could not be found in the facility and did not notify any facility staff before leaving the facility premises. The Progress Note indicated Resident 119 did not have an order to go out on pass. The Progress Note indicated the facility staff was waiting for Resident 119 ' s return. A review of Resident 119 ' s Progress Notes dated [DATE] timed at 7:35 AM, indicated the resident was found on the floor screaming. The Progress Notes indicated Resident 119 was assisted back to bed. A review of Resident 119 ' s Progress Notes dated [DATE] timed at 10:16 AM, indicated Resident 119 was unresponsive and difficult to arouse. The Progress Note indicated Resident 119 was shivering and uncooperative and had a fast heart rate of 136 (a normal resting heart rate for adult ranges from 60 to 100 beats per minute). The Progress Note indicated Resident 119 was transferred to the general acute care hospital (GACH 2) via 911 emergency services. A review of Resident 119 ' s Progress Notes dated [DATE] timed at 10:22 AM, indicated the licensed nurses found syringes and different types of drugs, including pills and liquid substances in syringes, and other items such as lighters, pipes, container to burn the substances . in the resident ' s personal drawer. The Progress Notes indicated the local law enforcement was notified. A review of Resident 119 ' s Hospital Transfer Form dated [DATE] timed at 10:35 AM, indicated the resident was transferred to the acute hospital via 911 (emergency services). The Form indicated the reason for transfer was altered mental status. A review of Resident 119 ' s Progress Notes dated [DATE] timed at 10:54 AM, indicated local law enforcement arrived at the facility and informed the facility that some of the items found in the resident ' s possession was crystal methamphetamine, heroin (highly addictive and rapidly acting substance), and marijuana (contains active chemicals that cause drug-like effects all through the body, including the central nervous system), fentanyl (a narcotic (controlled) medication used to treat pain that is up to 50 times stronger than heroin and 100 times stronger than morphine (narcotic pain medication) pills. A review of Resident 119 ' s Progress Notes dated [DATE] timed at 12:21 PM, indicated an Interdisciplinary Note attended by the DON, ADON, AD, ADM, and registered nurses. The IDT Note indicated a recount of Resident 119 ' s history of behavioral issues that included history of going out on pass without physician orders, the incident on [DATE] when the resident was found with drug paraphernalia in his room. The IDT Note indicated Resident 119 was not arrested by local law enforcement because the resident resides in a nursing home, for safety. The IDT note indicated that Resident 119 ' s friends and families visit the resident and privacy was provide during these visits. The IDT Note indicated Resident 119 out on pass order was reinstated on [DATE] and the resident went out on pass on [DATE], a day prior to Resident 119 ' s COC on [DATE]. The IDT Note indicated Resident 119 was not observed taking illicit drugs using the syringes while in the facility. The IDT Note indicated the IDT will reevaluate the resident once back in the facility. At 10:45 PM, the Progress Note indicated Resident 119 arrived back at the facility with no new orders. A review of GACH 2 ' s records titled Arrival dated [DATE] timed at 8:07 AM, with a chief complaint of altered level of consciousness indicated the resident arrived at GACH 2 with past medical history of extensive methamphetamine abuse with recurring cellulitis and getting IV antibiotics was found at the skilled nursing facility confused with a meth pipe (methamphetamine pipe- a crystal meth pipe is a small, handheld pipe that is used to smoke methamphetamine) next to his bed. The GACH 2 record indicated a diagnosis of acute methamphetamine intoxication and active drug abuse leading to the patient refusing to participate in his care. A review of the GACH 2 record titled Therapeutic Drug Monitoring dated [DATE] timed at 4:35 PM, that indicated Resident 119 ' s laboratory result as follows: -Cocaine (an addictive drug) [positive] -Opiates (a class of drugs that work to relieve pain) [positive] -Amphetamines (addictive, mood-altering drug, used illegally as a stimulant) [positive] -Fentanyl [positive] A review of Resident 119 ' s Change in Condition (COC) Evaluation documentation dated [DATE] timed at 1:56 PM, indicated that at around 2 AM, resident screaming for help and started vomiting (for three times), stated that he ' s having pain on his middle stomach. The COC indicated the resident had altered level of consciousness and refused to have his vital signs (blood pressure, pulse rate, temperature) taken. The COC indicated Resident 119 was transferred to GACH 3 via 911 emergency services. A review of Resident 119 ' s Hospital Transfer Form dated [DATE] timed at 3 AM, indicated the resident was transferred to GACH 3 via 911. The Form indicated the reason for transfer was stomach pain. A review of Resident 119 ' s Progress Notes dated [DATE] timed at 9:26 AM, indicated the resident returned to the facility from GACH 3. The Progress Note indicated that Physician 1 ordered to continue same prescribed medications. A review of Resident 119 ' s Late Entry Progress Notes dated [DATE] timed at 2:42 PM, indicated the IDT met inside resident ' s room to discuss the resident ' s behavior, behavior contract, and non-compliance. The IDT meeting was attended by the ADM, SSD, MDSN, and Nursing. The IDT note indicated the following topics were discussed: placement, smoking, out on pass, and behavior contract to address current situation. A review of a facility document titled Behavioral Contract signed and dated [DATE], by the facility ' s interdisciplinary team (social services director, MDS coordinator, and three unknown facility representatives). The Behavioral Contract showed a contract indicating The IDT is proposing a behavioral contract with you to facilitate compliance with facility rules, care plan adherence, and/or to promote optimal health, safety, and well-being for yourself and others. The Behavioral Contract indicated Resident 119 ' s Specific Safety Issues Behavioral Problems were Follow smoking policy, out on pass order compliance with medication. The Behavioral Contract indicated the specific things the resident will not do indicated Will not smoke outside of scheduled location times. A review of Resident 119 ' s Hospital Transfer Form dated [DATE] timed at 12:20 AM, indicated the resident was transferred to GACH 2 via 911 emergency services. The Form indicated the reason for transfer was Abnormal Vital Signs [low/high BP, high respiratory rate]. The Form indicated the resident ' s blood pressure was ,d+[DATE] and respiratory rate of 22. A review of the GACH 2 records titled History of Present Illness dated [DATE] timed at 12:31 AM, indicated Resident 119 arrived at the GACH 2 Emergency Department (ED) with a history of methamphetamine induced cardiomyopathy or cardiomyopathy seconday to IV drug abuse, and severe sepsis .who presented with altered level of consciousness and hypotension (low blood pressure). A review of the GACH 2 record titled ER (emergency room ) Physician Inpatient Consult with service date [DATE] and electronically signed by the GACH 2 physician on [DATE] timed at 11:36 AM, indicated that a Code Blue was called, and cardiopulmonary resuscitation (CPR) was performed on Resident 119. The GACH 2 record indicated Resident 119 was pronounced dead on [DATE] at 8:09 AM. During an interview with the Social Services Director (SSD) on [DATE] at 12:15 PM, the SSD stated Resident 119 was consistently verbally aggressive with facility staff and family. The SSD stated Resident 119 wheels himself around the facility in his wheelchair, screaming profanity. The SSD stated Resident 119 consistently threw everyone out of his room. The SSD stated on [DATE], when Resident 119 was transferred to GACH 2, the SSD was at bedside while local law enforcement confiscated the illicit drugs and paraphernalia found in Resident 119 ' s room. The SSD stated when Resident 119 returned from GACH 2, she had a one-to-one visit and started 72-hour monitoring with Resident 119. The SSD stated that on [DATE], she told Resident 119 he could be referred to psychosocial services if and as needed. The SSD stated Resident 119 denied the referral to psychosocial services, so she offered psychosocial support. On [DATE] at 12:28 PM, during a concurrent interview and record review of Resident 119 ' s Behavioral Contract dated [DATE], the SSD stated that on [DATE], a behavioral interdisciplinary team meeting was held to discuss the resident ' s behavior. The SSD stated there was no other behavior contracts developed with Resident 119 prior to [DATE]. The SSD stated Resident 119 signed the behavioral contract dated [DATE], which included following the smoking policy, compliance with medications, and discussion of an out on pass order. The SSD stated it did not indicate Resident 119 ' s issues with use of illicit drugs and paraphernalia. During an interview on [DATE] at 1:30 PM, Licensed Vocational Nurse (LVN) 1 stated in the morning of [DATE], LVN 1 was conducting room rounds and she saw Resident 119 in bed lying in bed, unresponsive. LVN 1 stated Resident 119 was lethargic (sluggish or drowsy) and could not make simple sentences. LVN 1 stated Resident 119 did not make sense of what he was saying. LVN 1 stated Resident 119 refused for facility staff to take his vital signs. LVN 1 stated when the Paramedics arrived they took vital signs. LVN 1 stated at the that time resident was not able to state his name, he was pale, shivering and lethargic, very out of himself. During the same interview, on [DATE] at 1:30 PM, LVN 1 stated the paramedics found a pipe (meth pipe) hidden on the right side of Resident 119 ' s bed. LVN 1 stated there was a lot of drugs and paraphernalia found in Resident 119 ' s bedside drawer. LVN 1 stated there were two pipes, one unknown drug in a tube, one white powder in a ziplock bag, one aerosol spray can, a couple of matches, five or more syringes containing some type of unknown solution inside, and multiple burned soda can bottom. LVN 1 stated the police confiscated the drugs and paraphernalia. LVN 1 stated she worked the next day on [DATE] and saw resident he was more awake and alert to name and place, however he was still out of it, it looked like resident was going through withdrawals (a term used to describe the physical and mental symptoms that a person has when they suddenly stop or cut back the use of an addictive substance). During a concurrent interview and record review of Resident 119 ' s care plans on [DATE] at 3:08 PM, the Assistant Director of Nursing (ADON) could not find documented evidence of a behavioral care plans or care plan developed for Resident 119 ' s diagnosis of drug abuse, including drug abuse counseling and surveillance of drug abuser. The ADON stated that the licensed nurse who admitted Resident 119 should include in the care plan the resident ' s medications and diagnoses. The ADON stated for a diagnosis of drug abuse, interventions that could be implemented are monitoring through the change of condition, surveillance monitoring of the resident, and follow ups with social services and the case manager. During a concurrent interview and record review of Resident 119 ' s IDT notes from admitted [DATE] to [DATE], on [DATE] at 3:20 PM, the ADON stated Resident 119 ' s IDT notes did not specify or discuss Resident 119 ' s diagnosis of polysubstance abuse and drug abuse counseling and surveillance. The ADON stated there was no documented evidence of an IDT meeting or conference performed for Resident 119 ' s ongoing issues specific to resident's drug counseling and surveillance. During a concurrent interview and record review of Resident 119 ' s nursing progress notes from ,d+[DATE] to ,d+[DATE], on [DATE] at 4:05 PM, the ADON stated she could not find documented evidence of what exactly happened with Resident 119 on [DATE], when drug paraphernalia was found in Resident 119 ' s room but the police spoke with Resident 119. The ADON stated there should have been a facility IDT meeting/conference to create a comprehensive care plan specific to Resident 119 ' s problem of bringing illicit drugs and paraphernalia to the facility. The ADON stated there should have been a care plan created to address the issue and create goals and interventions to prevent Resident 119 ' s continued drug abuse. During a concurrent interview and record review of Resident 119 ' s progress notes, COCs and medication administration records on [DATE] at 7:32 PM, the ADON could not find documented evidence when the licensed nurses was able to remove the midline central catheter as as ordered by Physician 1 on [DATE]. During another interview with the SSD on [DATE] at 2:58 PM, the SSD stated that if the resident had the polysubstance abuse noted in the social services assessment, the social services team would inform staff/nursing to ask Resident 119 if he wants to be referred for psychiatry and psychology consults. The SSD stated residents social services assessments gets reviewed every 3 months or as needed for significant change. The SSD stated a reassessment was done for Resident 119 on [DATE] (quarterly review) but did not indicate any issues about polysubstance abuse. SSD stated when Resident 119 came back after [DATE], resident was in and out of the GACH. The SSD stated the goal for Resident 119 should be to prevent drug overdose. The SSD stated that the facility ' s social services team attempted discharge planning with Resident 119, but the resident rescheduled the IDT meeting. The SSD stated during the IDT they would have presented to the Resident 119 the risks and benefits of staying at facility, versus being at facility more fit for him with counseling, and positive reinforcement for him. During an interview with the DON on [DATE] at 3:05 PM, the DON stated if a resident was admitted with a diagnosis or history of drug abuse, the facility should make sure the resident was seen by psychiatry and psychology. The DON stated monitoring should be mentioned at the initial IDT meeting. The DON stated the IDT should ask the resident when was the last time you used drugs? The DON stated they would remind resident that they are a drug free facility and must follow federal guidelines. The DON stated this was something that should have been discussed during initial IDT for Resident 119. The DON stated this information were not discussed with Resident 119. The DON stated discharge planning was started for Resident 119 to have lower level of care so he would have more independence. The DON stated we are not an institution and the facility will follow the recommendation of the physician. The DON stated as for the safety of other residents, it can pose a risk to other residents, on that aspect if there was a psych unit or if there was any suspicion that Resident 119 was using drugs, we could do urine or blood test and call police to make sure he was not a threat in the facility. During a concurrent interview and record review on Resident 119 ' s progress notes on [DATE] at 1:33 PM, the DON stated on [DATE], when drug paraphernalia was first found in Resident 119 ' s room, prompted the IDT to talk to the resident about behavior management. The DON stated she could not recall if a facility investigation was completed for [DATE]. The DON stated there was no documented evidence of a progress note or IDT narrative about what happened and interventions implemented on [DATE] when drug paraphernalia was first found in Resident 119 ' s room. The DON stated there were no other details documented in Resident 119 ' s progress notes on [DATE]. The DON stated she does not know if there was a facility policy specific to behavior management for residents with history of drug abuse. A review of the facility ' s policy and procedure titled Behavioral Management, dated [DATE] indicated a resident who is exhibiting behavioral symptoms including history or current diagnosis of substance abuse will be individually evaluated to determine the behavior. The policy indicated the facility will implement the following: (1) social services evaluation will be completed on admission/readmission quarterly and as needed to include mental health screening and substance abuse, (2) develop person centered plan of care, (3) implement non-pharmacalogic interventions, (4) refer to mental health services including substance abuse specialist treatment and/or substance abuse counseling if necessary. A review of the facility ' s policy and procedure titled Out on Pass revised on [DATE], indicated the licensed nurse would assess the resident prior to leaving out on pass and reassess the resident to determine the resident ' s condition .after going out on pass.

Based on observation, interview, and record review, the facility failed to provide pain management to one of two sampled residents receiving morphine sulfate (a drug used to treat moderate to severe pain) oral tablet 15 milligrams (a unit of measurement) to (Resident 121) by failing to: 1. Administer Resident 121's morphine sulfate as ordered by Resident 121's Pain Management Physician (PMP 1) on 3/21/24,3/22/2024,3/23/2024 and 3/24/2024. As a result of this deficient practice, Resident 121 verbalized suffering from excruciating pain (pain score of 10 on a scale of 0 to 10 where 0 is no pain and 10 is the worst pain possible) between 3/21/24, 3/22/24,3/23/24 and 3/24/24 that could have resulted in a decline in their mental, and psychosocial well-being. Findings: A review of Resident 121's Admission Record indicated the resident was initially admitted to the facility on [DATE] and then readmitted on [DATE] with diagnoses that included acute systolic heart failure(a condition that occurs when the left ventricle cannot pump blood effectively), lumbar spina bifida(a condition that occurs when the spine and spinal cord don't form properly) with hydrocephalus(a buildup of fluid in the brain). A review of Resident 121's Minimum Data Set (MDS - a comprehensive resident assessment tool) dated 2/13/24, indicated he the resident had a Brief Interview for Mental Status (BIMS - a 15-point cognitive screening measure that evaluates memory and orientation) score of 15 (cognitively intact.) A review of Resident 121's Order listing Report (a monthly summary of all active physician orders) for March 2024, indicated the following active orders for pain medications: Morphine Sulfate oral tablet 15 milligrams (a unit of measurement), give 1 tablet by mouth every 12 hours for severe pain (8-10) hold if systolic blood pressure is less than 110 or heart rate less than 65 with a start date of 3/21/2024. A review of the facility's Medication Administration Record (MAR) Chat Codes for 3/1/2024 to 3/31/2024 included the following MAR code descriptions: ZZ= In progress NN= No/ See nurses notes A review of Resident 121's Medication Administration Record, dated March 2024, indicated the following: a. On 3/21/2024 scheduled at 9:00 AM - with the initials of licensed vocational nurse (LVN 1, indicated Resident 121's Morphine Sulfate with the code ZZ(in progress). b. On 3/21/2024 scheduled at 9:00 PM - with the initials of LVN 10, indicated Resident 121's Morphine Sulfate with the code ZZ (in progress). c. On 3/22/2024 scheduled at 9:00 AM - with the initials of LVN 11, indicated Resident 121's Morphine Sulfate with the code ZZ (in progress). d. On 3/22/2024 scheduled at 9:00 PM - with the initials of LVN 10, indicated Resident 121's Morphine Sulfate with the code ZZ (in progress). e. On 3/23/2024 scheduled at 9:00 AM - with the initials of registered nurse (RN 5), indicated Resident 121's Morphine Sulfate with the code NN (No/see nurses notes). f. On 3/23/2024 scheduled at 9:00 PM - with the initials of LVN 10, indicated Resident 121's Morphine Sulfate with the code ZZ (in progress). g. On 3/24/2024 scheduled at 9:00 AM - with the initials of RN 1, indicated Resident 121's Morphine Sulfate with the code ZZ (in progress). h. On 3/24/2024 scheduled at 9:00 PM - with the initials of RN 1, indicated Resident 121's Morphine Sulfate with the code ZZ (in progress). During an interview with Resident 121 on 3/26/2024 at 11:49 AM, Resident 121 stated she had an inoperable hip fracture and suffers from excruciating pain and was unable to sleep for 3 to 4 days because she did not receive her scheduled pain medication. Resident 121 stated the facility's nurses had not administered her scheduled Morphine sulfate even when she would tell staff she was in excruciating pain. Resident 121 stated facility nurses would tell her the pharmacy would not supply the medication (Morphine sulfate) until PM 1 had signed off for the medication. Resident 121 stated she did not understand why facility staff were not contacting PM1 or MD 1 to sign off on her prescribed routine pain medication. During a concurrent interview and record review on 3/26/2024 at 11:05 AM with Registered Nurse (RN 4), Resident 121's March MAR and nursing notes were reviewed. RN 4 stated the zz on Resident 121's MAR indicated Resident 121's medication (morphine sulfate) was 'in progress,' which indicated that the medication was on hold. RN4 stated Resident 121 could not receive the administration of the medication until a physician signed off on the medication, as required from the facility's pharmacy. RN 4 stated when Resident 121 was admitted with a new standing order of a controlled pain medication the nurses should immediately contact Resident 121's PMP 1, so that the PMP1 could sign off on the medication order and have the facility's pharmacy fill the medication order timely. Resident 121's nursing notes did not indicate any attempts of notification to Resident 121's PMP1 to sign off on Resident 121's scheduled Morphine Sulfate. During an interview on 3/27/2024 at 5:07 PM with MD 1, MD 1 stated he was the facilities Medical Director and Resident 121's primary physician. MD 1 stated he was only contacted once on 3/22/2024 regarding Resident 121's pain medication, Morphine Sulfate. MD 1 stated the facility nurse notified MD1 regarding Resident 121's severe pain. MD 1 stated signing off on a one-time emergency dose of Resident 121's prescribed Morphine Sulfate and instructed the facility nurse to contact Resident 121's PMP1 so that Resident 121's order for morphine sulfate could be signed off and ready for administration per physician orders. MD 1 stated Resident 121 had an inoperable hip fracture along with other health conditions that caused Resident 121 to suffer from a lot of pain. During an interview on 3/28/2023 at 1:32 PM with Assistant Director of Nursing (ADON 1), ADON 1 stated facility Nurses should have documented attempts to contact Resident 121's PM1 and if Resident121's PM1 was unreachable, Nurses should have contacted MD 1 and notified him regarding Resident 121's morphine sulfate medication that was on hold, and not available for ordered administration to Resident 121 for severe pain. A review of the facility's policy and procedure (P&P), titled, Pain Assessment and Management, revised 3/2020, indicated the purpose of the P&P was to help staff identify pain in the resident and to develop interventions that were consistent with the residents' goals and needs and that address the underlying cause of pain. The P&P indicated pain management was defined as the process of alleviating the residents pain based on his or her clinical condition and established treatment goals. The P&P indicated pharmacological interventions may be prescribed to manage pain. The P&P indicated the physician and staff would establish a treatment regimen based on current medication regimen and implementing the medication regimen as ordered. The P&P indicated to report the following to the physician or practitioner significant changes in the level of resident pain.

Based on observation, interview and record review the facility failed to ensure that facility staff implement the facility's Abuse Prohibition Policy and Procedure during the provision of care and services for six of six sampled residents (Residents 1, 2, 3, 4, 5, and 6). The facility failed to: 1. Prevent sexual abuse when facility staff did not identify and intervene with Resident 1's sexually inappropriate behaviors that included lying on top of another resident with pants down, masturbating, and wandering (moving around inside the facility or home without awareness of personal safety, potentially putting themselves in harm's way) to Residents 2, 3 and 5's bedside. 2. Identify an allegation that constitutes sexual abuse which was reported by Resident 2 and witnessed by Resident 6 to facility staff when Resident 1 laid on top of Resident 2 with pants and underwear down on 8/24/2023 around 2 AM. In addition, the facility failed to identify an allegation of abuse when Resident 4 reported to facility staff observing Resident 1 wandering often to Resident 3's bedside at night. 3. Investigate and document investigation within two hours to determine if abuse had occurred and to protect Residents 2, 3, 4, 5, and 6 from non-consensual sexual relations by Resident 1. 4. Protect Resident 2 from sexual abuse by not responding immediately to protect Resident 2 when Resident 6 observed Resident 1 lying on top of Resident 2 while in bed, with pants and underwear down on 8/24/2023. 5. Protect Resident 3 from sexual abuse by not providing a safe environment to protect Resident 3 when Resident 4 observed Resident 1 wander frequently to Resident 3's bedside at night. 6. Protect Residents 2, 3, 4, 5, and 6 from Resident 1's wandering to other resident's rooms, other resident's bedside, and masturbating when facility staff did not provide a safe environment by increasing supervision and monitoring of Resident 1's wandering behavior. 7. Report all alleged violations of abuse made by Resident 2, 4, 5, and 6 to the Administrator and all other required agencies within two hours. These deficient practices resulted in Resident 2 and 3 experiencing sexual abuse and unwanted nonconsensual sexual contact from Resident 1. Resident 2 verbalized feeling angry and afraid of Resident 1. Resident 5 verbalized she could not sleep at night due to fear of Resident 1. These failures had the potential to result in serious harm, or injury to Residents 2, 3, 4, 5, and 6 who required extensive to total dependence from facility staff for activities of daily living which included bed mobility and transfers. On 9/06/2023 at 10:12 PM, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility reported incident regarding resident abuse. An Immediate Jeopardy (IJ-a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified and called on 9/7/2023, regarding the facility's failure to implement the facility's Abuse Prohibition Policy and Procedure during the provision of care and services for Residents 1, 2, 3, 4, 5, and 6. On 9/09/2023 at 8:24 PM, the IJ was removed after the surveyors verified and confirmed the facility implemented the facility's IJ Removal Plan (a detailed plan to address the IJ findings) while onsite by observation, interview, and record review. The IJ was removed in the presence of Administrator (ADM) and the Director of Nursing (DON). The acceptable IJ Removal Plan included the following information: 1. On 9/7/2023, All 3 reporting agencies were notified. 2. On 9/8/2023, [NAME] President of operations conducted a one-on -one education and training to administrator regarding abuse reporting and investigation. 3. On 9/7/2023, licensed nurse initiated a Change of Condition documentation for Residents 1 and 2 regarding the allegation of abuse. Monitoring of resident's condition post incident was initiated by licensed nurses and will ensure every shift for the next 72 hours. Daily resident activity and supervision worksheet will continue until Resident 1 is safely discharged in a secured unit (specially designed spaces/unit for people with dementia [a range of conditions that affects the ability to think, remember, and function normally]). 4. Residents comprehensive care plans were updated to reflect incident and corrective actions taken to prevent recurrence. 5. On 9/8/2023, trauma evaluation was completed for Resident 1 by the Social Service Director (SSD). 6. On 9/7/2023, Resident 1 was placed under one-to-one certified nursing assistant (CNA) supervision immediately until safely discharged to a secured unit. The facility's interdisciplinary team (IDT; composed of different facility departments which included the social services director, recreational director, DON, Assistant DON, and ADM) met with Resident 1's family to discuss placement to a secured unit . 7. Resident 1 was seen by a psychiatrist and psychologist (a professional who is an expert with the scientific study of the mind and behavior) on 9/8/23 evaluation, including medication regimen review for further recommendations. 8. On 9/7/2023, the DON and the Director of Staff Development (DSD) initiated in-services which included Abuse reporting and investigation and How to handle wanderers (considered moving around inside the facility or home without awareness of personal safety, potentially putting themselves in harm's way) that could potentially result in non-consensual contact with other residents. 9. On 9/8/2023, the Recreational Director conducted a resident council meeting to identify any concerns about safety and unsafe wandering . 11. On 9/8/2023, the facility's IDT scheduled care conference with Resident 1 and Resident 2's family and representatives to discuss care and for further recommendations. 12. On 9/8/2023 the Nurse Practitioner (a nurse who is qualified to treat certain medical conditions without the direct supervision of a physician) examined Resident 1 with order to reduce Quetiapine Fumarate (anti-psychotic [medication that treats psychosis [loss of contact with reality] medication) from 12.5 milligrams (mg; unit of measurement) two times a day to daily at bedtime for psychosis manifested by striking out and to start Resident on Aricept (medication for mild to moderate to severe dementia) 5 milligrams daily at bedtime for dementia. Cross referenced to F600, F609, and F867 Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident on 8/8/2019 and readmitted on [DATE], with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), dementia and psychosis. A review of Resident 1's Minimum Data Set (MDS; a care assessment screening tool) dated 7/26/2023, indicated the resident had severely impaired cognition (thought process). The MDS indicated the resident required limited assistance (resident highly involved in activity; staff provide guided maneuvering of legs) with bed mobility, transferring between surfaces, and walking inside and outside of his room. A review of Resident 1's History and Physical Examination (HPE) signed and dated by the attending physician on 2/2/2023, indicated the resident had fluctuating capacity to understand and make decisions. A review of a facility document titled Elopement Evaluation (assessment questionnaire that focuses on managing wandering and preventing elopement in older adults with dementia in long-term care settings) with effective date 7/26/2023, indicated Resident 1 was able to self-ambulate (walk). The Elopement Evaluation indicated No to the question Patient has a history of wandering that significantly intrudes on the privacy and/or activity of others. A review of Resident 1's Psychiatric Follow Up Note dated 7/5/2023, indicated the resident has had previous combative (ready and eager to fight) issues secondary to dementia and confusion. The Note indicated that Resident 1 was alert and oriented to self and place. A review of Resident 1's Progress Notes dated 8/24/2023 timed at 3:09 PM, indicated a late entry documentation indicating Resident 1 was asked if he recalled laying down on Resident 2's bed. The Progress Note indicated Resident 1 just stared shaking his head. The Progress Note indicated Resident 1 was very confused. A review of Resident 1's Progress Notes dated 8/24/2023 timed at 9:47 PM, indicated Resident 1 was Transferred to another room for his welfare to accompany other resident. A review of Resident 2's Admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included quadriplegia (a symptom of paralysis [the loss of the ability to move] that affects all a person's arms/legs and body from the neck down), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a mental disorder characterized by frequent intense, excessive and persistent worry and fear about everyday situations). A review of Resident 2's HPE dated 7/29/2023, indicated the resident had paralysis (loss of the ability to move) and no movements to both upper and lower extremities (parts of the human body, furthest from the heart, up to the hands and feet). The HPE indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2's MDS indicated Resident 2's cognition was intact. The MDS indicated Resident 2 did not have any difficulty in communicating ideas verbally. The MDS indicated Resident 2 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility and personal hygiene. The MDS indicated Resident 2 was totally dependent on and required two-person assistance for transfers. The MDS indicated Resident 2 could not walk. A review of Resident 2's Change in Condition [COC] Evaluation dated 8/24/2023 timed at 2:53 PM and authored by Registered Nurse (RN) 1, the COC evaluation indicated Resident [2] claimed that at 2 AM this morning, a confused resident from 'room (Resident 1's room)' mistaken his bed to his own and tried to lay down while he's in bed. Resident [2] c/o (complained/of) pain to his left rib and left leg . The Progress Notes indicated Resident 2's attending physician was notified and ordered for the resident to have X-ray (a machine that produces a safe level of radiation that passes through the body and records an image on a specialized plate) of the rib and left shoulder. A review of Resident 2's X-ray report of the left ribs due to pain dated 8/24/2023 timed at 9:25 AM, indicated there was no fractures or other acute abnormality identified. A review of Resident 2's Grievance/Concern form dated 8/24/2023, indicated Resident 2 reported concern to the Registered Nurse (RN) 1. The Grievance/Concern form indicated Resident [2] claims Resident 1 laid on his bed thinking it was his bed. The Grievance/Concern form indicated investigation was completed by RN 1 and the Social Services Director. The Grievance/Concern form indicated that the recommended corrective actions included Resident 1's room change and Resident 2's X-ray was carried per physician's order. A review of Resident 3's Admission Record indicated the facility admitted the resident on 2/01/2023 with diagnoses that included seizures (a sudden uncontrolled burst of electrical activity in the brain which can cause changes in behavior, uncontrolled movements, and change in level of consciousness) and intellectual disabilities (when limitations in a person's mental abilities affect intelligence, learning and everyday life skills). A review of Resident 3's HPE signed and dated by the attending physician on 2/02/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 3's MDS dated [DATE], indicated the resident had mildly impaired cognition. The MDS indicated Resident 3 did not have issues communicating ideas verbally. The MDS indicated Resident 3 required extensive assistance with bed mobility, dressing, toilet use and personal hygiene. The MDS indicated walking and transfers did not occur with Resident 3. A review of Resident 4's Admission Record indicated the facility admitted the resident on 3/17/2022 with diagnoses that included Type 2 diabetes mellitus (a chronic disease characterized with having high blood sugars) with hyperglycemia (a disease in which the blood sugar levels are too high). A review of Resident 4's MDS dated [DATE], indicated Resident 4 had intact cognition. The MDS indicated Resident 4 did not have problems communicating ideas verbally and had no vision and hearing difficulties. The MDS indicated Resident 4 required extensive assistance with bed mobility, transfers, and locomotion inside the room (how the resident moves in between locations inside his room). A review of Resident 5's Admission Record indicated the facility admitted the resident on 11/23/2022 and readmitted on [DATE] with diagnoses that included paraplegia complete (a type of paralyses that affects both legs) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 5's HPE signed and dated by the attending physician on 7/29/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 5's MDS dated [DATE], indicated Resident 5 was cognitively intact. The MDS indicated Resident 5 required extensive one-person physical assistance with bed mobility, dressing and personal hygiene. The MDS indicated Resident 5 required total dependence with one person for toilet use. The MDS indicated walking and transfer did not occur for Resident 5. A review of Resident 6's (Resident 2's roommate) Admission Record indicated the facility admitted the resident on 8/22/2023 with diagnoses that included hemiplegia (total or partial paralyses on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infraction (a medical condition that results in the death of brain cells due to lack of oxygen). A review of Resident 6's HPE signed and dated by the attending physician on 8/25/2023, indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 6's MDS dated [DATE], indicated Resident 6 was cognitively intact. The MDS indicated Resident 6 required extensive assistance with one-person for bed mobility, transfers, walking, dressing, toilet use. During an interview with Resident 2 on 9/06/2023 at 12:51 PM, Resident 2 stated he did not feel safe in the facility because about a week ago around 2 AM, Resident 1 came into his room and laid on top of him with his pants and underwear down. Resident 2 stated he was sleeping and woke up in pain. Resident 2 stated when he woke up, he saw Resident 1 lying on top of him, Resident 2 stated he immediately started screaming at Resident 1 to get off him. Resident 2 stated his roommate, Resident 6 woke up to the noise and started screaming at Resident 1 to get out and called facility staff to come help. Resident 2 stated Resident 1 got up from his bed appearing confused as he pulled up his pants. Resident 2 stated CNA 1 eventually came in his room and escorted Resident 1 back to his room (adjacent to Resident 2 and 6's room). Resident 2 stated he notified Licensed Vocational Nurse (LVN) 1 that Resident 1 had come inside his room and laid on top of him with his pants and underwear down. Resident 2 stated he told LVN 1 his body was in pain due to Resident 1 lying on top of him. Resident 2 stated later that day (8/24/2023) he notified Treatment Nurse (TN) 1 of what had happened to him that morning. Resident 2 stated later that day the facility's Social Service Director (SSD) came to his room and asked what had happened between him and Resident 1. Resident 2 stated he told the SSD that he woke up with Resident 1 lying on top of him with his pants and underwear down. Resident 2 stated that the SSD told him that Resident 1 was confused and a wanderer (someone who often travels from place to place, without clear aim or purpose). Resident 2 stated he felt angry and afraid due to the fact he could not get up and defend himself when Resident 1 came into his room and laid on top of him with his pants and underwear down. During an interview with Resident 6 on 9/6/2023 at 1:05 PM, Resident 6 stated he was in the bed next to Resident 2's bed the night (8/24/2023) when Resident 1 wandered inside their room and laid on top of Resident 2. Resident 6 stated he saw Resident 1's pants and underwear down. Resident 6 stated he was asleep when he woke to Resident 2 yelling at Resident 1 to get off him. Resident 6 stated Resident 1 got up and pulled his underwear and pants back on before CNA 1 walked in their room. Resident 6 stated CNA 1 escorted Resident 1 out of their room and back to his own room. During an interview with the SSD on 9/6/2023 at 2:07 PM, the SSD stated Resident 2 reported to her on 8/24/2023, Resident 1 went inside his room and laid on Resident 2's bed. The SSD stated she notified the DON, and the facility filed a grievance (complaint) on behalf of Resident 2 on the same day. The SSD stated Resident 2's physician was notified of Resident 2's complaint of Resident 1 lying on Resident 2's bed. The SSD stated that Resident 2's physician ordered a chest x-ray because of Resident 2's complaints of pain. The SSD stated Resident 1 was transferred to a different room on 8/24/2023. The SSD stated no one else was interviewed after Resident 2's complaint about Resident 1 because the incident was determined to be a grievance and was resolved by transferring Resident 1 to another room with new roommates. The SSD stated Resident 2's report of Resident 1 lying on Resident 2's bed was not investigated. The SSD stated Resident 1 was confused and was known to facility staff to wander around the facility. During an interview on 9/6/2023 at 3:05 PM with RN 1, RN 1 stated that on 8/24/2023, TN 1 informed RN 1 to go speak to Resident 2 because Resident 2 reported that Resident 1 Sat on him. RN 1 stated there were no previous reports from the night shift facility staff (licensed nurses and CNAs) regarding any incidents that happened between Residents 1 and 2. RN 1 stated she notified the SSD who she thought conducted the investigation of Resident 2's report that Resident [1] sat on him. RN 1 stated that Resident 1 was a confused resident and would often wander around the facility. During an interview on 9/07/2023 at 9:51 AM, LVN 1 stated he recalled Resident 2 reported to him on the early morning of 8/24/2023, Resident 1 had wandered inside Resident 2's room and laid on top of him LVN 1 stated he could not recall the time of Resident 2's report. LVN 1 stated he did not report or investigate Resident 2's allegations against Resident 1 because he did not believe Resident 2's claims that Resident 1 laid on top of him. LVN 1 stated Resident 2 reported he was in pain due to Resident 1 lying on top of him. LVN 1 stated he gave Resident 2 a pain medication and advised Resident 2 to notify the day shift licensed nurse if he continues to be in pain the next day. During an interview on 9/07/2023 at 2 PM with CNA 5, CNA 5 stated Resident 1 was moved to his present room after a previous incident on 8/24/2023. CNA 5 stated he had known Resident 1 for over a year and had observed Resident 1's wandering behavior getting worst in the last six months. CNA 5 stated he had observed Resident 1 wandering inside other resident's rooms. CNA 5 stated facility staff would redirect Resident 1 back to his room whenever Resident 1 was observed inside other resident's room. During a concurrent observation and interview on 9/07/2023 inside Resident 3's bedroom, Resident 3 was observed lying in his bed. During the observation, Resident 3's bed was next to Resident 1's bed inside the room. When Resident 3 was asked if Resident 1 had wandered over to Resident 3's bed, Resident 3 stated Yes and gestured pointing his index finger towards Resident 1's bed. Resident 3 verbalized and stated Masturbating, masturbate (stimulate one's own private area for sexual pleasure) . as Resident 3 was observed gesturing his own hips and moved it up and down while his index finger was still pointing towards Resident 1's bed. During a concurrent observation and interview, on 9/07/2023 at 3:16 PM inside Resident 4's bedroom, Resident 4 was observed sitting on his bed. During the observation, Resident 4 was observed to be roommates with Resident 1 and 3. During the observation, Resident 4's bed was located directly across from Resident 3 and Resident 1's beds inside the room. During the interview, Resident 4 stated Resident 1 was moved in their room a little over a week ago but could not recall exact date. Resident 4 stated he had often observed Resident 1 wander over to Resident 3's bed during the night. Resident 4 stated he could not see what was happening because Resident 3's privacy curtain was drawn around Resident 3's bed during the night. Resident 4 stated he had reported to facility staff because he was afraid something will happen to either Resident 1 or Resident 3 because he saw Resident 1 walking out of Resident 3's bedside a few nights ago crying with his hand placed over his eye as if Resident 1 was in pain. Resident 4 stated he reported the incident to multiple facility staff. Resident 4 stated that the facility staff's response to him was that Resident 1 was confused and a wanderer. During an interview on 9/07/2023 at 3:29 PM with Resident 5, Resident 5 stated she would see Resident 1 wander inside her room during the night. Resident 5 stated she could not sleep all night due to fear that Resident 1 would come in her bedroom and would not hear or feel because she was paralyzed. Resident 5 stated that when Resident 1 comes inside her room she would throw different things towards Resident 1 to try to defend herself and prevent Resident 1 from further walking closer to her. Resident 5 stated she would scream out to the facility staff for help, but facility staff would sometimes take too long to come to her room. Resident 5 stated that by the time the facility staff comes to her room, Resident 1 had already left because of the things she threw at Resident 1 to make him leave her room. Resident 5 stated she reported Resident 1 wandering in her room to facility staff. Resident 5 stated she was very scared and fearful of Resident 1 because she could not get up to defend herself when Resident 1 wanders inside her room. During an interview on 9/07/2023 at 8:30 PM with CNA 2, CNA 2 stated she had observed Resident 1 wandering and going to Resident 3's bedside. CNA stated she sees Resident 1 going to Resident 3's bedside happens as much as three times a day. CNA 2 stated when she sees Resident 1 at Resident 3's bedside, she would redirect Resident 1 back to his own bed. CNA 2 stated there was nothing else she could do. CNA 2 stated there were no measures in place for monitoring Resident 1's wandering behavior and everyone in the facility knows Resident 1 was a wanderer and facility staff tried to keep an eye on Resident 1 as much as possible. CNA 2 stated she recalled that Resident 5 reported to her that Resident 1 goes inside her bedroom at night about three nights ago. CNA 2 stated she did not report to the licensed nurse because it was not anything new about Resident 1 because everyone knew he was a wanderer. A review of the facility's policy and procedure titled Abuse Prohibition Policy and Procedure with a review date of 2/23/2021, indicated the facility would implement an abuse prohibition program though following . 1. Prevention of occurrences; The policy indicated that facility staff should identify, correct, and intervene in situations in which abuse, neglect . is more likely to occur and establish a safe environment for the resident. 2. Identification of possible incidents or allegations which need investigation; The policy indicated facility staff will identify events that may constitute abuse and determine the direction of the investigation. 3. Investigation of incidents and allegations; The policy indicated the facility staff should initiate investigation within two hours of abuse . The policy indicated that the investigation should be thoroughly documented. 4. Protection of patients during investigations: The policy indicated the facility would protect residents from further harm during investigation by providing the resident with safe environment by identifying persons with who he/she feels safe and conditions that would feel safe. 5. Reporting of incidents, investigations, and response to the results of their investigations. The policy indicated that upon receiving information on a report of alleged abuse . for facility staff to report allegations involving abuse no later than two hours after allegation is made. The policy indicated to notify local law enforcement, ombudsman, licensing district office, licensing boards, registries, and other agencies as required. During the same interview on 9/09/2023 at 4:15 PM, the DON stated that the facility staff did not implement the facility's Abuse Prohibition Policy and Procedure with regard to prevention of occurrences, identification of possible incidents or allegations which need investigation, investigation of incidents and allegations, protection of patients during investigation and reporting of incidents when Resident 2 reported the allegation to the facility staff on 8/24/2023 and when Resident 4 and Resident 5 reported allegations to facility staff. The DON stated that abuse should had been identified and investigated by the facility and all residents should had been protected from abuse by Resident 1.

Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Residents 2 and 3) were free from sexual abuse on 8/24/2023 around 2 AM when Resident 1 laid on top of Resident 2 while in bed, with pants and underwear down as observed by Resident 6. In addition, the facility failed to ensure Resident 3 was free from sexual abuse when Resident 1 wanders (a behavior characterize by aimless, repetitive walking without purpose) frequently to Resident 3's bedside and masturbates (when a person stimulates their genitals for sexual pleasure), as observed by Resident 4 after the facility staff moved Resident 1 to Resident 3 and 4's room. These deficient practices resulted in Resident 2 and 3 experiencing sexual abuse and unwanted nonconsensual sexual contact from Resident 1. Resident 2 verbalized feeling angry and afraid of Resident 1. Resident 4 verbalized feeling afraid for Resident 1 and 3's safety since Resident 1 frequently wanders to Resident 3's bedside. On 9/06/2023 at 10:10 PM, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility reported incident regarding resident abuse. An Immediate Jeopardy (IJ-a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified on 9/6/2023 regarding the facility's failure to ensure Residents 2 and 3 were free from sexual abuse by Resident 1. On 9/09/2023 at 8:24 PM, the IJ was removed after the surveyors verified and confirmed the facility implemented the facility's IJ Removal Plan (a detailed plan to address the IJ findings) while onsite by observation, interview, and record review. The IJ was removed in the presence of Administrator (ADM) and the Director of Nursing (DON). The acceptable IJ Removal Plan included the following information: 1. On 9/8/2023, the facility's [NAME] President of Operations (VPO) conducted a one-on-one education and training to the ADM regarding abuse reporting and investigation. 2. On 9/8/2023, the facility's licensed nurses initiated a change of condition documentation for Residents 1 and 2's allegation of abuse. Monitoring residents' condition was initiated and will ensure monitoring every shift for the next 72 hours. Daily resident activity and supervision worksheet will continue until safely discharge in a secured unit. Residents 1 and 2's comprehensive care plans were updated to reflect incident and corrective actions taken to prevent recurrence and to ensure that residents will continue to feel safe and secure. 3. On 9/8/2023, licensed nurses initiated a change of condition documentation for Residents 3 for monitoring of fear, anxiety (a mental disorder characterized by frequent intense, excessive, and persistent worry and fear about everyday situations), and inability to sleep because of Resident 1's wandering inside the room. Monitoring of the resident's condition every shift after the incident will continue for the next 72 hours. 4. On 9/8/23, trauma evaluation was completed by the Social Services worker for Residents 2, 3, 5, and 6. 5. On 9/7/2023, Resident 1 was placed under one-to-one certified nursing assistant (CNA) supervision until Resident 1's is safely discharged to a secured unit (specially designed spaces/unit for people with dementia [is a range of conditions that affects the ability to think, remember, and function normally]). The Interdisciplinary Team (IDT; composed of different facility departments which included the social service, recreational director, DON, Assistant DON, and ADM) met with Resident 1's family to discuss possible placement to a secured unit . 6. Residents 2, 3, 5, and 6 were seen by the psychologist (a professional who is an expert with the scientific study of the mind and behavior) on 9/8/2023 and medications were reviewed for further evaluation. Resident 1 is scheduled to be seen by a psychiatrist and psychologist on 9/8/2023 for further evaluation and recommendations. 7. On 9/7/2023, the DON and the Director of Staff and Development (DSD) initiated in-services which included Abuse reporting and investigation and How to handle wanderers (considered moving around inside the facility or home without awareness of personal safety, potentially putting themselves in harm's way) that could potentially result in non-consensual contact with other residents. 8. On 9/8/2023, the facility's Recreational Director conducted a Resident Council meeting to identify any concerns about safety and unsafe wandering . 9. On 9/8/2023, the facility's IDT, including licensed nurses will schedule care conferences with Residents 1 and 2, including their family and representative to discuss care and continue quarterly. 12. On 9/8/2023, the Nurse Practitioner (NP) examined Resident 1 with an order to reduce Quetiapine Fumarate (antipsychotic medication) from 12.5 mg twice a day to once at bedtime for psychosis (a loss of contact with reality) manifested by striking out and to start on Aricept (a medication used to treat confusion associated with dementia) 5 mg at bedtime for dementia. Resident 1's responsible party was informed about new change of order. Cross referenced to F607, F609, and F867 Findings: 1. A review of Resident 1's Admission Record indicated the facility admitted the resident on 8/8/2019 and readmitted on [DATE], with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), dementia and psychosis. A review of Resident 1's Minimum Data Set (MDS; a care assessment screening tool) dated 7/26/2023, indicated the resident had severely impaired cognition (thought process). The MDS indicated the resident required limited assistance (resident highly involved in activity; staff provide guided maneuvering of legs) with bed mobility, transferring between surfaces, and walking inside and outside of his room. A review of Resident 1's History and Physical Examination (HPE) signed and dated by the attending physician on 2/2/23, indicated the resident had fluctuating capacity to understand and make decisions. A review of a facility document titled Elopement Evaluation (assessment questionnaire that focuses on managing wandering and preventing elopement in older adults with dementia in long-term care settings) with effective date 7/26/2023, indicated Resident 1 was able to self-ambulate (walk). The Elopement Evaluation indicated No to the question Patient has a history of wandering that significantly intrudes on the privacy and/or activity of others. A review of Resident 1's Psychiatric Follow Up Note dated 7/5/23, indicated the resident has had previous combative (ready and eager to fight) issues secondary to dementia and confusion. The Note indicated that Resident 1 was alert and oriented to self and place. A review of Resident 1's Progress Notes dated 8/24/23 timed at 3:09 PM, indicated a late entry documentation indicating Resident 1 was asked if he recalled laying down on Resident 2's bed. The Progress Note indicated Resident 1 just stared shaking his head. The Progress Note indicated Resident 1 was very confused . A review of Resident 1's Progress Notes dated 8/24/23 timed at 9:47 PM, indicated Resident 1 was Transferred to another room for his welfare to accompany other resident. A review of Resident 2's Admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included quadriplegia (a symptom of paralysis [the loss of the ability to move] that affects all a person's arms/legs and body from the neck down), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder. A review of Resident 2's HPE dated 7/29/23, indicated the resident had paralysis (loss of the ability to move) and no movements to both upper and lower extremities (parts of the human body, furthest from the heart, up to the hands and feet). The HPE indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2's MDS indicated Resident 2's cognition was intact. The MDS indicated Resident 2 did not have any difficulty in communicating ideas verbally. The MDS indicated Resident 2 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility and personal hygiene. The MDS indicated Resident 2 was totally dependent on and required two-person assistance for transfers. The MDS indicated Resident 2 could not walk. A review of Resident 2's Change in Condition [COC] Evaluation dated 8/24/2023 timed at 2:53 PM and authored by Registered Nurse (RN) 1, the COC evaluation indicated Resident [2] claimed that at 2 AM this morning, a confused resident from 'room (Resident 1's room)' mistaken his bed to his own and tried to lay down while he's in bed. Resident [2] c/o (complained/of) pain to his left rib and left leg . The Progress Notes indicated Resident 2's attending physician was notified and ordered x-ray (a machine that produces a safe level of radiation that passes through the body and records an image on a specialized plate) of the rib and left shoulder. A review of Resident 2's x-ray report of the left ribs due to pain dated 8/24/2023 timed at 9:25 AM, indicated there was no fractures or other acute abnormality identified. A review of Resident 3's Admission Record indicated the facility admitted the resident on 2/01/2023 with diagnoses that included seizures (a sudden uncontrolled burst of electrical activity in the brain which can cause changes in behavior, uncontrolled movements, and change in level of consciousness), intellectual disabilities (when limitations in a person's mental abilities affect intelligence, learning and everyday life skills). A review of Resident 3's HPE signed and dated by the attending physician on 2/02/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 3's MDS dated [DATE], indicated the resident had mildly impaired cognition. The MDS indicated Resident 3 did not have issues communicating ideas verbally. The MDS indicated Resident 3 required extensive assistance with bed mobility, dressing, toilet use and personal hygiene. The MDS indicated walking and transfers did not occur with Resident 3. A review of Resident 4's Admission Record indicated the facility admitted the resident on 3/17/2022 with diagnoses that included Type 2 diabetes mellitus with hyperglycemia (a disease in which your blood glucose, or blood sugar, levels are too high). A review of Resident 4's MDS dated [DATE], indicated Resident 4 had intact cognition. The MDS indicated Resident 4 did not have problems communicating ideas verbally and had no vision and hearing difficulties. The MDS indicated Resident 4 required extensive assistance with bed mobility, transfers, and locomotion inside the room (how the resident moves in between locations inside his room). A review of Resident 5's Admission Record indicated the facility admitted the resident on 11/23/2022 and readmitted on [DATE] with diagnoses that included paraplegia complete (a type of paralyses that affects both legs) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 5's HPE signed and dated by the attending physician on 7/29/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 5's MDS dated [DATE], indicated Resident 5 was cognitively intact. The MDS indicated Resident 5 required extensive assistance one-person physical assist with bed mobility, dressing and personal hygiene. The MDS indicated Resident 5 required total dependance one person assist for toilet use. The MDS indicated walking and transfer did not occur for Resident 5. A review of Resident 6's (Resident 2's roommate) Admission Record indicated the facility admitted the resident on 8/22/2023 with diagnoses that included hemiplegia (total or partial paralyses on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (a medical condition that results in the death of brain cells due to lack of oxygen). A review of Resident 6's HPE signed and dated by the attending physician on 8/25/2023, indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 6's MDS dated [DATE], indicated Resident 6 was cognitively intact. The MDS indicated Resident 6 required extensive assistance with one-person with bed mobility, transfers, walking, dressing, toilet use. During an interview with Resident 2 on 9/06/2023 at 12:51 PM, Resident 2 stated he did not feel safe in the facility because about a week ago around 2 AM, Resident 1 came into his room and laid on top of him with his pants and underwear down. Resident 2 stated he was sleeping and woke up in pain. Resident 2 stated when he woke up, he saw Resident 1 lying on top of him, Resident 2 stated he immediately started screaming at Resident 1 to get off him. Resident 2 stated his roommate, Resident 6 woke up to the noise and started screaming at Resident 1 to get out and called facility staff to come help. Resident 2 stated Resident 1 got up from his bed appearing confused as he pulled up his pants. Resident 2 stated CNA 1 eventually came in his room and escorted Resident 1 back to his room (adjacent to Resident 2 and 6's room). Resident 2 stated he notified Licensed Vocational Nurse (LVN) 1 that Resident 1 had come inside his room and laid on top of him with his pants down. Resident 2 stated he told LVN 1 his body was in pain due to Resident 1 lying on top of him. Resident 2 stated later that day (8/24/2023) he notified Treatment Nurse (TN) 1 of what had happened to him that morning. Resident 2 stated later that day the facility's Social Service Director (SSD) came to his room and asked what had happened between him and Resident 1. Resident 2 stated he told the SSD that he woke up with Resident 1 lying on top of him with his pants down. Resident 2 stated that the SSD told him that Resident 1 was confused and a wanderer (someone who often travels from place to place, without clear aim or purpose). Resident 2 stated he felt angry and afraid due to the fact he cannot get up and defend himself when Resident 1 came into his room and laid on him with his pants and underwear off. During an interview with Resident 6 on 9/6/2023 at 1:05 PM, Resident 6 stated he was in the bed next to Resident 2's bed the night (8/24/2023) when Resident 1 wandered inside their room and laid on top of Resident 2. Resident 6 stated he saw Resident 1's pants and underwear down. Resident 6 stated he was asleep when he woke to Resident 2 yelling at Resident 1 to get off him. Resident 6 stated Resident 1 got up and pulled his underwear and pants back on before CNA 1 walked in their room. Resident 6 stated CNA 1 escorted Resident 1 out of their room and back to his own room. During an interview with the SSD on 9/6/2023 at 2:07 PM, the SSD stated Resident 2 reported to her on 8/24/2023, Resident 1 went inside his room and laid on Resident 2's bed. The SSD stated she notified the DON, and the facility filed a grievance (complaint) on behalf of Resident 2 on the same day. The SSD stated Resident 2's physician was notified of Resident 2's complaint of Resident 1 lying on Resident 2's bed. The SSD stated that Resident 2's physician ordered a chest x-ray because of Resident 2's complaints of pain to the chest area. The SSD stated Resident 1 was transferred to a different room on 8/24/2023. The SSD stated no one else was interviewed after Resident 2's complaint about Resident 1 because the incident was determined to be a grievance and was resolved by transferring Resident 1 to another room with new roommates. The SSD stated Resident 1 was confused and was known to facility staff to wander around the facility. During an interview on 9/6/2023 at 3:05 PM with RN 1, RN 1 stated that on 8/24/2023, TN 1 informed RN 1 to go speak to Resident 2 because Resident 2 reported that Resident 1 Sat on him. RN 1 stated there were no previous reports from the night shift facility staff (licensed nurses and CNAs) regarding any incidents that happened between Residents 1 and 2. RN 1 stated she notified the SSD who she thought conducted the investigation of Resident 2's report that Resident 1 sat on him. RN 1 stated that Resident 1 was a confused resident and would often wander around the facility. During an interview on 9/07/2023 at 9:51 AM, LVN 1 stated he recalled Resident 2 reported to him during the nightshift on 8/23/2023, Resident 1 had wandered inside Resident 2's room and laid on top of him. LVN 1 stated he could not recall the time of Resident 2's report. LVN 1 stated he did not report or investigate Resident 2's allegations against Resident 1 because he did not believe Resident 2's claims that Resident 1 laid on top of him. LVN 1 stated Resident 2 reported he was in pain due to Resident 1 lying on top of him. LVN 1 stated he gave Resident 2 a pain medication and advised Resident 2 to notify the day shift licensed nurse if he continues to be in pain the next day. During an interview on 9/07/2023 at 2 PM with CNA 5, CNA 5 stated Resident 1 was moved to his present room after a previous incident on 8/24/2023. CNA 5 stated he had known Resident 1 for over a year and had observed Resident 1 wandering behavior getting worst in the last six months. CNA 5 stated he had observed Resident 1 wandering inside other resident's rooms. CNA 5 stated facility staff would redirect Resident 1 back to his room whenever Resident 1 was observed inside other resident's rooms. During a concurrent observation and interview on 9/07/2023 at 3 PM inside Resident 3's bedroom, Resident 3 was observed lying in his bed. During the observation, Resident 3's bed was next to Resident 1's bed inside the room. When Resident 3 was asked if Resident 1 had wandered over to Resident 3's bed, Resident 3 stated Yes and gestured pointing his index finger towards Resident 1's bed. Resident 3 verbalized and stated Masturbating, masturbate . as Resident 3 was observed gesturing his own hips and moved it up and down while his index finger was still pointing towards Resident 1's bed. During a concurrent observation and interview, on 9/07/2023 at 3:16 PM inside Resident 4's bedroom, Resident 4 was observed sitting on his bed. During the observation, Resident 4 was observed to be roommates with Resident 1 and 3. During the observation, Resident 4's bed was located directly across from Resident 3 and Resident 1's beds inside the room. During the interview, Resident 4 stated Resident 1 was moved in their room a little over a week ago (could not recall exact date). Resident 4 stated he had often observed Resident 1 wander over to Resident 3's bed during the night. Resident 4 stated he could not see what was happening because Resident 3's privacy curtain was drawn around Resident 3's bed during the night. Resident 4 stated he had reported to facility staff because he was afraid something will happen to either Resident 1 or Resident 3 because he often sees Resident 1 walking out of Resident 3's bedside at night. During an interview on 9/07/2023 at 3:29 PM with Resident 5, Resident 5 stated she would see Resident 1 wander inside her room during the night. Resident 5 stated she could not sleep all night due to fear that Resident 1 would come in her bedroom and would not hear or feel because she was paralyzed. Resident 5 stated that when Resident 1 comes inside her room she would throw different things towards Resident 1 to try to defend herself and prevent Resident 1 from further walking closer to her. Resident 5 stated she would scream out to the facility staff for help but facility staff would sometimes take too long to come to her room. Resident 5 stated that by the time the facility staff comes to her room, Resident 1 had already left because of the things that she would throw to make Resident 1 leave her room. Resident 5 stated she is very scared and fearful of Resident 1 because she could not get up to defend herself when Resident 1 wanders inside her room. During an interview on 9/07/2023 at 8:30 PM with CNA 2, CNA 2 stated she had observed Resident 1 wandering and going to Resident 3's bedside. CNA stated she sees Resident 1 going to Resident 3's bedside happens as much as three times a day. CNA 2 stated when she sees Resident 1 at Resident 3's bedside, she would redirect Resident 1 back to his own bed. CNA 2 stated there was nothing else she could do . A review of the facility's policy and procedure titled Abuse Prohibition Policy and Procedure with a review date of 2/23/2021, indicated the facility would prohibit abuse . for all residents. The policy further indicated the facility would do all that is within their control to prevent occurrences of abuse. The policy indicated the types of abuse that included sexual abuse defined as a non-consensual (no consent) sexual contact of any type with a resident.

Based on observation, interview, and record review, the facility failed to provide accurate and safe pharmaceutical services and procedures to nine of nine residents (Residents 134, 174, 9, 133, 67, 98, 68, 7 and 482) when: 1. Resident 134's lisinopril (a medicine used to treat high blood pressure and heart failure) was administered without assessing the heart rate as ordered by the physician prior to medication administration. 2. Resident 134's potassium chloride ER ([ER-Extended Release] a medicine used to prevent or treat low potassium [a mineral] levels in the body) were administered for over one year without accurate indication of its use. 3. Resident 174's Losartan Potassium (a medicine used to treat high blood pressure) was not transcribed in the Medication Administration Record (MAR) and administered from 1/21/23 to 3/13/23. 4. Resident 133 received twenty-six doses of expired Lantus (an insulin medication to manage blood sugar levels). 5. Resident 9 received six doses of expired Tylenol with Codeine #3 (a medication for pain management that is regulated by the government). 6. Resident 67 received the multivitamin liquid, and the licensed nurse did not shake the multivitamin liquid bottle before administering in accordance with the manufacturer's instruction. 7. Resident 98 was discharged , and the facility failed to ensure proper disposition of a controlled medication, Tramadol (pain medication). 8. Resident 68 received Lorazepam Oral concentrate medication (a medication which act on the brain and nerves to produce a calming effect) unrefrigerated for 16 days, against medication specifications. 9. Resident 7 received expired Humulin R insulin medication (an insulin medication to manage blood sugar levels). 10. Failed to ensure there was no duplicate active physician order for Gabapentin (a medicine used to treat partial seizures, nerve pain from shingles and restless leg syndrome) for Resident 482. These deficient practices increase the risk of the residents (Residents 134, 174, 9, 133, 67, 98, 68, 7, and 482) to adverse consequences that are not limited to severe anxiety, hypertension (high blood pressure), stroke, cardiac (heart) arrest, hyperglycemia (increase blood sugar), pain, coma, and death. On 3/15/2023 at 5:45 PM, the Department called an Immediate Jeopardy (IJ), a situation in which the facility's noncompliance with one or more requirements of participation had caused, or is likely to cause, serious injury, harm, impairment, or death to a resident, in the presence of the Administrator and Director of Nursing (DON) due to facility's failure to provide accurate and safe pharmaceutical services during medication administration observation. On 3/16/2023, at 7:45 PM, the Administrator and DON provided an acceptable IJ removal plan that included the following: 1. In-service was provided to all License Nurses by the Director of Nursing related to proper administration of Lisinopril to assess resident's heart rate per physician's order. 2. In-service was provided by the Director of Nursing related to potassium administration based on manufacturer's specification for Potassium ER, swallow whole do not crush or chewed, do not allow to dissolve in the mouth and must be taken containing 8 ounces (oz, a unit of measurement) of water. 3. Nurse Practitioner was informed by a licensed nurse regarding non-administration of Losartan Potassium medication, advised resident and responsible party to contact Primary Physician. In-service to Registered Nurses (RNs) to follow policy and procedures related to transcribing new medication upon admission. 4. Resident 133 expired Lantus was replaced with a new open insulin pen on 3/15/2023. In-service to all licensed nurses to follow policy and procedures related to expired medication. 5. Residents 9 expired Tylenol with Codeine #3 replaced with new Tylenol Codeine #3 on 3/15/2023. In-service to all licensed nurses to follow policy and procedures related to expired medication. 6. In-service was provided by the Director of Nursing related to proper administration of multivitamins by shaking the bottle before administration. 7. Tramadol (pain medication) controlled medication endorsed to the DON and locked in for proper disposition. In-service to all licensed nurses to follow policy and procedures related to proper disposition of controlled medications. 8. Resident 68 Lorazepam Oral concentrate was replaced with new lorazepam on 3/15/2023. In-service to all licensed nurses to properly stored as per manufacturer instructions. 9. Resident 7 expired Humulin R insulin was replaced with new Insulin vial on 3/15/2023. In-service to all licensed nurses to follow policy and procedures related to expired medication. On 3/16/23 at 8:30 PM, the Department removed the IJ after verifying and confirming onsite that the facility implemented the IJ removal plan in the presence of the Administrator and DON. Findings: 1. A review of Resident 134's Admission Record indicated the facility admitted Resident 134 on 9/1/2021 with diagnoses that included nonrheumatic aortic valve stenosis (narrowing of the aortic valve [part of the heart] opening), mitral valve insufficiency (a heart disease in which the valve between the left heart chambers does not close completely), diabetes mellitus, hypertension and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). A review of Resident 134's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/7/23, indicated Resident 134 had no memory and cognitive (thought process and ability to reason or make decisions) impairment. During a medication pass observation, on 3/13/23, from 9:02 AM to 9:22 AM, with Licensed Vocational Nurse (LVN) 11, in Nursing Station 2, at Medication Cart (Med Cart 2), LVN 11 prepared one tablet of Lisinopril 2.5 milligrams (mg, a unit of measurement) and LVN 11 did not assess Resident 134's heart rate before administering the Lisinopril. During an interview with LVN 11, on 3/13/23, at 10:02 AM, LVN 11 stated that Resident 134's heart rate was not checked to see if it is below 60 beats per minute prior to administering Lisinopril. LVN 11 stated, I messed up on the heart rate. LVN 11 stated that one of the consequences of not checking the heart rate before administering Lisinopril can lower the resident's heart rate even more. LVN 11 stated it is important to check the resident's blood pressure and heart rate parameters as ordered by the physician. A review of Resident 134's record, titled Order Summary Report, dated 3/13/23, indicated Lisinopril tablet 2.5 mg, ordered on 9/1/2021, give 1 tablet by mouth, one time a day for hypertension, hold for Systolic Blood Pressure (SBP, measures the pressure of your blood in your arteries [tube like structure responsible for transporting blood]) less than (<) 110 milliliters per mercury (mmHg, unit of measurement) and heart rate (HR) < 60 beats per minute (bpm, unit of measurement). A review of Resident 134's Care Plan, initiated on 9/2/2021 and revised on 10/14/2021, indicated Resident 134 exhibits or is at risk for cardiovascular symptoms or complications related to hypertension, hyperlipidemia (an excess of fats in the blood), diabetes mellitus (blood sugar problem), AKI ([Acute Kidney Injury] sudden episode of kidney failure or damage), severe aortic stenosis (heart disease), heart failure and history of septic shock (a drop in blood pressure due to an infection). The care plan intervention indicated to assess and monitor vital signs as ordered and report abnormalities to physicians. A review of facility policy and procedures, titled Administering Medications, revised date April 2019, indicated, Policy Statement: Medication are administered in a safe and timely manner, and as prescribed ., and indicated, Policy Interpretation and implementation: 7. Medications are received, labeled, stored, administered, and disposed of according to all applicable state and federal laws and consistent with standard of practice .9. The consultant pharmacist, in collaboration with dispensing pharmacy and the facility, oversees the development of procedures related to pharmacy services, including (but not limited to): c. Administration of medications . 2. During a medication pass observation, on 3/13/23, from 9:02 AM to 9:22 AM, with LVN 11, in Nursing Station 2, at Medication Cart (Med Cart 2). LVN 11 prepared and gave one tablet of Potassium Chloride Extended Release (ER), 10 milliequivalents (mEq, unit of measurement) by mouth to Resident 134. During an interview with RN 4 and concurrent review of the physician Order Summary Report, dated 12/27/22, 1/23/23, and 3/13/23, on 3/13/23, at 11:08 AM, the Order Summary Report indicated Potassium Chloride ER tablet extended release 10 mEq one tablet by mouth, one time a day, as a supplement for Lasix (a medication which increases urine output). RN 4 stated Resident 134 continued to receive Potassium Chloride ER after Lasix was last given and discontinued on 1/17/22. RN 4 stated, Potassium Chloride ER order should have been clarified with the physician when Lasix was discontinued on 1/17/22. The RN 4 stated the purpose of Potassium Chloride ER supplement is to replenish the resident's potassium depleted by Lasix. RN 4 stated if Potassium Chloride ER is continued without Lasix, Resident 134 can have hyperkalemia (too much potassium in your blood) which can cause symptoms like chest pain, irregular heartbeat, and hospitalization . During an interview with Resident 134, on 3/13/23, at 3:13 PM, Resident 134 stated I felt tingling on my hands for one week when I rub my hands together. During an interview with LVN 11, on 3/13/23, at 3:19 PM, LVN 11 stated if Lasix is prescribed for a resident, it should be supplemented with potassium. LVN 11 stated once Lasix is discontinued, the potassium should be discontinued depending on the resident's potassium level. During an interview with the DON, on 3/13/23, at 3:34 PM, the DON stated, the pharmacy is informed when a medication is discontinued in PCC (Point Click Care, a software for digital data of residents). The DON stated the indication for potassium in Order Summary should be updated if potassium is ordered as a supplement for Lasix and should be discontinued after Lasix is discontinued. A review of Resident 134's record, titled Order Summary Report, dated 3/13/23, indicated Potassium Chloride ER Tablet Extended Release 10 mEq was ordered on 9/01/2021, to give one tablet by mouth, one time a day, for supplement of taking Lasix. 3. A review of Resident 174's Admission Record indicated the facility admitted Resident 174 on 1/21/23, with diagnoses that included end stage renal (kidney) disease (a medical condition in which the kidneys stop working permanently leading to dialysis [a procedure to remove waste product and excess fluid from the blood] or kidney transplant [a surgery done to replace a diseased kidney with a healthy kidney from a donor]), cerebral infarct (lack of adequate blood supply to brain cells), diabetes mellitus, and hypertension. A review of Resident 174's MDS, dated [DATE], indicated Resident 174 had no memory and cognitive impairment. A review of Resident 174's Order Summary, indicated an active medication order dated 1/21/23 for Losartan Potassium Oral Tablet 50 milligram, give one tablet by mouth one time a day for hypertension, to hold for SBP < 110 mmHg and HR < 60 bpm. A review of Resident 174's MAR, dated 1/1/23 to 1/31/23, 2/1/23 to 2/28/23, and 3/1/23 to 3/31/23, indicated there was no Losartan Potassium 50 mg one (1) tablet once daily by mouth listed. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 7, on 3/13/23, at 11:56 AM, LVN 7 reviewed Resident 174's MAR on 3/13/23. LVN 7 stated there was no Losartan Potassium 50 mg 1 tab once daily by mouth transcribed in the MAR. LVN 7 stated she had never administered Losartan Potassium to Resident 174. During an interview with Registered Nurse (RN) 4, on 3/13/23, at 11:59 AM, RN 4 stated Losartan Potassium 50 mg 1 tablet once daily by mouth was ordered on 1/21/23 and the medication was not transcribed on the MAR from 1/1/23 to 3/31/23. RN 4 stated Losartan Potassium was not administered to Resident 174. RN 4 stated Resident 174 was a dialysis resident and the resident's blood pressure needed to be managed and controlled (by medication). RN 4 stated elevated and uncontrolled blood pressure can lead to heart problems, stroke, and death. During an interview with Resident 174, on 3/13/23, at 2:52 PM, Resident 174 stated he has a history of hypertension. Resident 174 stated he was taking Losartan Potassium for high blood pressure and reported dizziness during wheelchair transfers (to and from the bed). A review of Resident 174 record, titled Weights and Vitals Summary, indicated Resident 174 had the following blood pressure readings: - 1/23/23- 159/67 mmHg - 1/24/23 - 168/50 mmHg - 1/25/23 - 154/80 mmHg - 1/31/23 - 176/57 mmHg - 2/03/23- 160/84 mmHg (8:46 AM) - 2/03/23 - 160/78 mmHg (4:57 PM) - 2/04/23 - 160/80 mmHg - 2/05/23 - 158/89 mmHg - 2/14/23 - 176/74 mmHg - 2/15/23 - 156/60 mmHg - 2/19/23 - 160/66 mmHg (8:06 AM) - 2/19/23 - 152/64 mmHg (12:05 PM) - 2/19/23 - 159/57 mmHg (4:01 PM) - 2/20/23 - 158/89 mmHg - 2/23/23 - 158/80 mmHg - 2/24/23 - 169/67 mmHg - 2/26/23 - 159/89 mmHg (8:16 AM) - 2/26/23 - 158/68 mmHg (5:52 PM) - 2/27/23 - 160/76 mmHg - 3/01/23 - 156/74 mmHg - 3/03/23 - 158/70 mmHg - 3/04/23 - 152/60 mmHg - 3/05/23 - 160/72 mmHg - 3/06/23 - 159/74 mmHg (10:46 AM) - 3/06/23 - 160/62 mmHg (6:10 PM) - 3/08/23 - 168/60 mmHg- - 3/10/23 - 160/72 mmHg - 3/11/23 - 156/68 mmHg (12:13 PM) - 3/11/23 - 160/66 mmHg (4:37 PM) - 3/11/23 - 152/62/mmHg (6:44 PM) A review of Resident 174's Care Plan initiated on 1/21/23 and revised on 1/24/23, indicated Resident exhibits or is at risk for cardiovascular symptoms or complications related to diagnosis of hypertension, bradycardia (low heart rate), hyperlipidemia and cerebrovascular accident (CVA, also known as stroke and complication of high blood pressure). The Care Plan intervention indicated To administer meds as ordered and assess for effectiveness and side effects and report abnormalities to physician. During an interview with the Registered Nurse Supervisor (RNS) on 3/13/23, at 3:07 PM, the RNS stated the RN or LVN carry out the physician order. The RNS stated, Pharmacy automatically receives medication order once order is entered in PCC. During an interview with the DON on 3/13/23, at 3:34 PM, the DON stated Licensed nurse enters physician order in PCC once order is received and confirmed. The pharmacy immediately has access to the new order once it is entered in PCC. The facility should call or fax the pharmacy to confirm if the order was received. A review of the facility's policy and procedure titled, Administering Medications, revised April 2019, indicated Policy Statement: Medication are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: . 4. Medications are administered in accordance with prescriber orders including any required timeframe . The policy indicated the following information is checked, verified for each resident prior to administering medications: vital signs, if necessary. A review of the facility's Policy and Procedure titled, Physician Orders, effective 3/22/22, indicated III. Procedures: VIII. Whenever possible, the Licensed Nurse receiving the order will be responsible for documenting and implementing the order. Medication treatment orders will be transcribed onto the appropriate resident administration record. Orders pertaining to other health care disciplines will be transcribed onto the appropriate communication system for that discipline. A review of the facility's Policy and Procedure titled, Pharmacy Services Overview, revised April 2019, indicated Policy Interpretation and Implementation: 1. Pharmaceutical services consists of: a. The process of receiving and interpreting prescriber's orders; acquiring, receiving, storing, controlling, reconciling, compounding .dispensing, packaging, labeling, distributing, administering, monitoring responses to, using and/or disposing of all medications . The policy also indicated Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration. 4. A review of Resident 133's Admission Record, indicated the facility admitted the resident on 5/31/22 for osteomyelitis (bone infection), respiratory (lungs) failure, type 2 diabetes (a condition caused by high blood sugar levels that can lead to blindness, improper wound healing, and increases risk for heart attack and stroke), and pressure ulcer (injury to tissue and skin resulting from pressure on the skin). A review of Resident 133's MDS, Section C (Cognitive or mental status), dated 12/8/22, indicated Resident 133 had severely impaired cognition. During a medication pass observation, on 3/14/23, at 1:10 PM, an opened vial of Lantus was found with the name of Resident 133 and dated 1/19/23, past 28 days from open date. During an interview with LVN 6, on 3/14/23, at 1:14 PM, LVN 6 stated the Lantus was expired based on the open date and should not be in the medication cart. LVN 6 stated the medication was given to the resident daily since 1/19/23 and needed to be unexpired because residents could become hyperglycemic (increased blood sugar) from using expired Lantus. LVN 6 stated expired Lantus might not provide full strength of the medication and will not lower the resident's blood sugar. During an interview with LVN 5, on 3/16/23, at 8:42 AM, LVN 5 stated nurses must check expiration dates when administering medication because expired medications will not be as effective. LVN 5 stated Lantus expires twenty-eight days after it is opened. During an interview with RN 2, on 3/16/23 at 8:25 AM, RN 2 stated expired Lantus might not be as effective and might cause an adverse consequence or hyperglycemia. During an interview with the Director of Nursing (DON), on 3/16/23 at 8:55 AM, the DON stated, expired medications should not be given, and staff are trained on checking the medication expiration date along with the seven rights of administration and should be checking the expiration dates when administering medications. During an interview with the Pharmacist, on 3/16/23 at 11:13 AM, the Pharmacist stated, expired medications should not be given to residents because the efficacy may be lowered. The Pharmacist stated Lantus expires twenty-eight days after the vial is opened. Pharmacist also stated a random spot check is done on the medication carts during the monthly pharmacist visit and it is possible to miss an expired medication. A review of Resident 133 record, titled Medication Administration Record (MAR) for the month of February 2023 to March 2023, indicated Resident 133 received twenty-six expired doses of Lantus every day at 9 PM from 2/16/23 to 3/13/23. A review of Resident 133's Progress Notes, dated 3/15/23, indicated Resident 133 received expired Lantus from a vial that had been opened for more than twenty-eight days. A review of the facility policy, titled Administering Medications, with revised date April 2019, indicated the expiration date or beyond use date on the medication label is checked during medication administration and if using a multidose container, the date of opening is recorded on the container. 5. A review of Resident 9's admission record indicated the facility admitted the resident on 7/14/22 for diagnoses including congestive heart failure (heart does not pump blood as well as it should to the rest of the body), hypertension, kidney disease, dementia (condition involving impairment of brain functions like memory), and chronic pain syndrome. A review of Resident 9's Minimum Data Set Assessment Section C, dated 1/27/23, indicated Resident 9 had severely impaired cognition. During a concurrent medication storage observation and interview with LVN 7, on 3/14/23, at 4:15 PM, at Med Cart 2 on Unit 2, Resident 9's bubble pack (supply of medications with individually sealed compartments) of Tylenol with Codeine #3 (a habit-forming pain medication) with an expiration date of 3/5/23 was printed on the bubble pack of the medication. LVN 7 stated Resident 9 had an order for Tylenol with Codeine #3 to be taken as needed for moderate pain and the resident had been receiving expired medication since 3/5/23. LVN 7 stated the resident received six expired doses of Tylenol with Codeine #3 with the last dose being administered on 3/14/23. During an interview with the DON, on 3/16/23 at 8:55 AM, the DON stated expired medications should not be given and staff are trained on checking the medication expiration date along with the seven rights of administration and should be checking the expiration dates when administering medications. The DON stated checking for expired controlled medications are done during the DON's daily rounds on the units. The DON stated the expectation is for nurses to bring expired controlled medications that are no longer in use to the DON's office immediately or before the end of the day. During an interview with the Pharmacist, on 3/16/23 at 11:13 AM, the Pharmacist stated expired medications should not be given to residents because the efficacy may be lowered. Pharmacist also stated a random spot check is done on the medication carts during the monthly pharmacist visit. A review of the facility policy, Administering Medications, dated April 2019, the policy indicated the expiration date or beyond use date on the medication label is checked during medication administration and if using a multidose container, the date of opening is recorded on the container. 6. A review of Resident 67's admission record indicated the facility admitted Resident 67 on 7/5/22 for diagnoses including chronic respiratory failure, sepsis (infection in the blood), kidney failure, anoxic brain injury (lack of oxygen to the brain), and gastroesophageal reflux disease (stomach acid backs up towards the throat and irritates the lining of the stomach and throat). A review of Resident 67's MDS, dated [DATE], indicated a test for cognition could not be completed due to impaired cognition. During an observation on 3/14/23, at 8:19 AM, LVN 6 was observed preparing multivitamin liquid for Resident 67 at Med Cart 2 and LVN 6 did not shake the multivitamin liquid bottle before administration. During an interview with LVN 6, on 3/14/23, at 1:20 PM, LVN 6 stated the multivitamin liquid was poured into the medication cup and LVN 6 was not aware of any special preparation for the multivitamin liquid. LVN 6 stated the multivitamin liquid bottle was not shaken prior to administration. LVN 6 stated it was important to follow manufacturer's instructions on the bottle to shake well prior to pouring to make sure the vitamins and minerals get dissolved and are not sitting at the bottom of the bottle and to receive the correct dose. During an interview LVN 5, on 3/16/23, at 8:42 AM, LVN 5 stated nurses must prepare medications like multivitamin liquid according to manufacturer's instructions and either shake or swirl to ensure there is equal distribution of the ingredients. During an interview with RN 2 on 3/16/23, at 8:25 AM, RN 2 stated nurses must check the manufacturer's instructions on the label to ensure proper administration of the medication. During an interview with the DON, on 3/16/23, at 8:55 AM, the DON stated that medication preparation depends on the instructions on the manufacturer's label. The DON stated that if the manufacturer's instructions on the label written to shake the bottle, then the nurse must follow the instruction prior to pouring the medication in the medication cup. 7. A review of Resident 98's admission record indicated an admission on 7/14/22 for diagnoses including acute and chronic respiratory failure, severe sepsis (infection in the blood), osteomyelitis (bone infection), and pressure ulcer Stage IV sacral region (deep injury to the tissue and skin reaching down to the bone resulting from pressure on the skin). Resident 98 was discharged to the hospital on 3/6/23. During a concurrent observation and interview with LVN 8, on 3/14/23, at 12:54 PM, a bubble pack containing tramadol (controlled pain medication) with eighteen doses with the narcotic (a drug or substance that affects mood and behavior) count sheet wrapped around the bubble pack and covered with a rubber band. Eight doses were removed from the bubble pack and eight doses were signed off on the count sheet. LVN 8 stated Resident 98 was sent to the hospital on 3/6/23 for gastrointestinal bleed and the tramadol was being held on the side of the drawer for disposal in the DON's office. LVN 8 stated the medication should have been taken to the DON's office immediately or at least by the end of the shift on 3/6/23 for proper storage and disposal. LVN 8 stated the resident last received Tramadol on 3/6/23. During an interview with RN 2, on 3/16/23, at 8:25 AM, RN 2 stated controlled medications are counted at change of shift and should be given to the DON as soon as the resident leaves, so they don't get stolen for personal use. During an interview with the DON, on 3/16/23, at 8:55 AM, the DON stated the nurse is to bring controlled medications to the DON office for storage. DON stated The nurse and the DON count the medications and cosign the count and the medication is held in the locked cabinet until the Pharmacist comes to witness the destruction of the controlled medication. The DON stated the expectation is for nurses to bring the controlled medications to the DON's office immediately or by the end of the shift. During an interview with the Pharmacist, on 3/16/23, at 10:21 AM, the Pharmacist stated the facility policy determines how soon the nurse should take discontinued controlled medications to the DON. The Pharmacist stated that a delay in taking the medications to the DON could result in drug diversion. A review of the facility records for Resident 98, titled Narcotic Count Sheet, indicated that eight doses were administered by the eight separate signatures and dates of administration. At the bottom of the sheet was a space designated for the balance remaining to be given to the DON or RN and it had no writings and was blank. The doses discharged and doses transferred part of Narcotic Count Sheet has no writings and were remain blank. A review of the facility policy and procedures, titled NSG 314 Disposal of Medication Waste, dated 10/24/22, indicated, the medications for discharged residents should be sent home with the resident if applicable or returned to the pharmacy when applicable or placed in a disposal bin for destruction. A review of the facility policy and procedures, titled, Pharmacy Services Overview, dated April 2019, indicated medications are stored and disposed of according to applicable laws and standards of practice. It also indicated the pharmacist and facility oversees the control of medications from point of receipt to secured storage of medications and the disposition of medications. A review of the facility policy, titled, Controlled Substances, dated April 2019, the policy indicated that controlled medication counts are completed at the end of every shift with the nurse coming on duty and the nurse going off duty. It also indicated that waste or disposal of controlled medications are done in the presence of a nurse and a witness who both sign the disposition sheet. A review of the facility policy, titled Storage of Medications, dated November 2020, indicated the discontinued medications are returned to the pharmacy or destroyed. 8. A review of Resident 68's Admission Record indicated the facility admitted Resident 68 on 1/26/22, with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area, also known as stroke) and bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows). During a medication storage observation, on 3/14/23, at 3:40 PM, found a medicine paper package labeled with Lorazepam Oral concentrate and labeled with Resident 68's name was stored in the narcotics drawer of the Medication Cart 1 of facility Station 1 at room temperature. The Lorazepam Oral Concentrate package indicated Discard 90 days after opening, and Store at cold temperature, refrigerate at 2-degree to 8-degree Celsius, No open date recorded or written on Lorazepam paper package. The bottle of Lorazepam was filled on 2/24/23. During an interview with LVN 10, on 3/14/23, at 3:55 PM, LVN 10 stated there were no open dates recorded on either the Lorazepam bottle or the paper package. LVN 10 stated this bottle of Lorazepam Oral Concentrate had been stored at room temperature in the medication cart 1 consistently and did not know when this bottle of Lorazepam was opened since there was no opening date on the bottle. LVN 10 further stated she did not know Lorazepam Oral Concentrate needed to be refrigerated after opening. A review of Resident 68's Order Summary Reports, dated 2/23 and 3/23, indicated, Resident 68 to receive Lorazepam Oral Concentrate (a medication is used to treat anxiety) 1 mg two times a day for anxiety manifested by inconsolable yelling and screaming, starting on 12/24/22. A review of Resident 68's MAR, dated 3/23, indicated, Resident 68 received Lorazepam Oral Concentrate 1 mg two times a day from 2/23 to 3/14/23. A review of Lorazepam Oral Concentrate package box and paper insert, indicated, Manufacture's Specifications for Lorazepam Oral Concentrate should be refrigerated at 2-degree Celsius to 8-degree Celsius and discard opened bottle after 90 days. During a concurrent record review and interview with LVN 10, on 3/14/23, at 4:00 PM, Resident 68's Narcotic Count Sheet, dated 3/14/23, indicated the current bottle of Lorazepam Oral Concentrate that was stored at room temperature in the Medication Cart 1 Station 1 was opened on 2/27/23. LVN 10 stated she had Resident 68 for multiple days and had been administered Lorazepam from this bottle of Lorazepam Oral Concentrate that was stored at room temperature and would lose its effectiveness if not stored in the refrigerator and would not have desired effect on Resident 68 to control his anxiety and agitation. During an interview with LVN1, on 03/16/23, at 10:39 AM, LVN 1 stated Lorazepam Liquid should be kept in the refrigerator and locked. LVN 1 stated the medication that required to be refrigerated would not be effective if it was not put in the refrigerator. LVN 1 stated the medication should be labeled with the opening date on the bottle when it was opened. During an interview with Director of Staff Development (DSD), on 3/16/23, at 10:49 AM, the DSD stated, If a medication was required to be refrigerated but was stored at room temperature, the potency of the medication would be affected and should not be given to residents. The DSD stated medication should be labeled with opening date on the bottle when it was opened. 9. A review of Resident 7's Admission Record indicated the facility admitted Resident 7 on 2/7/23 with diagnoses that included Type II diabetes mellitus and bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows). A review of Resident 7's MDS, dated [DATE], indicated Resident 7 had severely impaired memory and cognition. Resident 7 required limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight-bearing assistance) wit [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure seven of seven sampled residents (Residents 174, 134, 133, 7, 9, 68 and 482) in Stations 1, 2, and subacute unit to be free from significant medication errors when: 1. Resident 174, a dialysis (a procedure to remove waste product and excess fluid from the blood) resident, did not receive Losartan Potassium (a medicine used to treat high blood pressure) for 52 days from 1/21/23 to 3/13/23. 2. Resident 134 received Potassium Chloride ER ([ER-Extended Release] a medicine used to prevent or treat low potassium levels in the body) for over one year without adequate indication for its use. 3. Resident 134 chewed and swallowed Potassium Chloride ER with less than a glass of water. 4. Resident's 134's heart rate was not assessed before administering Lisinopril (a medication to treat high blood pressure and heart failure) based on physician's order to hold for Systolic Blood Pressure (SBP, measures the pressure of your blood in your arteries [tube like structure responsible for transporting blood]) less than (<) 110 milliliters per mercury (mmHg, unit of measurement) and heart rate (HR) < 60 beats per minute (bpm, unit of measurement). 5. Resident 133 received expired insulin medication, Lantus (lowers blood sugar), for 26 days past the expiration date. 6. Resident 7 received expired medication, Humulin R (lowers blood sugar), for 6 days past the expiration date. 7. Resident 9 received expired medication, Tylenol with Codeine #3 (controlled pain medication), for 6 doses past the expiration date. 8. Facility failed to refrigerate Lorazepam (anti-anxiety medication. Anxiety is a feeling of fear, dread and uneasiness) for 16 days in accordance with manufacturer's specifications for Resident 68. 9. Facility failed to ensure to administer Gabapentin (a medicine used to treat partial seizures, nerve pain from shingles and restless leg syndrome) capsule 200 mg three times a day to Resident 482 in accordance with the physician's order. These deficient practices increased the risk of Residents 174, 134, 133, 7, 9, and 68 to experienced serious medical complications such as restlessness, severe weakness, severe pain, high blood sugar, high blood pressure, stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), chest pain, cardiac (heart) arrest, hospitalization , and or death. On 3/15/2023 at 5:45 PM, the Department called an Immediate Jeopardy (IJ), a situation in which the facility's noncompliance with one or more requirements of participation had caused, or is likely to cause, serious injury, harm, impairment, or death to a resident, in the presence of the Administrator and Director of Nursing (DON) due to facility's failure to ensure Residents 174, 134, 133, 7, 9, and 68 were free from significant medication errors during medication administration observation. On 3/16/2023, at 7:45 PM, the Administrator and DON provided an acceptable IJ removal plan that included the following: 1. Nurse Practitioner was informed by a licensed nurse regarding non-administration of Losartan medication, advised resident and responsible party to contact Primary Physician. 2. Potassium chloride was discontinued on 3/13/2023 and completed a STAT (immediately) potassium (a mineral) level with normal level result. 3. In-service was provided by the Director of Nursing related to potassium administration based on manufacturer's specification for Potassium ER, swallow whole do not crush or chewed, do not allow to dissolve in the mouth and must be taken containing 8 ounces (oz, a unit of measurement) of water. 4. In-service was provided by the Director of Nursing related to proper administration of multivitamins by shaking the bottle before administration. 5. Resident 133 expired Lantus was replaced with a new open insulin pen on 3/15/2023. 6. Resident 7 expired Humulin R insulin was replaced with new Insulin vial on 3/15/2023. 7. Residents 9 expired Tylenol with codeine #3 replaced with new Tylenol Codeine #3 on 3/15/2023. 8. Resident 68 lorazepam was replaced with new lorazepam on 3/15/2023. 9. Resident 134 Artificial tears replaced with a new Artificial Tears on 3/13/2023. 10. The facility Medical Director was notified by the Assistant Director of Nursing (ADON) regarding the facility noncompliance of pharmacy services surrounding medication administrations, drug labeling and storage including residents affected. On 3/16/2023 at 8:30 PM, the Department removed the IJ after verifying and confirming onsite that the facility implemented the IJ removal plan in the presence of the Administrator and DON. Findings: 1. A review of Resident 174's Admission Record indicated the facility admitted Resident 174 on 1/21/23, with diagnoses that included end stage renal (kidney) disease (a medical condition in which the kidneys stop working permanently leading to dialysis [a procedure to remove waste product and excess fluid from the blood] or kidney transplant [a surgery done to replace a diseased kidney with a healthy kidney from a donor]), cerebral infarct (lack of adequate blood supply to brain cells), diabetes mellitus (blood sugar problem), and hypertension (high blood pressure). A review of Resident 174's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/27/23, indicated Resident 174 had no memory and cognitive (thought process and ability to reason or make decisions) impairment. A review of Resident 174's Order Summary, indicated an active medication order for Losartan Potassium Oral Tablet 50 milligrams (mg, a unit of measurement) give one tablet by mouth one time a day for hypertension, hold for SBP < 110 or HR < 60 with an order date of 1/21/23. A review of Resident 174's Order Summary, indicated an active medication order dated 1/21/23 for Losartan Potassium Oral Tablet 50 mg, give one tablet by mouth one time a day for hypertension, hold for SBP < 110 mmHg or HR < 60 bpm. A review of Resident 174's Medication Administration Record (MAR), dated 1/1/23 to 1/31/23, 2/1/23 to 2/28/23, and 3/1/23 to 3/31/23, indicated there was no Losartan Potassium 50 mg one (1) tablet once daily by mouth listed. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 7, on 3/13/23, at 11:56 AM, LVN 7 reviewed and verified Resident 174's MAR on 3/13/23. LVN 7 stated there was no Losartan Potassium 50 mg 1 tab once daily by mouth transcribed in the MAR. LVN 7 stated she had never administered Losartan Potassium to Resident 174. During an interview with Registered Nurse (RN) 4, on 3/13/23, at 11:59 AM, RN 4 stated Losartan Potassium 50 mg 1 tablet once daily by mouth was ordered on 1/21/23 and the medication was not transcribed on the MAR from 1/1/23 to 3/31/23. RN 4 stated Losartan Potassium was not administered to Resident 174. RN 4 stated Resident 174 was a dialysis resident and the resident's blood pressure needed to be managed and controlled (by medication). RN 4 stated elevated and uncontrolled blood pressure can lead to heart problems, stroke, and death. During an interview with Resident 174, on 3/13/23, at 2:52 PM, Resident 174 stated he has a history of hypertension. Resident 174 stated he was taking Losartan Potassium for high blood pressure and reported dizziness during wheelchair transfers (to and from the bed). A review of Resident 174 record, titled Weights and Vitals Summary, indicated Resident 174 had the following blood pressure readings: - 1/23/23- 159/67 mmHg - 1/24/23 - 168/50 mmHg - 1/25/23 - 154/80 mmHg - 1/31/23 - 176/57 mmHg - 2/03/23- 160/84 mmHg (8:46 AM) - 2/03/23 - 160/78 mmHg (4:57 PM) - 2/04/23 - 160/80 mmHg - 2/05/23 - 158/89 mmHg - 2/14/23 - 176/74 mmHg - 2/15/23 - 156/60 mmHg - 2/19/23 - 160/66 mmHg (8:06 AM) - 2/19/23 - 152/64 mmHg (12:05 PM) - 2/19/23 - 159/57 mmHg (4:01 PM) - 2/20/23 - 158/89 mmHg - 2/23/23 - 158/80 mmHg - 2/24/23 - 169/67 mmHg - 2/26/23 - 159/89 mmHg (8:16 AM) - 2/26/23 - 158/68 mmHg (5:52 PM) - 2/27/23 - 160/76 mmHg - 3/01/23 - 156/74 mmHg - 3/03/23 - 158/70 mmHg - 3/04/23 - 152/60 mmHg - 3/05/23 - 160/72 mmHg - 3/06/23 - 159/74 mmHg (10:46 AM) - 3/06/23 - 160/62 mmHg (6:10 PM) - 3/08/23 - 168/60 mmHg- - 3/10/23 - 160/72 mmHg - 3/11/23 - 156/68 mmHg (12:13 PM) - 3/11/23 - 160/66 mmHg (4:37 PM) - 3/11/23 - 152/62/mmHg (6:44 PM) A review of Resident 174's Care Plan initiated on 1/21/23 and revised on 1/24/23, indicated Resident exhibits or is at risk for cardiovascular (refers to heart and blood vessel disease) symptoms or complications related to diagnosis of hypertension, bradycardia (low heart rate), hyperlipidemia (high fats in the blood), and cerebrovascular accident (CVA, also known as stroke and complication of high blood pressure). The Care Plan intervention indicated, To administer meds as ordered and assess for effectiveness and side effects and report abnormalities to physician. During an interview with the Registered Nurse Supervisor (RNS) on 3/13/23, at 3:07 PM, the RNS stated the RN or LVN carry out the physician order. The RNS stated, Pharmacy automatically receives medication order once order is entered in PCC (Point Click Care, a software for digital data of residents). During an interview with the DON on 3/13/23, at 3:34 PM, the DON stated Licensed nurse enters physician order in PCC once order is received and confirmed. The pharmacy immediately has access to the new order once it is entered in PCC. The facility should call or fax the pharmacy to confirm if the order was received. 2. A review of Resident 134's Admission Record indicated the facility admitted Resident 134 on 9/1/2021 with diagnoses that included nonrheumatic aortic valve stenosis (narrowing of the aortic valve [part of the heart] opening), mitral valve insufficiency (a heart disease in which the valve between the left heart chambers does not close completely), diabetes mellitus, hypertension and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). A review of Resident 134's MDS, dated [DATE], indicated Resident 134 had no memory and cognitive impairment. During a medication pass observation, on 3/13/23, from 9:02 AM to 9:22 AM, with LVN 11, in Nursing Station 2, at Medication Cart (Med Cart 2). LVN 11 prepared and gave one tablet of Potassium Chloride Extended Release (ER), 10 milliequivalents (mEq, unit of measurement) by mouth to Resident 134. During an interview with RN 4, on 3/13/23, at 11:08 AM, and concurrent review of the physician Order Summary Report, dated 12/27/22, 1/23/23, and 3/13/23, indicated Potassium Chloride ER tablet extended release 10 mEq one tablet by mouth, one time a day, as a supplement for Lasix (a medication which increases urine output). RN 4 stated Resident 134 continued to receive Potassium Chloride ER after Lasix was last given and discontinued on 1/17/22. RN 4 stated, Potassium Chloride ER order should have been clarified with the physician when Lasix was discontinued on 1/17/22. The RN 4 stated the purpose of Potassium Chloride ER supplement is to replenish the resident's potassium depleted by Lasix. RN 4 stated if Potassium Chloride ER is continued without Lasix, Resident 134 can have hyperkalemia which can cause symptoms like chest pain, irregular heartbeat, and hospitalization . During an interview with Resident 134, on 3/13/23, at 3:13 PM, Resident 134 stated I felt tingling on my hands for one week when I rub my hands together. During an interview with LVN 11, on 3/13/23, at 3:19 PM, LVN 11 stated if Lasix is prescribed for a resident, it should be supplemented with potassium. LVN 11 stated once Lasix is discontinued, the potassium should be discontinued depending on the resident's potassium level. During an interview with the DON, on 3/13/23, at 3:34 PM, the DON stated, The pharmacy is informed when a medication is discontinued in PCC (Point Click Care, a software for digital data of residents). The DON stated, Indication for potassium in Order Summary should be updated if potassium is ordered as a supplement for Lasix and should be discontinued after Lasix is discontinued. A review of Resident 134's record, titled Order Summary Report, dated 3/13/23, indicated Potassium Chloride ER Tablet Extended Release 10 mEq was ordered on 9/01/2021, to give one tablet by mouth, one time a day, for supplement of taking Lasix. 3. During the medication pass observation with on 3/13/23, at 9:22 AM, LVN 11 administered Potassium Chloride ER 10 mEq one tablet and Resident 134 bit the tablet, quickly chewed, and swallowed the medication with less than 6-8 ounces of water. During an interview with Resident 134, on 3/13/23, at 9:31 AM, Resident 134 stated she bit the Potassium tablet to little pieces before swallowing it. Resident 134 stated she drank approximately 1 ounce of water with Potassium. During an interview with LVN 11, on 3/13/23 at 9:51 am, LVN 11 stated the plastic cup was a four-ounce cup. LVN 11 stated, Potassium Chloride tablet should be taken with 6-8 ounces of water. LVN 11 stated Potassium Chloride tablet should not be cut, crushed, or chewed because it is enteric coated (medication with special mechanism to protect the stomach from irritation when swallowed) and can cause stomach irritation. During an interview with RN 4, on 3/13/23, at 11:08 AM, RN 4 stated, Potassium Chloride tablet should be given as a whole tablet and should not be crushed or cut because it is an extended-release tablet. The RN 4 stated Potassium Chloride tablet should be given with a whole glass of water. A review of the facility's Policy and Procedure titled, Potassium Chloride (All Populations Monograph), dated 3/16/23, indicated to administer all oral dosage forms with a full glass of water (or other liquid) with or immediately after food. The policy indicated to swallow whole; do not crush or chew; do not allow to dissolve in mouth. 4. During a medication pass observation, on 3/13/23, from 9:02 AM to 9:22 AM, with LVN 11, in Nursing Station 2, at Med Cart 2, LVN 11 prepared one tablet of Lisinopril 2.5 mg and LVN 11 did not assess Resident 134's heart rate before administering the Lisinopril. During an interview with LVN 11, on 3/13/23, at 10:02 AM, LVN 11 stated that Resident 134's heart rate was not checked to see if it is below 60 beats per minute prior to administering Lisinopril. LVN 11 stated, I messed up on the heart rate. LVN 11 stated that one of the consequences of not checking the heart rate before administering Lisinopril can lower the resident's heart rate even more. LVN 11 stated it is important to check the resident's blood pressure and heart rate parameters as ordered by the physician. A review of Resident 134's record, titled Order Summary Report, dated 3/13/23, indicated Lisinopril tablet 2.5 mg, ordered on 9/1/2021, give 1 tablet by mouth, one time a day for hypertension, hold for SBP <110 and HR<60. 5. A review of Resident 133's Admission Record, indicated the facility admitted the resident on 5/31/22 for osteomyelitis (bone infection), respiratory (lungs) failure, type 2 diabetes (a condition caused by high blood sugar levels that can lead to blindness, improper wound healing, and increases risk for heart attack and stroke), and pressure ulcer (injury to tissue and skin resulting from pressure on the skin). A review of Resident 133's MDS, Section C (Cognitive or mental status), dated 12/8/22, indicated Resident 133 had severely impaired cognition. During a medication pass observation, on 3/14/23, at 1:10 PM, found an opened vial of Lantus with the name of Resident 133 and dated 1/19/23, past 28 days from open date. During an interview with LVN 6, on 3/14/23, at 1:14 PM, LVN 6 stated The Lantus was expired based on the open date and should not be in the medication cart. LVN 6 stated the medication was given to the resident daily since 1/19/23 and needed to be unexpired because residents could become hyperglycemic (increased blood sugar) from using expired Lantus. LVN 6 stated expired Lantus might not provide full strength of the medication and will not lower the resident's blood sugar During an interview with LVN 5, on 3/16/23, at 8:42 AM, LVN 5 stated Nurses must check expiration dates when administering medication because expired medications will not be as effective. LVN 5 stated Lantus expires twenty-eight days after it is opened. During an interview with RN 2, on 3/16/23 at 8:25 AM, RN 2 stated expired Lantus might not be as effective and might cause an adverse consequence or hyperglycemia. During an interview with the Director of Nursing (DON), on 3/16/23 at 8:55 AM, the DON stated, Expired medications should not be given, and staff are trained on checking the medication expiration date along with the seven rights of administration and should be checking the expiration dates when administering medications. During an interview with the Pharmacist, on 3/16/23 at 11:13 AM, the Pharmacist stated, Expired medications should not be given to residents because the efficacy may be lowered. Pharmacist stated Lantus expires twenty-eight days after the vial is opened. Pharmacist also stated a random spot check is done on the medication carts during the monthly pharmacist visit and it is possible to miss an expired medication. A review of Resident 133 record, titled Medication Administration Record (MAR), indicated Resident 133 received twenty-six expired doses of Lantus every day at 9 PM from 2/16/23 to 3/13/23. A review of Resident 133's Progress Notes, dated 3/15/23, indicated Resident 133 received expired Lantus from a vial that had been opened for more than twenty-eight days. A review of the facility policy, titled Administering Medications, with revised date 4/2019, indicated the expiration date or beyond use date on the medication label is checked during medication administration and if using a multidose container, the date of opening is recorded on the container. 46779 6. A review of Resident 7's Admission Record indicated the facility admitted Resident 7 on 2/7/23 with diagnoses that included type II diabetes mellitus and bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows). A review of Resident 7's MDS, dated [DATE], indicated Resident 7 had severely impaired memory and cognition. Resident 7 required limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with bed mobility and eating, and extensive assistance (resident involved in activity, staff provide weight-bearing support) with transfer, dressing, toilet use and personal hygiene. A review of Resident 7's Order Summary Report, dated 3/23, the Order Summary Report indicated, Resident 7 to receive Insulin Regular (a short-acting insulin) as per sliding scale (a sliding scale varies the dose of insulin based on blood sugar level) starting on 2/7/23. A review of Resident 7's Medication Administration Record (MAR), dated 3/23, the MAR indicated, Resident 7 received Insulin Regular from 3/1/23 to 3/14/23. During a medication storage observation, on 3/14/23, at 4:20 PM, found a medication bottle labeled with Humulin R and Resident 7's name in the top right drawer in the medication cart 2 of facility station 1. The 2/8 was written on the opened vial of Humulin R for date opened. During an interview with LVN 10, on 3/14/23, at 4:30 PM, LVN 10 stated, The opening date for this opened vial of Humulin R was 2/8/23 and it would expire after 28 days it was opened. LVN 10 stated the expired vial of Humulin R should have been removed from the medication cart. LVN 10 stated (Resident 7) continued to receive the expired Humulin R after the expiration date. LVN 10 stated the expired medication would lose its effectiveness and could lead to hyperglycemia and other negative reactions on Resident 7. During an interview with the DON, on 3/16/23, at 8:55 AM, the DON stated the expired medication should not be given to the residents and staff should check the medication expiration date along with the seven rights of administration when administering medications. During an interview with LVN 1, on 3/16/23, at 10:39 AM, LVN 1 stated the nurse would label the opening date on the insulin bottle and the insulin would expire after 28 days it was opened. LVN 1 stated The expired insulin was not effective and could develop allergic reaction or hyperglycemia. During an interview with Director of Staff Development (DSD), on 3/16/23, at 10:46 AM, the DSD stated, Insulin was good for 28 days after opening and the nurse should label the opening date on the bottle and possible reaction to a resident if receiving expired insulin could be hyperglycemia. A review of the facility policy, Administering Medications, dated 4/2019, the policy indicated the expiration date or beyond use date on the medication label is checked during medication administration and if using a multidose container, the date of opening is recorded on the container. 7. A review of Resident 9's admission record indicated the facility admitted the resident on 7/14/22 for diagnoses including congestive heart failure (heart does not pump blood as well as it should to the rest of the body), hypertension (high blood pressure), kidney disease, dementia (condition involving impairment of brain functions like memory), and chronic pain syndrome. A review of Resident 9's Minimum Data Set Assessment Section C, dated 1/27/23, indicated Resident 9 had severely impaired cognition. During a concurrent medication storage observation and interview with LVN 7, on 3/14/23, at 4:15 PM, at Med Cart 2 on Unit 2, Resident 9's bubble pack (supply of medications with individually sealed compartments) of Tylenol with Codeine #3 (a habit-forming pain medication) had an expiration date of 3/5/23 printed on the bubble pack of the medication. LVN 7 stated Resident 9 had an order for Tylenol with Codeine #3 to be taken as needed for moderate pain and had been receiving expired medication since 3/5/23. LVN 7 stated the resident received six expired doses of Tylenol with Codeine #3 with the last dose being administered on 3/14/23. During an interview with the DON, on 3/16/23 at 8:55 AM, the DON stated expired medications should not be given and staff are trained on checking the medication expiration date along with the seven rights of administration and should be checking the expiration dates when administering medications. The DON stated checking for expired controlled medications are done during the DON's daily rounds on the units. The DON stated the expectation is for nurses to bring expired controlled medications that are no longer in use to the DON office immediately or before the end of the day. During an interview with the Pharmacist, on 3/16/23 at 11:13 AM, the Pharmacist stated expired medications should not be given to residents because the efficacy may be lowered. Pharmacist also stated a random spot check is done on the medication carts during the monthly pharmacist visit. 8. A review of Resident 68's Admission Record indicated the facility admitted Resident 68 on 1/26/22, with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area, also known as stroke) and bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows). During a medication storage observation, on 3/14/23, at 3:40 PM, found a medicine paper package labeled with Lorazepam Oral concentrate and labeled with Resident 68's name was stored in the narcotics (a drug or substance that affects mood and behavior) drawer of the medication cart 1 of facility station 1 at room temperature. The Lorazepam Oral Concentrate package indicated Discard 90 days after opening, and Store at cold temperature, refrigerate at 2-degree to 8-degree Celsius, No open date recorded or written on Lorazepam paper package. The bottle of Lorazepam was filled on 2/24/23. During an interview with LVN 10, on 3/14/23, at 3:55 PM, LVN 10 stated there were no open dates recorded on either the Lorazepam bottle or the paper package. LVN 10 stated this bottle of Lorazepam Oral Concentrate had been stored at room temperature in the medication cart 1 consistently and did not know when this bottle of Lorazepam was opened since there was no opening date on the bottle. LVN 10 stated she did not know Lorazepam Oral Concentrate needed to be refrigerated after opening. A review of Resident 68's Order Summary Reports, dated 2/23 and 3/23, indicated, Resident 68 to receive Lorazepam Oral Concentrate (a medication is used to treat anxiety) 1 mg two times a day for anxiety manifested by inconsolable yelling and screaming, starting on 12/24/22. A review of Resident 68's Medication Administration Record (MAR), dated 3/23, indicated, Resident 68 received Lorazepam Oral Concentrate 1 mg two times a day from 2/23 to 3/14/23. A review of Lorazepam Oral Concentrate package box and paper insert, indicated, Manufacture's Specifications for Lorazepam Oral Concentrate should be refrigerated at 2-degree Celsius to 8-degree Celsius and discard opened bottle after 90 days. During a concurrent record review and interview with LVN 10, on 3/14/23, at 4:00 PM, Resident 68's Narcotic (a drug or other substance that affects mood or behavior) Count Sheet, dated 3/14/23, indicated the current bottle of Lorazepam Oral Concentrate that was stored at room temperature in the medication cart 1 station 1 was opened on 2/27/23. LVN 10 stated she had Resident 68 for multiple days and had been administered Lorazepam from this bottle of Lorazepam Oral Concentrate that was stored at room temperature and would lose its effectiveness if not stored in the refrigerator and would not have desired effect on Resident 68 to control his anxiety and agitation. During an interview with LVN 1, on 3/16/23, at 10:39 AM, LVN 1 stated Lorazepam liquid should be kept in the refrigerator and locked. LVN 1 stated the medication that required to be refrigerated would not be effective if it was not put in the refrigerator. LVN 1 stated the medication should be labeled with the opening date on the bottle when it was opened. During an interview with the Director of Staff Development (DSD), on 3/16/23, at 10:49 AM, the DSD stated, If a medication was required to be refrigerated but was stored at room temperature, the potency of the medication would be affected and should not be given to residents. The DSD stated medication should be labeled with opening date on the bottle when it was opened. 42878 9. A review of Resident 482's Admission Record indicated resident was originally admitted to the facility on [DATE] and then readmitted on [DATE] with diagnosis that included, metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently), type 1 diabetes mellitus (a chronic condition in which the pancreas produces little or no insulin with diabetic polyneuropathy(a condition in which a person's peripheral nerves are damaged) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning). A review of Resident 482's History and Physical (H&P) dated 3/09/23 indicated Resident 482 has fluctuating capacity to understand and make decisions. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/01/23, indicated Resident 482 requires two- person assist with total dependence (full staff performance every time) for bed mobility. The MDS indicated Resident 482 requires one- person total dependance for dressing, toilet use, personal hygiene. A review of Resident 482's Physician order summary for the month of March 2023, indicated, on 9/22/22, resident's physician ordered for Gabapentin capsule 100 milligrams (mg - a unit of measure for mass), give 2 capsules by mouth three times a day for neuropathic pain. The order did not indicate it was discontinued from 3/7/23 to 3/16/23. A review of Resident 482's Physician order summary for the month of March 2023, indicated on 3/7/23, resident's physician ordered for Gabapentin capsule 200 milligrams orally three times a day for neuropathy. A review Resident 482's Medication Administration Record (MAR) for the month of order summary, indicated an order for: a. Gabapentin capsule 100 mg, give 2 capsules by mouth three times a day for neuropathic pain and it was administered (MAR with a check mark) to Resident 482 from 3/7/23 to 3/12/23. b. Gabapentin capsule give 200 mg orally three times a day for neuropathy and it was administered (MAR with a check mark) to Resident 482 from 3/7/23 to 3/17/23. During an interview and concurrent record review on 3/16/23 at 4:16 PM with LVN 13, LVN 13 confirmed, a check mark in the MAR indicated the medication had been administered. LVN 13 confirmed she had administered Gabapentin 100 mg, 2 capsules to Resident 482 on 03//23 at 5:00 PM and she administered Gabapentin capsule 200 mg to Resident 482 on 03//23 at 9:00 PM. LVN 13 stated she did not realize that the Gabapentin was a duplicate order. LVN 13 stated Gabapentin 100 mg ordered should have been discontinued when Resident 482 was readmitted on [DATE] since there was a new order of Gabapentin 200 mg three times days on March 7. LVN 13 stated all nurses should always check medications including the physician's order before administering to prevent Resident's from being over medicated. During an interview and concurrent record review with the Director of Nursing (DON) on 3/16/23 at 5:08 PM, the DON stated admitting nurses should always review all the resident's medication and discontinue any previous orders and enter all new set of orders when a resident is readmitted to the facility. The DON stated it was important to make sure to check the physician orders to ensure there was no duplicate order of the same medicine with the same dose and to make sure the facility is giving the correct dose to the resident in accordance with the physician's order. A review of the facility's policy and procedure titled, Administering Medications, revised April 2019, indicated Policy Statement: Medication are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: . 4. Medications are administered in accordance with prescriber orders including any required timeframe . 47331

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Five medication errors out of 29 total opportunities contributed to an overall medication error rate of 17.24 % affecting three of three residents (Residents 174, 134, and 67) observed for medication administration. The medication errors were as follows: 1. Resident 174 failed to receive the physician order of Losartan Potassium (a medicine used to treat high blood pressure) from [DATE] to [DATE]. 2. Resident 134 received the physician order of Potassium Chloride ER ([ER-Extended Release] a medicine used to prevent or treat low potassium [a mineral] levels in the body) for over one year without adequate indication for its use. 3. Resident 134's physician ordered parameters to hold for Systolic Blood Pressure (SBP, measures the pressure of your blood in your arteries [tube like structure responsible for transporting blood]) less than (<) 110 milliliters per mercury (mmHg, unit of measurement) and heart rate (HR) < 60 beats per minute (bpm, unit of measurement) was not obtained prior to the administration of Lisinopril (a medicine used to treat high blood pressure and heart failure). 4. Resident 134 did not receive one drop of Artificial Tears Solution (a medicine used to relieve dry, irritated eyes) for both eyes per physician's order. 5. Resident 67 received the multivitamin liquid from a bottle that was not shaken prior to administration per manufacturer's instruction. These deficient practices had the potential to result in serious medical complications such as severe weakness, eye irritation, blindness, high blood pressure, stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), hyperkalemia (increase potassium, a supplement, in the blood) chest pain, cardiac (heart) arrest, hospitalization , and or death. On [DATE] at 5:45 PM, the Department called an Immediate Jeopardy (IJ), a situation in which the facility's noncompliance with one or more requirements of participation had caused, or is likely to cause, serious injury, harm, impairment, or death to a resident, in the presence of the Administrator and Director of Nursing (DON) due to facility's failure to ensure that its medication error rate was less than five percent (%) during medication administration observation. On [DATE], at 7:45 PM, the Administrator and DON provided an acceptable IJ removal plan that included the following: 1. The Nurse Practitioner was informed by a licensed nurse regarding non-administration of Losartan Potassium medication, advised resident and responsible party to contact Primary Physician. In-service to Registered Nurses (RNs) to follow policy and procedures related to transcribing new medication upon admission. 2. In-service was provided by the Director of Nursing related to potassium administration based on manufacturer's specification for Potassium ER, swallow whole do not crush or chewed, do not allow to dissolve in the mouth and must be taken containing 8 ounces (oz, a unit of measurement) of water. 3. In-service was provided to all License Nurses by the Director of Nursing related to proper administration of Lisinopril to assess resident heart rate per physician's order. 4. Resident 134 Artificial tears replaced with a new Artificial Tears on [DATE]. In-service to all licensed nurses to follow policy and procedures related to expired medication. 5. In-service was provided by the Director of Nursing related to proper administration of Multivitamins by shaking the bottle before administration. On [DATE] at 8:30 PM, the Department removed the IJ after verifying and confirming onsite that the facility implemented the IJ removal plan in the presence of the Administrator and DON. Findings: 1. A review of Resident 174's Admission Record indicated the facility admitted Resident 174 on [DATE], with diagnoses that included end stage renal (kidney) disease (a medical condition in which the kidneys stop working permanently leading to dialysis [a procedure to remove waste product and excess fluid from the blood] or kidney transplant [a surgery done to replace a diseased kidney with a healthy kidney from a donor]), cerebral infarct (lack of adequate blood supply to brain cells), diabetes mellitus (blood sugar problem), and hypertension (high blood pressure). A review of Resident 174's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated [DATE], indicated Resident 174 had no memory and cognitive (thought process and ability to reason or make decisions) impairment. A review of Resident 174's Order Summary, indicated an active medication order dated [DATE] for Losartan Potassium Oral Tablet 50 milligram (mg, as unit of measurement), give one tablet by mouth one time a day for hypertension, hold for SBP < 110 mmHg or HR < 60 bpm. A review of Resident 174's Medication Administration Record (MAR), dated [DATE] to [DATE], [DATE] to [DATE], and [DATE] to [DATE], indicated there was no Losartan Potassium 50 mg one (1) tablet once daily by mouth listed. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 7, on [DATE], at 11:56 AM, LVN 7 reviewed Resident 174's MAR on [DATE]. LVN 7 stated there was no Losartan Potassium 50 mg 1 tab once daily by mouth transcribed in the MAR. LVN 7 stated she had never administered Losartan Potassium to Resident 174. During an interview with Registered Nurse (RN) 4, on [DATE], at 11:59 AM, RN 4 stated Losartan Potassium 50 mg 1 tablet once daily by mouth was ordered on [DATE] and the medication was not transcribed on the MAR from [DATE] to [DATE]. RN 4 stated Losartan Potassium was not administered to Resident 174. RN 4 stated Resident 174 was a dialysis resident and the resident's blood pressure needed to be managed and controlled (by medication). RN 4 stated elevated and uncontrolled blood pressure can lead to heart problems, stroke, and death. During an interview with Resident 174, on [DATE], at 2:52 PM, Resident 174 stated he has a history of hypertension. Resident 174 stated he was taking Losartan Potassium for high blood pressure and reported dizziness during wheelchair transfers (to and from the bed). A review of Resident 174 record, titled Weights and Vitals Summary, indicated Resident 174 had the following blood pressure readings: - [DATE]- ,d+[DATE] mmHg - [DATE] - ,d+[DATE] mmHg - [DATE] - ,d+[DATE] mmHg - [DATE] - ,d+[DATE] mmHg - [DATE]- ,d+[DATE] mmHg (8:46 AM) - [DATE] - ,d+[DATE] mmHg (4:57 PM) - [DATE] - ,d+[DATE] mmHg - [DATE] - ,d+[DATE] mmHg - [DATE] - ,d+[DATE] mmHg - [DATE] - ,d+[DATE] mmHg - [DATE] - ,d+[DATE] mmHg (8: 06 AM) - [DATE] - ,d+[DATE] mmHg (12:05 PM) - [DATE] - ,d+[DATE] mmHg (4:01 PM) - [DATE] - ,d+[DATE] mmHg - [DATE] - ,d+[DATE] mmHg - [DATE] - ,d+[DATE] mmHg - [DATE] - ,d+[DATE] mmHg (8:16 AM) - [DATE] - ,d+[DATE] mmHg (5:52 PM) - [DATE] - ,d+[DATE] mmHg - [DATE] - ,d+[DATE] mmHg - [DATE] - ,d+[DATE] mmHg - [DATE]- ,d+[DATE] mmHg - [DATE] - ,d+[DATE] mmHg - [DATE] - ,d+[DATE] mmHg (10:46 AM) - [DATE] - ,d+[DATE] mmHg (6:10 PM) - [DATE] - ,d+[DATE] mmHg - [DATE] - ,d+[DATE] mmHg - [DATE] - ,d+[DATE] mmHg (12:13 PM) - [DATE] - ,d+[DATE] mmHg (4:37 PM) - [DATE] - ,d+[DATE]/mmHg (6:44 PM) A review of Resident 174's Care Plan initiated on [DATE] and revised on [DATE], indicated Resident exhibits or is at risk for cardiovascular (refers to heart and blood vessel disease) symptoms or complications related to diagnosis of hypertension, bradycardia (low heart rate), hyperlipidemia (high fats in the blood), and cerebrovascular accident (CVA, also known as stroke and complication of high blood pressure). The Care Plan intervention indicated, To administer meds as ordered and assess for effectiveness and side effects and report abnormalities to physician. During an interview with the Registered Nurse Supervisor (RNS) on [DATE], at 3:07 PM, the RNS stated the RN or LVN carry out the physician order. The RNS stated, Pharmacy automatically receives medication order once order is entered in PCC (Point Click Care, a software for digital data of residents). During an interview with the DON on [DATE], at 3:34 PM, the DON stated Licensed nurse enters physician order in PCC once order is received and confirmed. The pharmacy immediately has access to the new order once it is entered in PCC. The facility should call or fax the pharmacy to confirm if the order was received. 2. A review of Resident 134's Admission Record indicated the facility admitted Resident 134 on [DATE] with diagnoses that included nonrheumatic aortic valve stenosis (narrowing of the aortic valve [part of the heart] opening), mitral valve insufficiency (a heart disease in which the valve between the left heart chambers does not close completely), diabetes mellitus, hypertension and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). A review of Resident 134's MDS, dated [DATE], indicated Resident 134 had no memory and cognitive impairment. During a medication pass observation, on [DATE], from 9:02 AM to 9:22 AM, with LVN 11, in Nursing Station 2, at Medication Cart (Med Cart 2). LVN 11 prepared and gave one tablet of Potassium Chloride Extended Release (ER), 10 milliequivalents (mEq, unit of measurement) by mouth to Resident 134. During an interview with RN 4, on [DATE], at 11:08 AM, and concurrent review of the physician Order Summary Report, dated [DATE], [DATE], and [DATE], indicated Potassium Chloride ER tablet extended release 10 mEq one tablet by mouth, one time a day, as a supplement for Lasix (a medication which increases urine output). RN 4 stated Resident 134 continued to receive Potassium Chloride ER after Lasix was last given and discontinued on [DATE]. RN 4 stated, Potassium Chloride ER order should have been clarified with the physician when Lasix was discontinued on [DATE]. The RN 4 stated the purpose of Potassium Chloride ER supplement is to replenish the resident's potassium depleted by Lasix. RN 4 stated if Potassium Chloride ER is continued without Lasix, Resident 134 can have hyperkalemia which can cause symptoms like chest pain, irregular heartbeat, and hospitalization . During an interview with Resident 134, on [DATE], at 3:13 PM, Resident 134 stated I felt tingling on my hands for one week when I rub my hands together. During an interview with LVN 11, on [DATE], at 3:19 PM, LVN 11 stated if Lasix was prescribed for a resident, it should be supplemented with potassium. LVN 11 stated once Lasix was discontinued, the potassium should be discontinued depending on the resident's potassium level. During an interview with the DON, on [DATE], at 3:34 PM, the DON stated, The pharmacy is informed when a medication is discontinued in PCC (Point Click Care, a software for digital data of residents). The DON stated, Indication for potassium in Order Summary should be updated if potassium is ordered as a supplement for Lasix and should be discontinued after Lasix is discontinued. A review of Resident 134's Order Summary, dated [DATE], indicated Lasix 40 mg 1 tablet by mouth one time a day for hypertension was initially ordered on [DATE] and changed on [DATE] to Lasix 40 mg 1 tablet by mouth, one time only for edema for 1 day, and give 1 tablet by mouth, one time a day every other day for edema for 90 days (Wednesday, Friday, Sunday). A review of Resident 134's record, titled Order Summary Report, dated [DATE], indicated Potassium Chloride ER Tablet Extended Release 10 mEq was ordered on [DATE], to give one tablet by mouth, one time a day, for supplement of taking Lasix. A review of Resident 134's MAR, dated [DATE] to [DATE], indicated Lasix 40 mg was last administered on [DATE]. There was no order to discontinue Potassium Chloride ER which was a supplement to Lasix. A review of Resident 134's MAR, dated [DATE] to [DATE], [DATE] to [DATE], [DATE] to [DATE], and [DATE] to [DATE], indicated Resident 134 received Potassium Chloride ER tablet extended release 10 mEq one tablet daily. 3. During a medication pass observation, on [DATE], from 9:02 AM to 9:22 AM, with LVN 11, in Nursing Station 2, at Medication Cart (Med Cart 2), LVN 11 prepared one tablet of Lisinopril 2.5 mg and LVN 11 did not assess Resident 134's heart rate before administering the Lisinopril. During an interview with LVN 11, on [DATE], at 10:02 AM, LVN 11 stated that Resident 134's heart rate was not checked to see if it is below 60 beats per minute prior to administering Lisinopril. LVN 11 stated I messed up on the heart rate. LVN 11 stated that one of the consequences of not checking the heart rate before administering Lisinopril can lower the resident's heart rate even more. LVN 11 stated it is important to check the resident's blood pressure and heart rate parameters as ordered by the physician. A review of Resident 134's record, titled Order Summary Report, dated [DATE], indicated Lisinopril tablet 2.5 mg, ordered on [DATE], give 1 tablet by mouth, one time a day for hypertension, hold for SBP <110 and HR<60. 4. During a medication pass observation, on [DATE], from 9:02 AM to 9:22 AM, with LVN 11, in Nursing Station 2, at Med Cart 2, LVN 11 administered to Resident 134, Artificial Tears Solution 1% (Carboxymethylcellulose Sodium) 2 drops in right eye three times a day for redness. A review of Resident 134's record, titled Order Summary Report, dated [DATE], indicated, on [DATE], the physician ordered Artificial Tears Solution 1%, 2 drops in right eye three times a day. A review of Resident 134's Physician's Telephone Orders, dated [DATE], indicated Artificial Tears Eye Drops 1 drop OU (both eyes) BID (twice daily) for 1 week then 1 drop OU BID PRN (as needed) for dry eyes and contusion to the right eye. A review of Resident 134's MAR, dated [DATE] to [DATE], indicated Artificial Tears Solution 1% 2 drops in right eye three times daily was administered for Resident 134 from [DATE] to [DATE]. No administration record of Artificial Tears Eye Drops, 1 drop OU BID for 1 week, then 1 drop OU BID PRN. During an interview with RN 4, on [DATE], at 10:48 AM, RN 4 stated the physician order dated [DATE] was not transcribed to the MAR and not getting the eye drop on both eyes would cause harm and discomfort to the untreated eye. A review of the facility's Policy and Procedure titled, Physician Orders, effective [DATE] indicated III. Procedures: VIII. Whenever possible, the Licensed Nurse receiving the order will be responsible for documenting and implementing the order. 5. A review of Resident 67's admission record indicated the facility admitted Resident 67 on [DATE] for diagnoses including chronic respiratory (lungs) failure, sepsis (infection in the blood), kidney failure, anoxic brain injury (lack of oxygen to the brain), and gastroesophageal reflux disease (stomach acid backs up towards the throat and irritates the lining of the stomach and throat). A review of Resident 67's MDS, dated [DATE], indicated a test for cognition could not be completed due to impaired cognition. During an observation on [DATE], at 8:19 AM, LVN 6 was observed preparing multivitamin liquid for Resident 67 at Med Cart 2 and did not shake the multivitamin liquid bottle before administration. During an interview with LVN 6, on [DATE], at 1:20 PM, LVN 6 stated the multivitamin liquid was poured into the medication cup and LVN 6 was not aware of any special preparation for the multivitamin liquid. LVN 6 stated the multivitamin liquid bottle was not shaken prior to administration. LVN 6 stated it was important to follow manufacturer's instructions on the bottle to shake well prior to pouring to make sure the vitamins and minerals get dissolved and are not sitting at the bottom of the bottle and to receive the correct dose. During an interview LVN 5, on [DATE], at 8:42 AM, LVN 5 stated nurses must prepare medications like multivitamin liquid according to manufacturer's instructions and either shake or swirl to ensure there is equal distribution of the ingredients. During an interview with RN 2 on [DATE], at 8:25 AM, RN 2 stated nurses must check the manufacturer's instructions on the label to ensure proper administration of the medication. During an interview with the DON, on [DATE], at 8:55 AM, the DON stated that medication preparation depends on the instructions on the manufacturer's label. The DON stated that if the manufacturer's instructions on the label written to shake the bottle, then the nurse must follow the instruction prior to pouring the medication in the medication cup. A review of the facility's policy and procedure titled, Administering Medications, revised [DATE], indicated Policy Statement: Medication are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: . 4. Medications are administered in accordance with prescriber orders including any required timeframe . 47331

Based on observation, interview and record review, the facility failed to provided treatment to maintain normal bowel movement for one of seven sampled residents (Resident 1). Resident 1 was not provided care according to Resident 1' s care plan, physician order, and facility's policies and procedures by failing to: 1. The Certified Nurse Assistant (CNA) failed to document and report to the charge nurse the lack of BM of Resident 1 for eight (8) days. 2. The facility's electronic system does not allow the CNA's to update changes in BM episodes. 3. The Licensed Vocational Nurse (LVN) did not give the standing orders to treat Resident 1 for constipation. 4. The physician was not notified of Resident 1's lack of BM for 5 days from [DATE] to [DATE]; 6 days from [DATE] to [DATE]; and 8 days from [DATE] to [DATE]. The deficient practice resulted in Resident 1 large feculent matter output from a nasogastric tube (NGT, a flexible tube or plastic or rubber that passes through the nose down through the esophagus [tube were food passes] at the hospital on [DATE]. Resident 1 had died on [DATE] with cause of death included [CONDITION(S)] (life-threatening complication of infection). On [DATE] at 8:34 p.m., an Immediate Jeopardy was called, (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death of a resident) in the facility. During a teleconference with Director of Nursing (DON) and in the presence of Licensed Vocational Nurse 4 (LVN 4), were notified of the findings regarding the facility's failure to identify residents Bowel Movement (BM) program not implemented, gaps on communication, and monitoring residents with no BM. On [DATE] at 3:44 p.m., the Administrator (ADM), provided an acceptable plan of action (POA) that included the following summarized actions: 1. The identification of other residents potentially affected by the deficient practice identified. On [DATE], the medical records and/or designee conducted BM documentation audit of all residents for the last two weeks to identify gaps and records of no BM in the last three (3) days. The facility identified twenty-three (23) residents with no record of BM in the last 3 days. Residents identified were assessed by a licensed nurse, on [DATE] and provided bowel regimen as ordered. 2. A systemic changes of all current and new admit residents will develop a bowel protocol per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3. The Regional Nurse Resource (RNR), DON and or designee initiated an in-service education on [DATE]to licensed nurses to be completed by [DATE]regarding the following (a) BM observation and monitoring, (b) BM assessment and notification, (c) BM regimen protocols and administrations, (d) BM documentation and updating electronically when there is changes. 4. The RNR, DON and or designee initiated an in-service education on [DATE] to CNA's to be completed by [DATE] regarding the following: (a) BM observation and monitoring related to frequency, consistency and size, (b) BM episodes reporting to licensed nurses and (c) BM documentation and updating electronically when changes occurs. 5. Medical records and or designee will conduct a daily BM audit Monday to Friday to capture any sign of gaps or omission and findings will be provided to the DON, ADON, Registered Nurse (RN) supervisors and or designee for follow up interventions an discussions during daily stand up meeting Monday to Friday. 6. Licensed nurses and or designee will review the BM episode through the CNA's report, point click care (PCC) dashboard and from task bar in resident's profile every shift and as needed. Licensed nurses will assess and initiate change of condition (COC) notifying the physician for further interventions and responsible party (RP) for any reported and or identified residents with no BM for the last seventy-two (72) hours. 7. CNA's will create a new BM entry should there be a BM after the CNA has already documented to update current information of resident BM and report to their respective charge nurse for further intervention and evaluation. 8. Director of Staff Development (DSD) will conduct activities of daily living (ADL) record review specific to BM episodes daily Monday to Friday to capture any omissions and or with no BM episodes. Findings will be discussed during daily stand up meeting Monday to Friday for further interventions, License nurses will review BM records for the last seven (7) days and document summary during their licensed weekly summary notes. 9. The monitoring process included DON and or designee will present and discuss BM audit findings utilizing medical records audit tool forms to the Quality Assurance Committee (QAC) monthly for three (3) months for further recommendations and will re-evaluate thereafter for compliance. The DON will be responsible for the compliance review and follow up. On [DATE] at 6:54 p.m., after verifying and confirming on-site the implementation of the facility's immediate corrective actions within the POA, the IJ was lifted in the presence of the ADM and DON. Cross reference F 726 and F 760. Findings: A review of Resident 1's Admission Record indicated Resident 1 was initially admitted to the facility, on [DATE], and was readmitted on [DATE], with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS, a resident assessment and care plan screening tool), dated [DATE], indicated Resident 1 had severe impairment in cognitive skills (the resident ability to understand, remember and make decisions). Resident 1 required one-person extensive assistance (resident involved in activity, staff provided weight-bearing support) from staff with bed mobility, transfer, eating, toilet use, and personal hygiene. Resident 1 bowel and bladder assessment indicated no episodes of continence (ability to control) in voiding (urinating) and BM. A review of Resident 1's History and Physical (H & P), dated [DATE], indicated Resident 1 general appearance was chronically ill. Resident 1 had a fluctuating capacity to understand and make decisions. A review of Resident 1's care plan, titled Resident exhibits or is at risk for GI symptoms or complication related to constipation, created on [DATE] and reviewed date [DATE], indicated interventions that included the following: licensed nurse to administer medications as ordered, observe for effectiveness and side effects, report to the resident's physician, assess signs and symptoms for constipation, provide a bowel regimen, utilize pharmacologic (medication treatment) agents as appropriate such as laxatives and stool softeners (medication that helps relieve constipation), and document the effectiveness. The listed goals were the following: resident would not develop GI complications for 90 days and the resident would pass a soft stool every 1 to 2 days. A review of Resident 1's ADL, indicated on the following dates that Resident 1 did not have any BM: a. [DATE] to [DATE] (5 days) b. [DATE] to [DATE] (6 days) c. [DATE] to ,d+[DATE] (8 days) A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] suppository (a stool softener given rectally) 10 milligrams (mg, a unit of measurement) every 24 hours (hrs.) PRN for constipation, initially ordered on [DATE] and reordered on [DATE] (readmitted ). 2. Fleet enema (works by increasing water in the intestine to hydrate and soften the stool to help produce a bowel movement given rectally) 7 to 19 grams (gm) every 24 hrs. PRN for constipation if [MEDICATION(S)] suppository is not effective, initially ordered on [DATE] and reordered on [DATE]. 3. Milk of Magnesia (MOM, used for a short time to treat occasional constipation) 400 mg give 30 milliliter (ml) by mouth (PO) PRN at bedtime if no BM in 3 days, initially ordered on [DATE] and reordered on [DATE]. 4. [MEDICATION(S)] powder (increases frequency of BMs and softens the stool) give 17 gm PO with 4 to 8 ounces (oz) of fluid PRN if no BM in past 72 hrs., ordered on [DATE]. A review of Resident 1's physician's ORR for the month of ,d+[DATE], indicated the physician ordered the following medications for the resident to receive routinely: 1.Senna 8.6 mg give 2 tablets at bedtime for constipation, hold for loose stool (watery BM), initially ordered on [DATE] and reordered on [DATE]. 2.[MEDICATION(S)] Powder (same as [MEDICATION(S)], increases frequency of BMs and softens the stool) give 17 gm PO one time a day (QDay) for constipation (mix in 4 to 8 oz. of liquid) and hold for loose stool, initially ordered on [DATE]. A review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's physician's Progress Note, dated [DATE], indicated Resident's 1 abdomen was soft and non-tender. A review of Resident 1's Medication Review Report (MRR), dated [DATE], indicated the physician ordered initially on [DATE] the following PRN [MEDICATION(S)] medications: [MEDICAL RECORD OR PHYSICIAN ORDER] 1.MOM 30 ml PO every 24 hrs. PRN if no BM in past 72 hrs. 2.[MEDICATION(S)] suppository 10 mg rectally every 24 hrs. PRN if MOM was not effective. 3.Fleet enema 7 to 19 gm/118 ml insert rectally every 24 hrs. PRN if [MEDICATION(S)] suppository was not effective. 4.[MEDICATION(S)] 17 gm PO every 24 hrs. PRN for constipation if the resident has not had a BM in past 72 hrs. A review of Resident 1's MAR, dated ,d+[DATE], indicated the facility did not administer Resident 1 any PRN [MEDICATION(S)] medications as ordered between the dates of [DATE] to [DATE]. A review of Resident 1's nurse's Progress Notes dated from [DATE] to [DATE], there were no documentation indicating that the facility notified Resident 1's physician regarding the resident not having any BM or having constipation. A review of Resident 1's Situation Background Assessment and Review (SBAR) Communication Form, dated [DATE], indicated Resident 1 had a blood pressure (BP) of ,d+[DATE] (critical high, normal level less than ,d+[DATE]), pulse rate 114 (PR, normal rate 60 to 100 beats per minute), and pulse oximetry of 85% (O2 sat, a saturation level of blood oxygen, normal level 95% to 100%). A review of Resident 1's nurse's Progress Notes, dated [DATE] 1:20 p.m., the notes indicated that a CNA (unknown name) reported that Resident 1 had refused lunch and did not appear to be himself. The note indicated that Resident 1's O2 sat was 80 % on room air (no oxygen supplement) and placed on 5 liters (L) via nasal cannula (NC, a lightweight tube with one end split into two prongs which are placed in nostrils to deliver oxygen). RN 1 documented that Resident 1's O2 sat only improved to 83%. Resident 1 was the placed on 15 L via a non-rebreather mask (NRB, a device used to deliver a high oxygen concentration during emergency). Resident 1 was transferred to a General Acute Care Hospital (GACH) for further evaluation. A review of Resident 1's GACH Emergency Department (ED) notes, dated [DATE] at 5:28 p.m., indicated the GACH admitted Resident 1 to the intensive care unit (ICU) for a large bowel obstruction, septic shock (widespread infection causing organ failure and dangerously low blood pressure), and pneumonia (a lung infection). A review of Resident 1's GACH radiology (a branch of medicine that uses imaging technology to diagnose and treat disease) report, dated [DATE], a Computerized Tomography Angiogram (CTA, series of x-ray angles using a computer to provide detailed picture of body organs) chest, CT abdomen (stomach), and pelvic (basin shape bone that protects abdominal organs), indicated the following impression: 1.A bilateral lower lobe atelectasis (collapsed lungs) and/or pneumonia, 2.Severe fecal impaction (severe bowel condition in which a hard, dry mass of stool becomes stuck in the colon or rectum (anus) suspicious for stercoral [CONDITION(S)] (rare [CONDITION(S)] form of colon infection that occurs when impacted fecal materials leads to distention of the colon and eventually fecaloma [hard feces] formation). 3.Associated large bowel obstruction with diffuse colonic distention (build-up of gas or fluid) in the cecum (pouch connecting the small and large in intestines) measuring up to 10 centimeter (cm) in diameter. Diffusely dilated (wider in diameter size) small bowel loops are likely secondary to the large bowel obstruction. A review of Resident 1's GACH emergency room (ER) Inpatient Consult notes, dated [DATE], indicated Resident 1 had a Code Blue (hospital emergency code used to describe a critical status of a patient). The notes indicated Resident 1 was admitted for [CONDITION(S)] with GI source with possible obstruction as patient had a large feculent (waste matter) output from a nasogastric tube (NGT, a flexible tube or plastic or rubber that passes through the nose down through the esophagus [tube were food passes] and into the stomach), and surgery was considered a possibility. A review of Resident 1 Certificate of Death, dated [DATE] at 1:15 p.m., indicated Resident 1's cause of death was acute hypoxic respiratory failure (condition in which the blood does not have enough oxygen or has too much carbon dioxide), [CONDITION(S)], and pneumonia. During a telephone interview on [DATE] at 1:57 p.m., LVN 1 stated she was familiar and took of Resident 1 but could not recall giving any laxatives in the past. LVN 1 stated Resident 1 was incontinent of BM. LVN 1 stated generally CNA staff would give report to her at the end of the shift for that day on BM status. LVN 1 added and stated if during stand up meeting a resident was reported of no BM, she would give PRN and if no result, she would call the physician. During a telephone interview on [DATE] at 2:15 p.m., CNA 1 stated she was familiar and had took care of Resident 1 in the past. CNA 1 stated she took care of Resident 1 on [DATE] the day Resident 1 was transferred to the hospital. CNA 1 stated that morning, Resident 1 was not acting his usual behavior. CNA 1 stated Resident 1's face looked different but did not look like he was in pain. CNA 1 stated Resident 1 did not finish his breakfast tray and had a small BM. CNA 1 stated she reported her observation to her charge nurse unable to recall the charge nurse name. During a telephone interview on [DATE] at 2:25 p.m., CNA 2 stated she took care of Resident 1 on and off in ,d+[DATE] and ,d+[DATE]. CNA 2 unable to recall Resident 1 BM consistency. CNA 2 stated Resident 1 was incontinent of bladder and BM. During a telephone interview and concurrent record review of Resident 1's ADL record, on [DATE] at 8:55 a.m., the DSD verified and stated CNA staffs' ADL entries for [DATE] to [DATE], indicated Resident 1 had no BM for 8 days. The DSD stated she was not aware of or no report from CNA regarding Resident 1 had BM issues. The DSD verified and stated Resident 1's ,d+[DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a random telephone interview on [DATE] at 10:28 a.m., CNA 3 stated she documents on ADL resident's bladder and bowel toileting early morning or at 12 p.m. unable to recall dates. CNA 3 stated she would give report at the end of the shift to the licensed nurse if resident had no BM. CNA 3 added and stated the computer gives an alert box in the ADL to those residents who had not have BM for 2 to 3 days and during stand up meeting from the outgoing licensed nurse. During a telephone interview and concurrent record review of Resident's 1 ADL records, on [DATE] at 12 p.m., the DON verified and stated there had been an issue in the past that CNA staff documented early and once the record were saved in the computer, it could not be changed or altered. The DON stated if the resident had a BM towards the end of the shift, the CNA had to report it to the licensed nurse. The DON stated the licensed nurse would document the BM on their progress notes. The DON stated he was not sure how would the computer picked up when licensed nurse documented in narrative regarding resident's BM. The DON stated Resident 1 listed [MEDICATION(S)] PRN medications were standing orders (a prescribed order in place permanently or until changed or cancelled). During a telephone interview and concurrent record review on [DATE] at 8:30 a.m., the DSD verified and stated the CNA staff did not document any BM entries for 5 days (from [DATE] to [DATE]) and 6 days (from [DATE] to [DATE]). The DSD also stated she was not aware of Resident 1 not having any BM or the CNA staff was not reporting that Resident 1 did not have any BM on those dates ([DATE] to [DATE] and [DATE] to [DATE]). The DSD also verified and stated ,d+[DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview on [DATE] at 9:20 a.m., LVN 2 stated the facility's process was that the CNA staff would report to the charge nurse if the resident had no BM during the shift. LVN 2 stated the facility's licensed nurse would know which residents did not have a BM in the last three days through a dashboard (a computerized generated resident list). LVN 2 stated if a resident had no BM in the last three days, he would give the PRN [MEDICATION(S)] medication as ordered. LVN 2 stated if in 1 to 2 hours the [MEDICATION(S)] was not effective, he would call the resident's physician. LVN 2 stated he took care of Resident 1 in [DATE] but could not recall giving PRN [MEDICATION(S)] medication. During a telephone interview on [DATE] at 7:10 p.m., LVN 3 stated she could not recall Resident 1. LVN 3 stated she would normally ask the CNA staff assigned to her residents if the residents had a BM at the end of the shift and documented in her nurse's notes. LVN 3 stated she would check the resident's profile task and or dashboard for residents who had no BM for 3 days. LVN 3 stated she does not check residents ADL because it had the same information. LVN 3 stated if the resident had no BM for 2 to 3 days, she would give the PRN [MEDICATION(S)] medication, wait for 1 to 2 hours, and if the resident still had no BM, she would call the resident's physician. During a telephone interview on [DATE] at 1:45 p.m., LVN 4 stated regularly worked in Station 4 and at times covers Station 3 where Resident 1 was located. LVN 4 stated she could not recall Resident 1. LVN 4 stated she does weekly assessment on assigned resident's and recollected a question resident last BM history. During another interview on [DATE] at 6:10 p.m., LVN 4 stated she was able to monitor residents with bowel incontinence and residents who have not had BM during her shift through computer. A review of the facility's Abuse Prohibition policy, indicating effective date [DATE] and revised date [DATE]. The policy indicated, Centers prohibits abuse, mistreatment, neglect, misappropriation of resident/patient (hereinafter patient) property, and exploitation for all resident. A review of the facility's P & P titled, Continence Management, reviewed date [DATE], indicated a bowel incontinence assessment would be completed if the resident was incontinent upon admission or readmission and with a change in condition or change in continence status. A continence status would be reviewed quarterly and with significant changes as part of the nursing assessment. The purpose of the policy and procedure was to provide an appropriate treatment and services for residents who were incontinent of bowel to restore as much bowel function as possible. A review of the facility's P & P titled, Notification of Change in Condition, effective date [DATE] and revised on [DATE], indicated the facility must immediately inform the resident and consult with the resident's physician when there was a significant change in the resident's physical status and/or a need to alter treatment significantly (that was a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment). A review of facility's P & P titled Standing Order, effective date [DATE] and revised on [DATE], indicated standing orders may be used for the following but not limited to constipation, pain, and weekly skin checks. If a standing order had not been used within 90 days, it would be reviewed with the physician for continued use.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received supervision and assistance devices to prevent accidents, including, 1. Failure to implement the facility's policy on Falls Management by not reviewing and updating Resident 1's care plans after each fall, and by not conducting an interdisciplinary team (IDT, professional disciplines that work together to provide the greatest benefit for the resident) meeting within 72 hours of Resident 1's fall to evaluate interventions to prevent further falls. 2. Failure to implement the facility's policy on Accidents/Incidents by not reviewing all fall incidents to determine if interventions to prevent further accidents or incidents have been identified and implemented. As a result, Resident 1 sustained multiple falls, and on 5/13/18, Resident 1 sustained a hematoma (bruise) and a laceration (deep cut in the skin) to the forehead which required stitches (sutures) to repair the skin injury. Findings: A review of the Admission Record indicated Resident 1 was originally admitted to the facility on [DATE], and was re-admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS, standardized assessment and care-planning tool), dated 4/12/18, indicated Resident 1 had severe impairment in cognition (mental action of acquiring knowledge and understanding). Resident 1 needed extensive assistance with one-person assist with transfers to or from bed, chair, wheelchair, or standing position, and needed limited assistance with one-person assist during locomotion (ability to move from one place to another) on the unit. A review of Resident 1's nursing notes, dated 2/12/18 to 5/13/18, indicated Resident 1 fell on [DATE], 2/27/18, 3/1/18, 3/11/18, 4/9/18, and 5/13/18. During a review of Resident 1's medical records, dated 2/12/18 to 5/13/18, and a concurrent interview, RN 2 stated since Resident 1's most recent readmission to the facility on [DATE], Resident 1 had the following episodes of fall: On 2/12/18, Resident 1 was found sitting on the floor in an upright position in Resident 1's room. Resident 1 had laceration with active bleeding to the forehead, and tape was applied. On 2/27/18, Resident 1 had an unwitnessed fall in the hallway with no injury. On 3/1/18, Licensed Vocational Nurse 6 (LVN 6) witnessed Resident 1's fall when Resident 1 tried to stand up from the wheelchair. Resident 1 sustained a skin tear to the right shoulder. On 3/11/18, Certified Nursing Assistant 6 (CNA 6) and LVN 4 witnessed Resident 1 self-propelling her wheelchair in the hallway and sitting too close to the edge of the seat, which resulted in Resident 1 sliding down to the floor. On 4/9/18, CNA 7 and LVN 4 witnessed Resident 1 slid down to the floor while the resident was self-propelling her wheelchair and sitting at the edge of the seat. On 5/13/18, Resident 1 fell and sustained a cut to the forehead requiring transfer to General Acute Care Hospital 1 (GACH 1) for evaluation and treatment. A review of the Fall Care Plan Evaluation Progress Note, dated 2/12/18 to 5/2/18, indicated the fall care plan dated 2/13/18 included interventions of 1 on 1 monitoring (one staff to one resident), and possible placement to dementia care unit. Resident 1's care plans were not updated after the fall incidents on 2/27/18 and 3/11/18. A review of the IDT Notes, dated 2/12/18 to 5/13/18, indicated there was no IDT meetings conducted by the team within 72 hours after each fall episode to address Resident 1's falls, possible causal factors, preventive measures, and effectiveness of interventions, or possible new interventions to implement and prevent further falls. During an interview on 7/24/18 at 2:44 p.m., LVN 4 stated nursing staff must update the care plan for falls prevention after every fall incident, add new interventions, and discontinue the ineffective interventions. LVN 4 stated the care plan interventions must be tailored to Resident 1's specific needs. During an interview on 7/24/18 at 3:59 p.m., Registered Nurse 1 (RN 1) stated Resident 1 had multiples fall due to the resident slid down from the wheelchair seat while she was self-propelling the wheelchair. During an interview on 7/25/18 at 3:33 p.m., the Director of Rehabilitation Services stated Resident 1 should have had physical therapy evaluation after each fall incident. On 7/27/18 at 9:35 a.m., during an interview, Physical Therapist (licensed health care professional who can help patients reduce pain and improve or restore mobility) 1 (PT 1) stated he was not aware Resident 1 was sitting too close to the edge of the wheelchair seat. PT 1 stated during the physical therapy (PT, care that aims to ease pain and help patients function, move, and live better) evaluation, on 5/5/18, he recommended for Resident 1 to use the wheelchair for mobility by self-propelling. PT 1 stated he was not aware of the problem that Resident 1 had multiple incidents of fall due to the resident was sliding down the ground while sitting too close to the edge of the wheelchair seat. PT 1 stated that he would have added in his recommendations for Resident 1 to have a 1 on 1 monitoring and/or a chair cushion with a raised front ridge to prevent the resident from sliding off the wheelchair seat. During a telephone interview on 7/27/18 at 11:33 a.m., CNA 6 stated Resident 1 had a flat gel cushion on the wheelchair. CNA 6 stated Resident 1 fell due to the resident sat at the edge of the wheelchair seat and wheeled herself in the hallways too fast. During an interview on 7/27/18 at 12:52 p.m., the Director of Nursing (DON) stated on 4/9/18 and 3/11/18, Resident 1 fell due to the resident sat at the edge of the wheelchair but this problem was not brought to the attention of the Rehabilitation Services. A review of GACH 1's Admission Note, dated 5/13/18, indicated Resident 1 fell when she slipped from the wheelchair and fell to the ground with injury to the left forehead. Resident 1 had a bruise and a 1.5-centimeter (cm) laceration requiring stitches. A review of the facility's policy and procedures titled, Falls Management, revised on 3/15/16, indicated that after every fall incident, the care plan must be updated to reflect the new interventions. It also indicated an interdisciplinary meeting must be conducted within 72 hours of the fall. A review of the facility's policy and procedures titled, Accidents/Incidents, revised on 11/28/16, indicated the Administrator or DON would review all incidents in the Risk Management System to determine if interventions to prevent further accidents or incidents have been identified and implemented.

Based on interview and record review, the facility failed to consult immediately with the Resident 1's Physician (Physician 1) when there was a significant change in clinical condition and the need to alter the treatment significantly, including, 1. Failure to inform Physician 1 when Resident 1 was not responding to Family Member 1 (FM 1)'s verbal commands, when FM 1 reported to Licensed Vocational Nurse 2 (LVN 2) on [DATE] at around 3 p.m. (the start of the 3 p.m. to 11 p.m. shift). 2. Failure to notify Physician 1 when Resident 1 was non-responsive as reported by the Speech Therapy (ST) to LVN 2 on [DATE], at 5:01 p.m. 3. Failure to implement the facility's policy on Nursing Assessment, to accurately reflect the resident's status at the time of assessment, include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members to determine the resident's condition and clinical needs. 4. Failure to implement the facility's policy on Notification of Change in Condition, by not immediately consult with Physician 1, when there was a significant change in Resident 1's physical and mental status (a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complication). As a result, on [DATE], Resident 1's appropriate medical care and interventions were delayed, approximately five hours from the time FM 1 informed LVN 2 Resident 1 was non-responsive, and three hours from the time the Speech Therapist (ST) informed LVN 2 Resident 1 was not responding and was observed shaking. At 8:09 p.m., paramedics evaluated Resident 1 at the facility after FM 1 and FM 2 insisted the nurses to call 911. At 8:43 p.m., Resident 1 arrived to the emergency room (ER) of General Acute Care Hospital 1 (GACH 1) and at 10:50 p.m., Resident 1 expired. Findings: On [DATE], an unannounced visit was made to the facility to investigate a complaint regarding Resident 1's death. A review of the Admission Record indicated, Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - standardized assessment and care-planning tool), dated [DATE] indicated, Resident 1 had severely impaired cognition (mental processes involved in thinking and reasoning), was alert, was able to respond to questions, and spoke in a low tone of voice. Resident 1 required extensive assistance with all activities of daily living (ADLs - such as, bed mobility, transfer, dressing, and personal hygiene). Resident 1 was dependent on a gastrostomy tube (GT - flexible tube surgically inserted in the stomach through the abdominal wall to administer nutrition and medications). A review of the Nursing Care Plan, dated [DATE], indicated Resident 1 was at risk for complications of infection related to septic shock. The goal was for the resident to remain free of complications/infection for 90 days. The interventions included monitoring signs and symptoms of infections and report to the physician as indicated. A review of the ST Treatment Encounter Note (TEN), dated [DATE], indicated Resident 1 was on trials of liquid textures including honey thick liquids due to swallowing problem. Resident 1 became nervous trialing liquids, and told the ST she was anxious all the time and wanted to get better. A review of the Nursing Progress Notes, dated [DATE], timed at 3:19 p.m. LVN 2 indicated Resident 1 was observed with change of condition, altered metal status (loss of alertness). The progress note indicated Resident 1 had increased confusion in the afternoon. A review of the SBAR (Situation, Background, Assessment and Recommendation (SBAR) form dated [DATE], at 3:29 p.m., LVN 2 indicated Resident 1 had increased confusion or disorientation. The SBAR indicated Resident 1's blood pressure was ,[DATE] mmHg (millimeters of Mercury, normal range ,[DATE] - ,[DATE]), the heart rate was 97 beats per minute (normal range ,[DATE]), and the respiration rate was 16 breaths per minutes (normal respiration rate ,[DATE]). LVN 2 notified Physician 1 at around 4 p.m. and the Physician ordered STAT (urgent) blood and urine laboratory tests. A review of the ST TEN, dated [DATE], timed at 5:01 p.m., indicated Resident 1 was non-responsive to name and was observed shaking. FM 1 was at the bedside, expressed concerns regarding Resident 1 not responding and shaking all day. The ST notified LVN 2 and Registered Dietitian 1 (RD 1) as the ST was worried about possible dehydration (a harmful reduction of water in the body). A review of Resident 1's record indicated there was no further documentation by LVN 2 to indicate Resident 1's condition was monitored after 3:29 p.m. when the altered mental status was noted and reported to the physician and after the ST reported to LVN 2, at 5:01 p.m., that Resident 1 was unresponsive and shaking. There was no evidence Resident 1's ability to respond to verbal commands or to touch was assessed, there were no documented vital signs to determine resident's blood pressure, heart rate, and respiratory rate were monitored. A review of the Nursing Progress Notes, dated [DATE], timed at 8:20 p.m., LVN 2 indicated Resident 1 was transferred to GACH 1 via paramedics (911) in stable condition. There was no documentation of Resident 1's condition (vital signs and level of consciousness) leading to the 911 call. A review of the EMT (Emergency Medical Technician or paramedics) Record dated [DATE], indicated EMTs arrived at the facility at 8:09 p.m. Resident 1 was found lying supine (lying flat on the back), non-verbal, and had altered level of consciousness (AL[NAME]). At 8:22 p.m., Resident 1's blood pressure was ,[DATE] mmHg, the heart rate was 110 bpm, and the respiration rate was 18 breaths per minute. The EMT record indicated Resident 1 was arrived at GACH 1 8:40 p.m. A review of GACH 1 ER Record, dated [DATE], timed at 8:43 p.m., indicated Resident 1 was hypotensive (low blood pressure) and did not respond to deep painful stimuli (touch). Resident 1 had agonal breathing (shallow breathing pattern related to [MEDICAL CONDITION] and death). Resident 1 was intubated (a tube inserted into the airway to assist with breathing). At 8:48 p.m., Resident 1's blood pressure was at ,[DATE] mmHg, and the resident went into [MEDICAL CONDITION] (the heart stops beating), cardiopulmonary resuscitation (CPR) was given. Resident 1's family requested for all heroic measures (life-sustaining treatment). At 10:50 p.m., Resident 1 expired. According to the Certificate of Death, Resident 1's immediate cause of death was cardiopulmonary arrest. Underlying conditions were respiratory arrest, [MEDICAL CONDITION] (life-threatening blood infection) and pneumonia (lungs infection). On [DATE] at 11:05 a.m., during an interview, LVN 2 stated on [DATE], while she was making her rounds at the beginning of her shift (around 3 p.m.), FM 1 approached her concerned about Resident 1 being non-responsive. LVN 2 stated she saw Resident 1 and the resident did not appear to be non-responsive. LVN 2 indicated she notified Physician 1 that Resident 1 had increased confusion. On [DATE] at 11:45 a.m., during review of Resident 1's clinical record with LVN 2, she confirmed she was not monitoring Resident 1's condition and not checking Resident 1's vital signs after 3:29 p.m. LVN 2 stated Resident 1 was stable until 8 p.m. LVN 2 stated Resident 1 had a low blood pressure and low oxygen saturation (the amount of oxygen carried by the red blood cells). LVN 2 stated Resident 1's oxygen saturation was at 80% (normal range 95%-100%) and she called 911. LVN 2 stated she did not remember Resident 1's blood pressure reading and she did not document the values. LVN 2 stated she reported Resident 1 increased in confusion to Registered Nurse 1 (RN 1) and she was not sure if RN 1 assessed Resident 1 for change in condition. On [DATE], at 3:15 p.m., during a review of Resident 1's clinical records, and a concurrent telephone interview with RN 1, she stated she could not remember Resident 1's condition. RN 1 stated there was no documentation in Resident 1's clinical records indicated she assessed Resident 1 on [DATE]. On [DATE], at 10:52 a.m., during a telephone interview, Physician 1 stated the nurses should have notified him regarding Resident 1 was not responsive. Physician 1 further stated Resident 1 should have been transferred to the nearest GACH (emergency transfer) when she was non-responsive and was observered shaking. Physician 1 stated there was a three-hour delay response (from 5 p.m. to 8 p.m.) from the ST assessment at 5:01 p.m. On [DATE] at 3:30 p.m., during a telephone interview, the Director of Nursing (DON) stated when Resident 1 had a change in condition, RN 1 should have assessed Resident 1. A review of FM 1's declaration dated [DATE] indicated on [DATE], at 3 p.m., Resident 1 was not responding to FM 1's voice as she used to. FM 1 requested Certified Nurse Assistant 5 (CNA 5) to call Physician 1 and CNA 5 told FM 1 that Resident 1 had a change in condition earlier in the day. At around 8:15 p.m. FM 1 requested LVN 2 to call 911 or FM 1 would call 911 herself. A review of FM 2's declaration dated [DATE], indicated on [DATE], 7:54 p.m. Resident 1 had shallow and labored breathing. FM 2 notified a nurse (not identified by FM 2). The nurses kept assuring the family Resident 1's vital signs were fine, but FM 1 and FM 2 did not see any nurse taking Resident 1's vital signs. According to the facility's policy on Notification of Change in Condition, dated [DATE], immediately consult with the resident's physician, when there is a significant change in the resident's physical, mental, or psychosocial status (a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complication). A review of the facility's policy and procedure on Nursing Assessment, revised on [DATE], indicated the assessment must accurately reflect the resident's status at the time of assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts to determine the resident's condition and clinical needs.

Based on observation, interview, and record review, the facility failed to provide treatment and services to prevent the development of a pressure ulcer (localized injury to the skin and or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and/or friction) for three of five of sample residents with pressure ulcers in a total of 34 sampled residents (Resident 127, 105, and 91). 1. Resident 127: a. The facility failed to monitor Resident 127's skin integrity. b. Obtain and provide treatment to Resident 127's pressure ulcer on the right ischium (bone that makes up the lower-rear part of the pelvis). c. Develop a care plan to address the treatment and progression of pressure ulcer on the right ischium. 2. Resident 105 treatment was not done on 12/5/17, 12/10/17, and 12/12/17 as ordered. 3. Resident 91, who was ordered for bilateral heel protectors for pressure ulcer management. Resident 91 had a left heel deep tissue injury (DTI) and did not have them on as ordered. These deficient practices resulted in Resident 127 developing an unstageable pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) and/or had the potential for other residents to develop and/or have worsened pressure ulcers. Findings: These deficient practices led to Resident 127 developing an unstageable pressure ulcer (pressure ulcer with full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown soft substance) and/or eschar (tan, brown or black hard substance) in the wound bed) on the right ischium on 12/19/17 measuring: 4.1 centimeters (cm) in length by 5.2 cm in width, and an undetermined depth. Findings: A review of the Admission Face Sheet indicated that Resident 127's was readmitted to the facility on [DATE]. Resident 127's [DIAGNOSES REDACTED]. in mental ability severe enough to interfere with daily life). A review of the Skin assessment dated [DATE] indicated Resident 127 had the following pressure ulcers: 1. Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle, slough or eschar may be present) to the sacral area (area above the triangular-shaped bone at the bottom of the spine back). 2. Stage II pressure ulcer (partial-thickness loss of skin with exposed dermis. The wound bed was pink or red, moist, and may also present as an intact or ruptured serum-filled blister) to the left inner heel. 3. DTI (deep tissue injury, intact or non-intact skin with localized area of persistent non-blanchable (when pressure applied the skin does not turn lighter color) deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister) to the left heel. 4. Stage I pressure ulcer (intact skin with non-blanchable redness) to the right heel. 5. DTI to the right hip. A review of the Skin Integrity Report, dated 11/7/17 and 11/8/17 indicated the following: 1. Stage IV to the sacrococcyx (pertaining to both the triangular-shaped bone at the bottom of the spine and the tailbone). 2. Stage II pressure ulcer to the left heel (two sites). 3. Stage I right heel. 4. Stage II pressure ulcer to the right hip. There was no evidence DTI on the left heel and right hip were identified in the Skin Integrity Report dated 11/7/17 and 11/8/17. A review of Resident 127's Braden scale (tool to predict pressure ulcer risk), dated 11/21/17 indicated a score of 10 (score of 10-12 represents high risk). Further review of the form indicated risk factors included limited perception (responds only to painful stimuli), skin was often moist, bedfast (confined to bed), on tube feeding (tube inserted into the stomach for feeding and administration of medications), and required moderate to maximum assistance in moving. A review of the Significant Change in Status Assessment Minimum Data Set (MDS, assessment and care screening tool), dated 12/7/17, indicated Resident 127's brief interview for mental status (BIMS, screening that aids in detecting cognitive impairment) score was 3 (a score of 0-7 indicated severe impairment ). Resident 127 was totally dependent on the staff for bed mobility, transfer, dressing, toilet use, personal hygiene, eating (via feeding tube) and bathing. Resident 127 was incontinent of bowel and bladder. Resident 127 was at risk for pressure ulcer and had two Stage I I pressure ulcers (location not indicated) and one Stage IV pressure ulcer (location not indicated). On 1/10/18 at 8:22 a.m., Resident 127 was observed sleeping on her back on a low air loss mattress (special mattress which uses an air pump to reduce pressure to the body surface to prevent or help heal pressure ulcers). On 1/11/18 at 3:10 p.m., during concurrent record review and interview with the MDS coordinator, he stated that Resident 127 was readmitted to the facility from the general acute care hospital (GACH) on 10/31/17 with a Stage IV pressure ulcer to the sacrococcyx and a Stage I I pressure ulcer to the right hip and left heel. The MDS coordinator stated a significant change of condition assessment, dated 12/7/17, was completed because of the new pressure ulcers. A review of the Weekly Summary, dated 12/18/17, indicated Resident 127 had the following pressure ulcers: 1. Stage II to the right hip. 2. Stage IV to the sacrococcyx. 3. Stage II to the right and left heel. A review of the Skin Assessment, dated 12/18/17, indicated Resident 127 had the following pressure ulcers : 1. Stage IV to the sacrococcyx. 2. Stage II to the right and left heel. A review of the wound consultant's (PA-physician's assistant) progress notes, dated 12/19/17, indicated an unstageable pressure ulcer on the right ischium. The wound consultant indicated a treatment recommendation of Santyl (enzyme that breaks down collagen in damaged tissue and helps healthy tissue to grow). This pressure ulcer on the right was ischium, was not on the Weekly Summary or Skin Assessment completed by the licensed nurse on 12/18/17. There was no documented evidence that the physician was called by the licensed nurse on 12/19/17 regarding the treatment recommendations by the wound consultant. A review of the Treatment Administration Record (TAR), dated 12/2017 did not show any documented evidence that the treatment on Resident 127's right ischial pressure ulcer had been done from 12/19/18 to 12/29/18. On 1/12/18 at 11:10 a.m., during an interview, the Director of Nurses (DON) stated that recommendation's from the consultants such as dietary and wound care consultants, should be followed up by the charge nurse on the same day or carried over to the next shift. The DON confirmed that on 12/ 19/18, there was a recommendation from the wound consultant to treat Resident 127's right ischium pressure ulcer with Santyl. The DON stated there was no documented evidence that the physician was notified by the licensed nurse of the wound consultant's recommendation. The DON confirmed that there was no treatment order obtained for the right ischium pressure ulcer. The DON stated the nurse must have been overwhelmed, but should have called the physician to obtain wound consultant's treatment recommendation. The DON acknowledged that there was no documented evidence that the treatment was done on the right ischium pressure ulcer from 12/19/17 to 12/29/17. The DON confirmed that the treatment order was obtained for the right ischium pressure ulcer on 12/29/17. A review of Resident 127's physician's orders [REDACTED]. Cleanse site with normal saline 75% and Dakin's solution 25% (prevent and treat skin and tissue infections that could result from cuts, scrapes and pressure ulcers), pat dry and cover with dry dressing. On 1/12/18 at 2:11 p.m., during an interview, Licensed Vocational Nurse (LVN 9) stated resident's skin integrity was checked daily. LVN 9 added that for newly developed pressure ulcer, which was considered a change of condition, licensed nurse should notify the physician and obtain a treatment order. On 1/18/18 at 1:10 p.m., during a concurrent record review and interview with Registered Nurse (RN 2), she confirmed that Resident 127 did not have a physician's orders [REDACTED]. RN 2 stated licensed nurse should have notified the physician and obtained a treatment order to prevent pressure ulcer from getting worse. RN 2 also acknowledged that there was no care plan developed for Resident 127's right ischium unstageable pressure ulcer. RN 2 added that a care plan should have been developed to be able to have a plan of action to treat the pressure ulcer and be able to evaluate its effectiveness. A review of the wound consultant summary, dated 12/29/17 indicated that right ischium pressure ulcer increased in size from: 1. 4.1 cm in length on 12/19/17 to 5.1 cm on 12/29/17. 2. 5.2 cm in width on 12/29/17 to 6.2 cm on 12/29/17. 3. Depth remained undetermined. On 1/18/18 at 3:25 p.m., during an interview, the wound consultant stated that her role was to make patient rounds weekly to assess, evaluate, and recommend treatment for [REDACTED]. The wound consultant stated Resident 127 had moisture associated skin damage (MASD, inflammation and erosion caused by prolong exposure to various sources of moisture such as urine, stool, perspiration or saliva) from the buttock to thigh areas including right ischium which made Resident 127's skin compromised. On 1/18/18 at 2:45 p.m.,during interview, the DON stated that according to the licensed nurse who regularly took care of Resident 127, she thought that the right ischium pressure ulcer was the same as the right hip pressure ulcer. The DON stated that the licensed nurse acknowledged that both pressure ulcers were a finger width apart and therefore, were two different pressure ulcers. The DON stated the licensed nurse should have followed¿ up with the wound consultant's recommendation, notified the physician, obtained a treatment order, and provided treatment for [REDACTED]. On 1/18/18 at 3:58 p.m., during a concurrent record review and an interview with LVN 10, he stated that weekly summary and skin assessment were done for every resident. LVN 10 stated that resident's skin was checked for any abnormality such as pressure ulcer, discoloration, redness, rashes, and MASD. LVN 10 stated Resident 127 was totally dependent on the staff for all activities of daily living, was bed bound and had a [DIAGNOSES REDACTED]. LVN 10 stated the right ischium did not have MASD prior to being assessed as unstageable. LVN 10 stated that pressure ulcer usually start with as a Stage I or some abnormality in the skin, but not initially with as an unstageable pressure ulcer. LVN 10 stated to that it was important to accurately document the condition of the resident's skin through the weekly summary or skin check form to be able to assess, monitor the skin condition, and know the progress or decline of the skin condition. LVN 10 stated Resident 127's weekly summary, dated 12/18/17 and 12/25/17 should have reflected all of the resident's pressure ulcers in order to be able to know whether there were newly developed pressure ulcers and be able to evaluate effectiveness of treatment for [REDACTED]. A review of the facility's policy and procedure titled,Skin Integrity Management, revised 11/28/16, indicated that the staff continually observes and monitors patients for changes and implements revisions to the plan of care as needed. It also indicated to identify patient's skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information. Perform skin inspection on admission/readmission and weekly. Perform wound observations and measurements and complete Skin Integrity Report upon initial identification of altered skin integrity weekly, and with anticipated decline of wound. Perform daily monitoring of wounds or dressings for presence of complications or declines and document. It also indicted to develop comprehensive, interdisciplinary plan of care including prevention and wound treatments as indicated. Implement special wound care treatments· and techniques as indicated and ordered. Notify physician and review care plan weekly and revise as indicated. Document daily monitoring of ulcer site, with or without dressing. A review of the facility's policy and procedure titled, Notification of Change in Condition, revised 11/28/16, indicated that the Center must immediately inform the patient, consult with the patient's physician, and notify, consistent with his/her authority, the patient's Health Care Decision Maker, where there is: a significant change in the patient's physical, mental,or psychologic al status (that is, a deterioration in health, mental or psychological status in either life threatening conditions or clinical complications; a need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment to avoid adverse consequences, or to commence a new form of treatment). Pressure ulcer: https://www.cms.gov/Medicare/Quality¿ lnitiatives Patient-Assessment-lnstruments/IRF-Quality-Reporting/Downloads/IRF-QRP-Training-%E2%80%93-PrU-Staging-May-12-2014-.pdf 2. A review of the clinical record indicated Resident 105 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent Minimum Data Set (MDS, a standardized comprehensive assessment and care planning tool) dated 11/24/17 indicated the resident required extensive assistance( resident involved in activity, staff provide weight bearing support) with bed mobility, dressing and personal hygiene and total dependence (full staff performance every time) with eating and toilet use. MDS indicated Resident 105 was always incontinent of bowel and bladder. A review of Resident 105's Braden Scale for predicting pressure ulcer risk dated 1/15/18 indicated the resident had a high risk for pressure ulcers. A review of Resident 105's skin check dated 11/17/17 indicated the resident had left buttock pressure ulcer #1, left buttock pressure ulcer #2 and a sacrum pressure ulcer. A review of the physician's orders [REDACTED]. 1. Sacrum pressure ulcer, apply Dermaseptin cream (skin protectant and ointment) every shift and PRN when patient is soiled x 14 days, every shift for stage II (partial-thickness loss of skin presenting as a shallow open ulcer with a red-pink wound base) pressure ulcer for 14 days. On 1/17/18 at 8:15 a.m., a review of Resident 105's Treatment Administration Record (TAR) was conducted. TAR indicated resident did not receive treatment of [REDACTED]. The TAR did not indicate why treatment was not provided on 1/5/18 (11-7 shift), 1/10/18 (11-7 shift) and 1/12/18 (11-7 shift). On 1/17/18 at 8:20 a.m. an interview was conducted with licensed vocational nurse (LVN 8) and registered nurse (RN 3). Both staff confirmed there was no treatment provided to Resident 105's sacrum pressure ulcer on 1/5/18 (11-7 shift), 1/10/18 (11-7 shift) and 1/12/18 (11-7 shift). On 1/17/18 at 8:35 am, an interview was conducted with RN 4 who stated the licensed staff should provide treatment every shift as ordered. RN 4 indicated based on the TAR, treatment for [REDACTED]. A review of Resident 105's care plan dated 1/1/18 indicated resident has actual skin breakdown related to shear/friction risks, limited mobility, sacrum stage II pressure ulcer. Identified interventions included apply barrier cream with each cleansing and provide wound treatment as ordered. A review of the facility's Policy and Procedure titled Skin Integrity Management, revised 11/28/16 indicated the purpose of the policy was to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment and promote healing of all wounds. 3. During an interview and record review, on 1/17/18 at 8:15 a.m., the director of nursing (DON) stated that Resident 91 has an order for [REDACTED]. During an observation and interview, on 1/17/18 at 8:47 a.m., at the bedside of Resident 91 with the DON, the resident's heel protectors were not on the resident and none were found amongst the resident's belongings. The DON stated that when the heel protectors were not in place, it put the resident at risk for potential reopening of the wound and/or further skin breakdown. A review of Resident 91's Admission Record indicated the resident was initially admitted to the facility on [DATE] and was re-admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of Resident 91's MDS, dated [DATE], indicated the resident sometimes or rarely made self-understood or understood others, and had moderate impairment in cognitive skills. The resident required extensive assistance (resident involved in activity, staff provided weight-bearing support) from staff for transferring, dressing, toileting, and bathing. A review of Resident 91's monthly physician's orders [REDACTED]. A review of the facility's policy and procedure titled, Skin Integrity Management, dated 11/28/16, indicated to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds.

Based on observation, interview, and record review, the facility failed to ensure residents were free of unnecessary drugs by administering medications without adequate monitoring, not indicating clinical rationale for medication treatment, and excessive duration of medication usage, with the presence of adverse consequences for three of 27 sampled residents (Residents 3, 12, and 14). 1a. Resident 12, who had both kidney and liver failure, was receiving an unnecessary drug in the presence of adverse consequences. Resident 12 had a physician's orders [REDACTED]. On 12/7/15, Resident 12 had an altered level of consciousness (ALOC), and the laboratory results indicated an increased K+ level of 7.0 ([MEDICAL CONDITION] (high K+ levels)). This deficient practice resulted in Resident 12 receiving KCL without an indication for its use, in the presence of adverse consequences, requiring Resident 12 to transfer to an urgent care hospital on [DATE], for the elevated potassium level. This put Resident 12 at high risk for serious medical complications [REDACTED]. 1b. Resident 12, had a physician's orders [REDACTED]. Resident 12 continued to receive the laxative twice a day, over two months, with documentation indicating the resident had loose stools for five days, resulting in skin excoriation (scratch or abrasion of the skin) and a Stage II pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). The laxative was not held until 12/18/15, when the survey team questioned the staff about the continued use in the presence of adverse reaction. This deficient practice, of not following the physician's orders [REDACTED]. 2. Resident 3 was receiving Tylenol (pain medication) 650 milligrams (mg) tablet for almost two years, from 2/13/14 to 12/17/15, twice a day, without any documented evidence of pain, reassessment and/or continued need for, and without any non-pharmacological interventions attempted. Resident 3 denied having any pain upon interview. This deficient practice resulted in an excessive duration, without adequate monitoring, and the potential to result in an adverse reaction, such as liver failure for Resident 3. 3. Resident 14 was receiving Tylenol 650 milligrams (mg) routinely daily for pain management since 11/16/15, without an adequate indication and proper assessment in the absence of persistent acute/chronic pain and clinical reevaluation for its continued use. This deficient practice had the potential to put Resident 14 at risk for overuse of an unnecessary medication, with the potential for an adverse reaction. Findings: 1a. A review of Resident 12's Face Sheet indicated the resident was re-admitted to the facility on [DATE]. Resident 12's [DIAGNOSES REDACTED]. blood flow). A review of Resident 12's significant change, in the Minimum Data Set ((MDS) a standardized assessment and care screening tool), dated 11/19/15, indicated the resident had limited ability to express needs and understand verbal content. According to the MDS, Resident 12 had short and long-term memory problems, was moderately impaired in cognitive skills for daily decision-making, and required extensive assistance (resident was involved in activity, but staff provided weight-bearing support) for most activities of daily living ((ADL) dressing, toilet use, personal hygiene, and transferring from one area to another). A review of the physician's orders [REDACTED]. A review of a laboratory report ((BMP) basic metabolic panel test), dated 11/23/15, indicated Resident 12 had an elevated potassium level of 5.6. A handwritten note of BMP (laboratory test that included potassium level) and MD notified, was documented on the laboratory report, without a date and a time. A review of Resident 12's Medication Administration Records (MARs) indicated Resident 12 continued to receive potassium chloride (KCL), extended release (ER), 20 mEq by mouth daily, from 11/23/15 to 12/6/15. Resident 12 received a total of 280 mEq of KCL supplement, after Resident 12's K+ was identified to be elevated on 11/23/15. A review of the physician's orders [REDACTED]. There was no documented evidence that KCL was held or discontinued, or that the resident was monitored for physical signs and symptoms of [MEDICAL CONDITION] (high potassium levels), during the 14-day period from 11/23/15 through 12/6/15. A review of the BMP result, prescribed by the physician, dated 12/7/15, indicated Resident 12's potassium level increased to 7.0 mEq/L. A review of the physician's orders [REDACTED]. A review of an ambulance service report ((BLS) basic life support), dated 12/7/15, indicated Resident 12's vital signs as the following: blood pressure of 90/54 (NRR120/80), heart rate of 84 (NRR 60-100), respiratory rate at 20 (NRR 16-20), and pain assessment at 0/10 (0=no pain and 10=being the worst). According to the BLS report, Resident 12 was lethargic (drowsy; sluggish), with an altered level of consciousness (ALOC). A review of the urgent care record indicated Resident 12 presented with a [DIAGNOSES REDACTED]. Resident 12 received an IV infusion of sodium chloride 0.9% (salt water similar to body concentration) and received 30 grams of [MEDICATION NAME] (a medication that helps remove excess K+ from the body) orally. Another BMP level was drawn at the urgent care, resulting in a decreased level in K+ of 6.6 mEq/L. On the same day (12/7/15), Resident 12 transferred back to the skilled nursing facility (SNF). A review of Resident 12's progress note and care plan meeting, dated 11/23/15, and timed at 12:05 p.m., indicated the facility's Interdisciplinary Team (IDT) discussed and documented care of Resident 12's overall condition. However, there was no documented evidence to indicate the resident's elevated K+ level at 5.6 mEq/L, was included in the care plan meeting. There was also no indication if the physician was notified of Resident 12 continuing to receive a KCL supplement daily, with an elevated K+ level, in addition to having [DIAGNOSES REDACTED]. On 12/22/15, at 12:20 p.m., during an interview, the directors of staff development (DSD) stated if a resident's laboratory results were abnormal, the nurse should notify the physician immediately and compare it to previous labs to identify what was normal and abnormal. The DSD was asked what was the licensed nurse's responsibility if a resident's K+ level was elevated. The DSD stated if she was the licensed nurse taking care of that resident, she would assess the resident's vital signs, neurological check (assessment of the sensory motor responses, to determine whether the nervous system was impaired), assess for heart rhythm, and notify the physician. The DSD further stated if the resident's K+ was elevated and the resident was still receiving KCL supplements, she would question the physician to clarify why the resident still received KCL supplements with an elevated potassium level. The DSD also stated she would document everything discussed with the physician. On 12/22/15, at 12:35 p.m., during a telephone interview, a licensed vocational nurse (LVN 13) stated she was Resident 12's nurse on 11/23/15, during the 7 a.m. to 3 p.m. shift. LVN 13 stated she notified Resident 12's physician of all the abnormal results on the BMP, dated 11/23/15. LVN 13 further stated that usually when the licensed nurses notify physicians of abnormal laboratory results, the physicians would ask what medications the resident was receiving. However, LVN 13 could not recall if she had documented the information discussed with the physician during that time, but stated it should be in the clinical records. LVN 13 was asked about Resident 12's condition during the time the resident's K+ was elevated to 7.0. LVN 13 stated Resident 12 was responsive, but restless and more confused than the resident's usual behavior and cognitive level. A review of Resident 12's care plans indicated there was no plan of care developed for Resident 12's elevated K+ level on 11/23/15. A review of the Skilled Nursing PPS Note, for 11/23/15, indicated there was no documentation regarding Resident 12's elevated K+, including the information discussed with the physician, as stated by LVN 13. During an interview with the assistant nursing director (ADON), on 12/22/15, at 2:35 p.m., she acknowledged that there was no other documented evidence in Resident 12's clinical record, indicating the facility monitored the resident for signs and symptoms of [MEDICAL CONDITION]. On 12/22/15, at 1:30 p.m., during a telephone interview with a physician (MD1), he stated he recently took over the care of Resident 12 on 12/6/15. MD1 stated he remembered receiving a telephone call about Resident 12's abnormally high K+ levels on 12/7/15. MD1 stated he ordered for Resident 12 to transfer to the hospital. MD1 was asked what a physician would order if a resident's K+ level was elevated at 5.6 mEq/L. MD1 stated he would order a repeated K+ level right away to monitor the resident. MD1 was asked if he was aware that Resident 12 was receiving KCL supplements of 20 meq daily, while the K+ was elevated. MD1 stated, Oh really, then definitely I will discontinue the KCL. MD1 reiterated that a physician's response also depended on the information communicated to them by the nurse. MD1 stated it was important for the physician to receive the complete information regarding a resident, because they do not see residents every day. On 12/22/15, at 2:40 p.m., during an interview, the facility's registered dietician (RD) stated if she assessed a resident who had an elevated K+, she would recommend a reduction in KCL intake and refer to the physician to prescribe [MEDICATION NAME]. The RD stated she was aware that Resident 12 had [MEDICAL CONDITION], but did not include that [DIAGNOSES REDACTED]. The RD stated she usually writes the laboratory values in her notes when the value is abnormal. The RD stated if she did not recommend the laboratory work, she usually does not follow-up on the laboratory results. A review of a Nutrition Progress Note, written by the RD, dated 12/11/15, indicated the RD documented Resident 12 was receiving KCL. The RD included Resident 12's labs from 11/19/15, but the RD did not note Resident 12's recent labs from 11/23/15 and 12/7/15, which included the resident's elevated K+. A review of the licensed nurse's Daily and QShift Charting, dated 12/7/15, and timed at 9:35 p.m., indicated Resident 12 returned to the facility from the urgent care with a K+ level decreased to 6.6. A review of Resident 12's care plans indicated no plan of care was developed regarding Resident 12's elevated K+ levels of 6.6, after Resident 12 returned to the facility from the urgent care. A review of the facility's policy and procedures, with a revision date of 11/2005, titled, Physician Notification of Change Resident Condition, indicated that staff should notify the physician when there is a need to alter the resident's treatments significantly. Before notifying the physician, the licensed nurse must observe and assess the overall condition utilizing physical assessment and chart review. The policy also stipulated that notification to the physician includes a summary of the condition change and an assessment of the resident's vital signs and system review, focusing on the condition and/or signs and symptoms for which the notification is required, and to document in the resident's medical record. A review of an online reference from Omnicare Pharmacy, provided by the facility titled, Omniview-Drug Information for Potassium Chloride 10% liquid, printed on 12/22/2015, at 3:40 p.m., indicated the side effects of potassium included upset stomach, nausea, vomiting, gas, or diarrhea. The article indicated if too much K+ was in the blood, it could cause serious side effects. Symptoms of overdose may include muscle weakness and confusion. The KCL reference further indicated that precautions were necessary when taking potassium, especially with residents who have a medical history of [REDACTED]. Caution is advised if you have diabetes, liver disease, or any other condition that requires you to limit/avoid these substances in your diet. A review of an online article, titled, [MEDICAL CONDITION]: Nutritional Considerations, indicated unhealthy kidneys cannot tolerate a high K+ diet because the kidneys are unable to excrete the K+. This causes an increase of K+ in the blood that can result in life-threatening medical conditions, such as [MEDICAL CONDITION]-induced arrhythmia (an irregular beating of the heart caused by elevated potassium levels in the blood). 1b. A review of Resident 12's Admission Face Sheet indicated the resident was re-admitted to the facility on [DATE]. Resident 12's [DIAGNOSES REDACTED]. levels are abnormally high in the blood), [MEDICAL CONDITION] (an [MEDICAL CONDITION] reaction in the colon), hepatic failure (loss of liver function), [MEDICAL CONDITION] (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and [MEDICAL CONDITION] (an irregular, often rapid heart rate that commonly causes poor blood flow). A review of Resident 12's significant change in the MDS, dated [DATE], indicated the resident had limited ability to express needs and understand verbal content. According to the MDS, Resident 12 had short and long-term memory problems, was moderately impaired in cognitive skills for daily decision-making and required extensive assistance (resident was involved in activity, but staff provided weight-bearing support) for most ADLs. Resident 12 required assistance of a one-person physical assist for ADLs. The MDS indicated the resident was always incontinent (inability to control) of bladder and frequently incontinent of bowel, but did not participate in a toileting program. The MDS indicated Resident 12 had a Stage II pressure ulcer and was at risk of developing pressure ulcers. The treatments listed on the MDS included pressure-reducing device for the bed, pressure ulcer care, and the application of ointments and medications. A review of Resident 12's History and Physical (H/P) Examination, dated 11/13/15, indicated the resident had a [DIAGNOSES REDACTED]. According to the H/P, Resident 12 did not have the capacity to understand and make decisions, generally appeared sleepy, but can be aroused, and had bilateral lower extremity weakness. A review of Resident 12's physician's orders [REDACTED]. A review of the DailyMed, an online drug reference, indicated [MEDICATION NAME] was a laxative, and not a stool softener, used to relieve constipation. The article indicated [MEDICATION NAME] should not be used longer than one week, unless directed by a physician. A review of the progress notes from the RD, dated 12/11/15, indicated Resident 12 lost 10 pounds in one month at 7.5% of body weight. Resident 12, who was incontinent of bowel and bladder, and assessed as at risk for developing pressure sores, had loose and watery stools for five (5) days. The licensed nurse did not re-assess the resident for increased risk for skin breakdown, after the resident's change of condition of watery stools, and did not hold the laxative ([MEDICATION NAME]) as ordered by the physician, if the resident had loose stool. On 12/17/15, the night shift (11 p.m. -7 a.m.) certified nursing assistant (CNA) did not document the consistency of Resident 12's stool on the ADL tracking record. On 12/18/15, at 7 a.m., Resident 12 was observed with her eyes closed, lying in a supine position in bed with the privacy curtains completely closed. The bottom half of Resident 12's dress and both of her hands were soiled with watery stool. Resident 12 was observed touching the wet stool on the front lower half of her dress with her fingers, with her eyes closed. At 7:25 a.m., on 12/18/15, during an ADL care observation, CNA 1 was observed cleaning Resident 12. Resident 12's sacrum (a triangular-shaped bone consisting of five segments), and left and right upper buttocks were observed red with two, circular, opened areas on Resident 12's left buttocks. Resident 12 had a large amount of watery, dark brown colored stool on the buttocks and the perineal area (below the pelvic diaphragm and between the legs; a diamond-shaped area that includes the anus and, in females, the vaginal area). Resident 12 required extensive assistance from CNA 1 for positioning during care. Treatment Nurse 1 (TN1) received a telephone physician's orders [REDACTED].). On 12/18/15, at 9:40 a.m., during a treatment observation, of Resident 12's pressure ulcer with TN 1, a small amount of watery stool was observed on Resident 12's perineal and buttocks area. Resident 12 was observed drowsy with eyes closed, and did not respond to her name when called twice. TN 1 stated the resident had a Stage II pressure sore to sacrococcygeal area ((sic) which was actually on the resident's left buttocks) that measured 0.5 cm x 0.5 cm. On 12/18/15, at 2:30 p.m., during an interview, CNA 1 stated, I let the charge nurse, (LVN 3) know that her (Resident 12) poop was watery. CNA 1 stated Resident 12 had a large, watery bowel movement (BM) on the morning of 12/18/15, and then a smaller BM at approximately 11:40 a.m. CNA 1 stated she had been taking care of Resident 12 since 12/16/15, and stated she documented, during her shift, SL (soft/loose) as the resident's stool consistency since 12/16/15, under Bowel category on the ADL Tracking Record. She stated the CNA who worked the night prior (12/17/15) informed her that Resident 12 had loose stool two times during the night shift. However, CNA 1 stated the night shift CNA did not document Resident 12's loose BM for the night shift on 12/17/15. During an interview, on 12/18/15, at 2:45 p.m., with LVN 5 (assigned nurse of Resident 12 for 12/18/15, 7-3 p.m. day shift) and LVN 3 (assigned charge nurse for 12/18/15), LVN 5 stated when she arrived in the morning to start her shift; Resident 12 had a soft stool. LVN 5 stated, I know it (stool) wasn't formed, but I didn't know it was wet. LVN 5 stated, Typically, when a CNA says the bowel movement is loose, we hold the medicine and call the doctor. The December 2015 medication reconciliation record (MAR) was shown to LVNs 3 and 5, which indicated to hold [MEDICATION NAME] when Resident 12's stool was loose. LVN 5 stated and verified she administered [MEDICATION NAME] to Resident 12, on 12/18/15 at 9 a.m., although the resident was having loose watery stools. LVN 3 stated, I go by the CNAs, in telling me about the stool because they know better. LVN 3 stated that CNA 1 informed her of Resident 12's loose BM that morning. LVN 3 stated she notified LVN 5, but stated LVN 5 might have forgotten and administered the [MEDICATION NAME] anyway. LVN 5 denied receiving this information, which resulted in LVN 5 continuing to administer the morning dose of laxative to Resident 12 for that day. A review of Resident 12's ADL Tracking Record indicated Resident 12 was incontinent with soft/loose stools on the following dates/shifts: a. On 12/14/15, twice during the day shift (7 a.m.-3 p.m.). b. On 12/15/15, three times during the day shift (7 a.m. - 3 p.m.), and two extra-large during the night shift. c. On 12/16/15, one small soft/loose stool during the day shift and one large loose stool during the night shift. d. On 12/17/15, one medium loose stool during the day shift. e. On 12/18/15, two large soft/loose stools during the day shift. f. On 12/19/15, two medium size soft/loose stools during the day shift. g. On 12/20/15, two soft/loose stools during the day shift. h. On 12/21/15, one medium soft/loose stool during the night shift. A review of Resident 12's Medication Administration Record (MAR), dated 12/14/15 through 12/18/15, indicated Resident 12 received [MEDICATION NAME] 8.6 milligram (mg) tablet twice a day. According to the MAR, ADL tracking, and interviews, the licensed nurses did not hold the [MEDICATION NAME] as ordered by the physician, during the five days Resident 12 was having loose bowel movements, from 12/14/18 through 12/18/15, which resulted in skin excoriation, Stage II pressure sore, and a 10 pound body weight loss. A review of an online drug reference, titled, Omni view-Drug Information, (for Senna (brand name for [MEDICATION NAME])) 8.6 MG soft gel, provided by the director of nursing (DON), with a print date of 12/22/15, and timed at 3:38 p.m., indicated [MEDICATION NAME] was known as a stimulant laxative, used to treat constipation. The side effects of the medication included nausea, diarrhea (loose watery stools), weakness, and mental/mood changes (confusion). The drug information stated if any of the side effects persisted, to notify the physician or pharmacist promptly. 2. On 12/16/15 at 8:30 a.m., during a medication pass observation, licensed vocational nurse, (LVN 3) did not ask Resident 3 where she was having pain, the severity of her pain, and the type of pain she was experiencing prior to administration of Tylenol 650 mg tablet. LVN 3 was also not observed informing Resident 3 what medications she was receiving, prior to administering. A review of Resident 3's Admission Record indicated Resident 3 was readmitted to the facility on [DATE]. Resident 3's [DIAGNOSES REDACTED]. According to Resident 3's Minimum Data Set (MDS), an assessment and care screening tool, dated 12/3/15, indicated Resident 3 was usually able to make needs known and usually understood others. Resident 3 required limited assistance, of a one-person physical assist (resident involved in the activity) in transferring, ambulating and hygiene. A review of a physician's orders [REDACTED]. A review of a physician's orders [REDACTED]. The order did not indicate for what type of pain or location. A review of the medication administration record (MAR) indicated Resident 3 received Tylenol tablet (s) from 9/29/11 to 12/17/15, for over four years. According to the MARs, Resident 3's pain level was documented as 0/10 (0=no pain and 10=worse pain) on the pain scale from 2/13/14 to 12/17/15. There was no documented evidence of what type of pain the Tylenol was given. There were no documented evidence from 2/13/14, in Resident 3's nursing record or physician record, indicating why Tylenol 650 mg was increased to twice a day and the clinical rationale Tylenol was continually administered with the documented pain level of 0/10 on the pain scale. In an interview on 12/16/15 at 9:15 a.m., LVN 3 was asked what Resident 3's pain level was prior to administration of the pain medication, since it was not documented on the MAR. LVN 3 stated, I did not assess Resident 3's pain level before I gave the pain medication because the medication was ordered routine, but we usually do. LVN 3 stated she did not explain to Resident 3 what medications she was receiving, but she should have. On 12/17/15, at 6:40 a.m., during a concurrent interview and record review, a registered nurse supervisor (RN 6) stated, Resident 3 does not have pain, the order for the routine Tylenol must have been ordered as needed, not routine, this is wrong. On 12/17/15 at 7:15 a.m., during an interview, Resident 3 was asked if she was having pain, the resident stated, I do not have pain. When Resident 3 was asked if she was aware that she was receiving Tylenol 650 mg twice a day for pain, she answered, I did not know that, they never told me. I do not have pain, so I do not need Tylenol. On 12/22/15 at 12:45 p.m., during a concurrent interview and record review, the director of nursing (DON) and the assistant director of nursing (ADON) stated, The physician and the monthly pharmacist medication reviews, dated 1/2015 through 12/2015, indicated no documented evidence for Tylenol tablets to be given routinely to Resident 3. The DON stated, If Resident 3's pain level was assessed as 0/10, the pain medications should not have been given. We will call the physician right away to correct the order. A review of the facility's policy and procedure, dated 8/2009 and titled, Pain Management, indicated the licensed nurse shall administer pain medication as ordered and document in the medication administration record the pain scale rating before the pain medication was administered. The policy also indicated the staff would develop a plan of care that included non-pharmacological interventions. 3. A review of Resident 14's Admission Record indicated Resident 14 was originally admitted to the facility on [DATE]. Resident 14's [DIAGNOSES REDACTED]. A review of Resident 14's MDS, dated [DATE], indicated the resident had clear speech, was able to express needs, understand verbal content and capable of independent decision-making. According to the MDS, the resident required extensive assistance (weight bearing support) in bed mobility and transferring. A review of Resident 14's physician's telephone order, dated 11/16/15, indicated to start Tylenol 650 mg by mouth daily for pain management. There was no documented evidence in the clinical record of which part of the resident's body the pain management was indicated for. A review of Resident 14's Pain Medication Assessments for the months of 8/2015, 9/2015, 10/2015, 11/2015, and 12/2015 indicated Resident 14 did not have any pain. On 12/16/15, at 5:35 p.m., during an interview, in the presence of certified nursing assistant (CNA 11), who translated from Spanish to English, Resident 14 was asked if he had any pain. Resident 14 stated, No, I don't have any pain. Why would I have pain? Resident 14 was asked if he had any pain from the pressure ulcer in his right buttock. Resident 14 stated he could not feel any pain in his right buttock pressure ulcer because he did not have any sensation from the waist down. Resident 14 was also asked if he knew that he was receiving pain medication (Tylenol) every day for pain. Resident 14 stated, Really, I did not know. Nobody told me. I don't need it. I don't have pain. On 12/17/15, at 5:15 p.m., during an interview, LVN 12 stated he was the one who called the physician to obtain the routine pain medication for Resident 14 for the order of Tylenol on 11/16/15. LVN 12 stated he called the physician because Resident 14 would sometimes feel tingling sensation on his buttocks during transfers and sometimes during the treatment of [REDACTED]. When LVN 12 was asked if the resident requested for the pain medication, he stated, Once in a while . and because we want all our residents to be pain free. During a concurrent interview and record review, of Resident 14's clinical records, in the presence of LVN 12, it did not indicate that a care plan was developed for Resident 14's pain management. LVN 12 stated during the interview, he thought the care plan developed on 8/7/15, during admission, for Resident 14's pressure ulcer, and would apply for the pain management initiated on 11/6/15. A further review of the clinical records did not indicate that a comprehensive pain assessment was conducted, prior to the administration of pain management given routinely. LVN 12 acknowledged that he did not assess and document a comprehensive pain assessment of Resident 14's pain, prior to initiating the pain management. A review of a facility's policy and procedure, dated 8/31/09 and titled, Pain Management, indicated the licensed nurse would complete a comprehensive pain assessment, notify the physician of the pain assessment findings and obtain orders for pharmacological interventions, if indicated. The policy also indicated the licensed nurse would develop a plan of care for pain management, including the use of a non-pharmacological intervention. 3. On 12/16/15 at 8:30 a.m., during a medication pass observation, licensed vocational nurse, (LVN 3) did not ask Resident 3 where she was having pain, the severity of her pain, and the type of pain she was experiencing prior to administration of Tylenol 650 mg tablet. LVN 3 was also not observed informing Resident 3 what medications she was receiving, prior to administering. A review of Resident 3's Admission Record indicated Resident 3 was readmitted to the facility on [DATE]. Resident 3's [DIAGNOSES REDACTED]. According to Resident 3's Minimum Data Set (MDS), an assessment and care screening tool, dated 12/3/15, indicated Resident 3 was usually able to make needs known and usually understood others. Resident 3 required limited assistance, of a one-person physical assist (resident involved in the activity) in transferring, ambulating and hygiene. A review of a physician's orders [REDACTED].

Based on observation, interview, and record review, the facility failed to identify a newly developed pressure sore (injuries to skin and underlying tissue resulting from prolonged pressure on the skin); accurately assess a resident's risk for pressure sore development, during a change of condition; to implement its policy and the resident's plan of care for the use of pressure relieving devices for high risk residents; follow the physician's orders [REDACTED]., and communicate effectively among the facility's staff the plan of care for one of 27 sampled residents (Resident 12) cross reference to F329 (1 b.). Resident 12, who was incontinent (inability to control) of bowel and bladder, had low protein levels, and was assessed as at risk for developing pressure sores had loose and watery stools for five (5) days. The licensed nurse did not re-assess the resident for increased risk for skin breakdown, after the resident had a change in condition, had watery loose stools and did not hold the laxative ([MEDICATION NAME]) as ordered by the physician. The facility also failed to implement interventions to manage the complications of Resident 12 having loose and watery stools to prevent skin breakdown, especially on the areas of the body, such as the sacrococcygeal (pertaining to the sacrum and coccyx part of the body (triangular area)). On 12/17/15, the night shift (11 p.m. -7 a.m.) certified nursing assistant (CNA 1) did not document the consistency of Resident 12's stool on the ADL (activities of daily living) tracking record. On 12/18/15, CNA 1 informed a licensed vocational nurse (LVN 3), who informed the assigned charge nurse, LVN 5, that Resident 12 was having loose stools. LVN 5 denied receiving this information, which resulted in LVN 5 continuing to administer the laxative. As a result of this deficient practice, Resident 12 developed a skin breakdown on the left buttocks, which the facility failed to identify and assess until the surveyor observed opened wounds, which was later identified as a Stage II pressure ulcer (the outer layer of skin and part of the underlying layer of skin is damaged or removed and the wound appearing pink or red) during an ADL care observation. The Stage II pressure ulcer required wound care and treatment every three days. Findings: On 12/17/15, at 9 a.m during a room observation, Resident 12 was observed lying on her back (supine position) in bed. At 2:15 p.m., on 12/17/15, Resident 12 remained lying in supine position in the bed, not repositioned. On 12/18/15, at 7 a.m., Resident 12 was observed with her eyes closed while lying in supine position in bed with the privacy curtains completely closed. The bottom half of Resident 12's dress and both of her hands were soiled with brown color watery stool. Resident 12 was observed touching the wet stool on the front lower half of her dress, while her eyes were closed. At 7:25 a.m., on 12/18/15, during an ADL care observation, CNA 1 was observed cleaning Resident 12. Resident 12's sacrum (a triangular-shaped bone and consists of five segments), left and right upper buttocks were observed red with two circular opened areas on Resident 12's left buttocks. Resident 12 had a large amount of watery dark brown color stool on the buttocks and the perineal area (below the pelvic diaphragm and between the legs; a diamond-shaped area that includes the anus and, in females, the vagina) area. Resident 12 required extensive assistance from CNA 1 for positioning during care. During an interview on 12/18/15, at 9:28 a.m., a treatment nurse (TN 1) stated she was just informed that Resident 12 had a Stage II pressure ulcer on the sacrum. TN 1 stated she had never noticed it before and was not sure if Resident 12 was admitted with the pressure ulcer. A review of the physician's progress note, dated 11/16/15, and timed at 2:30 p.m., indicated Resident 12 had mild redness in the inguinal ((groin) located on the lower portion of the anterior abdominal wall) and buttocks area, contrary to TN 1 interview. TN 1 received a telephone physician's orders [REDACTED]. On 12/18/15, at 9:40 a.m., during a treatment observation, of Resident 12's pressure ulcer with TN 1, a small amount of watery stool was observed on Resident 12's perineal and buttocks area. Resident 12 was observed drowsy with eyes closed and did not respond to her name when called twice. TN 1 stated the resident had a Stage II pressure sore to sacrococcygeal area ((sic) which was actually on the resident ' s left buttocks) that measured 0.5 centimeter (cm) x 0.5 cm. On 12/18/15, at 2:30 p.m., during an interview, CNA 1 stated, I let the charge nurse (LVN 3) know that her (Resident 12) poop was watery. CNA 1 stated Resident 12 had a large, watery BM on the morning of 12/18/15, and then a smaller BM at approximately 11:40 a.m. CNA 1 stated she had been taking care of Resident 12 since 12/16/15, and stated she documented, during her shift, SL (soft/loose) as the resident's stool consistency since 12/16/15, under Bowel category on the ADL (Activities of Daily Living) Tracking Record. CNA1 stated the CNA who worked the night prior (12/17/15) informed her that Resident 12 had loose stool two times during the night shift. However, CNA 1 stated the night shift CNA did not document Resident 12's BM for the night shift on 12/17/15. During an interview, on 12/18/15, at 2:45 p.m., with LVN 5 (Resident 12's assigned nurse on 12/18/15), and LVN 3 (Resident 12's assigned nurse on 12/17-12/18/15), LVN 5 stated when she arrived in the morning to start her shift and was informed Resident 12 had a soft stool. LVN 5 stated, I know it wasn't formed, but I didn't know it was wet. LVN 5 stated, Typically, when a CNA says the bowel movement was loose, we hold the medicine and call the doctor. The MARs for 12/2015 was shown to LVNs 3 and 5, which indicated to hold [MEDICATION NAME] when Resident 12's stool was loose. LVN 5 stated and verified she administered [MEDICATION NAME] to Resident 12 on 12/18/15 at 9 a.m., although the resident was having loose watery stools. LVN 3 stated, I go by the CNAs, in telling me about the stool because they know better. LVN 3 stated CNA 1 informed her of Resident 12's loose BM that morning and she stated she notified LVN 5, but stated LVN 5 might have forgotten and administered the [MEDICATION NAME] anyway. A review of Resident 12's Admission Face Sheet indicated the resident was re-admitted to the facility on [DATE]. Resident 12's [DIAGNOSES REDACTED]. levels are abnormally high in the blood), [MEDICAL CONDITION] (an [MEDICAL CONDITION] reaction in the colon), hepatic failure (loss of liver function), [MEDICAL CONDITION] (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and [MEDICAL CONDITION] (an irregular, often rapid heart rate that commonly causes poor blood flow). A review of Resident 12's History and Physical (H/P) Examination, dated 11/13/15, indicated the resident had a [DIAGNOSES REDACTED]. According to the H/P, Resident 12 did not have the capacity to understand and make decisions, generally appeared sleepy, but can be aroused, and had bilateral lower extremity weakness. A review of Resident 12's Bowel and Bladder Assessment, dated 11/12/15, upon Resident 12's readmission, indicated Resident 12 had a total score of 15 (score of 15-21=good candidate for training). However, the assessment indicated Resident 12 had control of both B/B without any incontinence, which was contrary to the resident's MDS assessment. During a concurrent interview and record review, on 12/18/15, at 3:10 p.m., a registered nurse supervisor (RN 1) stated Resident 12's B/B Assessment, dated 11/12/15, did not correspond to the resident's current health condition. RN 1 stated the admission charge nurse was responsible for completing the B/B Assessment. RN 1 stated Resident 12 was incontinent and the B/B assessment would be corrected. A review of Resident 12's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 10/23/15, indicated Resident 12 expressed needs and wants, and understood verbal content. The MDS indicated Resident 12 had a score of 10, for the cognitive brief interview for mental status (BIMS), indicating the resident was interviewable. According to the MDS, Resident 12 required total assistance (full staff performance every time during a 7-day period), with a one-person physical assist for activities of daily living (ADLs) such as, dressing, toilet use, personal hygiene, and transferring from one area to another. The MDS indicated the resident was always incontinent of bladder and frequently incontinent of bowel, but did not participate in a toileting program. The MDS indicated Resident 12 had a Stage II pressure ulcer and was at risk of developing pressure ulcers. The treatments provided were pressure-reducing device for the bed, pressure ulcer care, and the application of ointments and medications. However, at 3:30 p.m., on 12/18/15, during a concurrent interview and observation, while at Resident 12's bedside, TN 1 verified Resident 12's mattress was a regular, standard mattress, and it did not provide pressure relief. A review of Resident 12's basic metabolic panel ((BMP) a chemistry blood test), dated 11/16/15, indicated Resident 12's [MEDICATION NAME] was low at 1.8 (normal reference range (NRR) is 3.5-5.7 gram per deciliter (g/dl)) and total protein level was low at 5.0 g/dl (NRR 6.4-8.9). According to the National Pressure Ulcer Advisory Panel (NPUAP), indicated low serum [MEDICATION NAME] and protein puts residents at a higher risk of developing pressure ulcers. Because poor nutritional status was a contributing factor in pressure sore development and impaired wound healing. The facility failed to address this a risk for Resident 12 to develop pressures. A review of the Licensed Nurses Weekly Summary, dated 11/24/15, during the 7-3 p.m. shift, indicated Resident 12 was bed bound (spends most of the time in bed), required total assistance with activities of daily living ADL (eating, toilet use, dressing, walking, bathing, personal hygiene, transferring, and repositioning in bed). The weekly summary for Resident 12's decubitus care had not been completed and indicated N/A (not applicable). A review of Resident 12's care plan, initiated on 11/12/15, titled Actual Skin Breakdown related to Perineal Irritation, the plan of care had no documented timeframes for the goal. The staff's interventions included to monitor the wound every day, provide good peri/incontinent care and provide wound care treatment as ordered. A review of all of Resident 12's care plans, provided by the director of nursing (DON) on 12/22/15, did not indicate there was a plan of care initiated for Resident 12's ongoing risk for pressure sores. A review of Resident 12's significant change in status assessment, MDS, dated [DATE], indicated the resident was at risk of developing pressure ulcers. According to the MDS, Resident 12 sometimes expressed needs and wants, and sometimes understood verbal content. Resident 12 was unable to complete the brief interview for mental status (BIMS) and Resident 12 had short and long-term memory problems, with moderately impaired cognitive skills for daily decision-making. According to the MDS, Resident 12 required extensive assistance with ADLs and was always incontinent of B/B and did not participate in a toileting program. A review of Resident 12's ADLs Tracking Record indicated Resident 12 was incontinent with soft/loose stool on the following dates: a. On 12/14/15, twice during the day shift (7 a.m.-3 p.m.). b. On 12/15/15, three (3) times during the day shift (7 a.m. - 3 p.m.), and two (2) extra-large during the night shift. c. On 12/16/15, one small soft/loose stool during the day shift and one large loose stool during the night shift. d. On 12/17/15, one medium loose stool during the day shift. e. On 12/18/15, two large soft/loose stool during the day shift. f. On 12/19/15, two medium soft/loose stool during the day shift. g. On 12/20/15, two soft/loose stool during the day shift. h. On 12/21/15, one medium soft/loose stool during the night shift. A review of Resident 12's physician's orders [REDACTED]. A review of the DailyMed, an online article, indicated [MEDICATION NAME] was a laxative, and not a stool softener, used to relieve constipation. The article also indicated [MEDICATION NAME] should not be used longer than one week, unless directed by a physician. A review of Resident 12's Medication Administration Records (MAR), dated 12/14/15 through 12/18/15, indicated Resident 12 received [MEDICATION NAME] 8.6 milligram (mg) tablet twice a day. According to the MAR, ADL tracking, and interviews, the licensed nurses did not hold the [MEDICATION NAME] as ordered by the physician during the five days Resident 12 was having loose bowel movements 12/14/18 through 12/18/15. A review of an online drug description, titled, Omni view-Drug Information, (for Senna (brand name for [MEDICATION NAME])) 8.6 MG soft gel, provided by the DON, with a print date of 12/22/15, and timed at 3:38 p.m., indicated [MEDICATION NAME] was known as stimulant laxative, used to treat constipation. The side effects of the medication included nausea, diarrhea (loose watery stools), weakness, mental/mood changes (confusion). The drug information stated if any of the side effects persisted, to notify the physician or pharmacist promptly. A review of the Resident 12's Braden Scale (assessment tool for predicting pressure sore risk), from 10/16/15 admission, dated 10/16/15 through 10/30/15, indicated Resident 12 had a score of 9. According to the scale, a total score of nine and below, indicated the resident was at severe risk of developing a pressure sore. A review of the Braden Scale, dated 11/12/15 through 12/3/15, indicated Resident 12 had a score of 18, indicating Resident 12 had a mild risk of developing a pressure sore, although the resident had developed excoriation and had history of pressure sore. The resident's health condition improved compared to the previous month's Braden Scale, but did not correspond to the MDS, dated [DATE], which indicated Resident was at risk for developing pressure ulcers. A review of the Nursing Admission and Assessment, during Resident 12's re-admission on 11/12/15, did not indicate Resident 12 had a pressure sore at re-admission. The Nursing Admission and Assessment also indicated Resident 12 was continent (able to control) of bowel and bladder, which was also contrary to the MDS assessment. A review of the Braden Scale, dated 12/19/15, indicated Resident 12 had a score of 9, which indicated Resident 12 was at severe risk of developing a pressure sore. There was no documented evidence the resident's risk for developing a pressure sore was re-assessed when the resident had loose stools from 12/14/15 to 12/18/15. A review of the facility's policy, dated 8/31/11, and titled, Pressure Ulcer Prevention and Management Policy, indicated risk factors that increased the resident's susceptibility to develop or to not heal pressure ulcers included, diabetes, chronic bowel and urinary incontinence, chronic or end stage [MEDICAL CONDITION], impaired mobility, decreased functional ability, malnutrition (lack of proper nutrition) or hydration deficits, and cognitive impairment. The policy also stipulated that a licensed nurse would complete a skin assessment as well as a risk assessment using a standardized risk assessment tool and develop a care plan to address the resident's risk for skin breakdown. The policy indicated the licensed nurse and dietician would assess resident's medications and nutritional status if contributing to break in skin integrity. For prevention, the facility's policy indicated applying pressure redistribution devices for residents in bed, and to turn and reposition residents if unable to do so independently. The policy indicated preventative measures might need to be kept in place indefinitely due to resident's risk of the wound reopening. During an interview, on 12/22/15, at 10 a.m., TN 3 stated, she completed the Braden Scale (assessment tool for predicting pressure sore risk) for Resident 12, from 11/12/15 through 12/3/15. TN 3 stated, sensory perception category with a score of four (4) (no impairment) means the resident was responsive and able to notify when wet but Resident 12 has been too weak recently. TN 3 stated that Resident 12 was often moist, but was documented with a score of four (rarely moist). TN 3 stated, She wears diapers, which mean she has no control using the bathroom. I guess I could have changed it to moist. After reviewing both Resident 12's Braden Scales, dated 10/16/15 through 10/30/15 and 11/12/15 through 12/3/15, TN 3 stated the sensory perception, moisture, and mobility, scores for Resident 12 was incorrect. TN 3 stated a correct score for Resident 12 was a score of nine or below, which indicated Resident 12 was at severe risk for developing pressure sores. TN 3 stated when resident was admitted to the facility in October her poor health conditions remained unchanged, but according to TN 3 from her observation recently, Resident 12's health was getting worse and slowly declining. On 12/22/15, at 11:20 a.m., during an interview, the director of staff development (DSD) stated, You need to consider co-morbidity (the simultaneous presence of two chronic diseases or conditions in a patient) and overall overview of all shifts to do the Braden Scale Assessment. The DSD stated the content of the Braden Scale, B/B Program Assessment Tool, and Neurological Evaluation Flow Sheet as inaccurate for Resident 12. The DSD stated, the nursing supervisor admitting the resident was responsible for completing the assessments and the charge nurse and treatment nurse needed to assess the resident within two hours of admission. DSD stated, the director of nurses (DON), assistant director of nurses (ADON), and MDS (Minimum Data Set) Nurse were responsible for educating staff on how to accurately complete the assessment forms.