Every finding on record at Riverside Postacute Care

Based on observation, interview, and record review, the facility failed to provide a comfortable environment for 12 of 151 residents (Residents 2, 3, 4, 5, 6, 7, 8, 9,10, 11, 12 and 13), when the temperature in the resident's rooms was above 81 degrees Fahrenheit. This failure has the potential to result in physical discomfort which could lead to fatigue, mood swings, and respiratory and allergy issues, for Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13. Findings: On July 9, 2026, at 1:03 p.m., an unannounced visit at the facility was conducted to investigate issues on physical environment. On July 9, 2026, multiple observations and interviews were conducted with residents: a. At 1:50 p.m., Resident 2 was observed sitting at the side of the bed, with a tower fan close to the head of his bed. Resident 2 stated it was too hot in his room. Resident 2 stated it affects his sleep; b. At 3:27 p.m., Resident 3 was observed in the hallway, standing outside of his room, in front of a swamp cooler with his shirt lifted. Resident 3 stated his room was very hot and that he felt uncomfortable; c. At 5:14 p.m., Resident 4 was observed resting in bed, without a shirt. Resident 4 stated his room was too hot and he felt more comfortable not wearing a shirt; and d. At 5:22 p.m., Resident 8 was observed in bed with head of the bed elevated, without a shirt. Resident 8 stated if his window curtain was opened just a little bit, the whole room would turn into an inferno. Resident 8 stated he felt cooler and more comfortable without a shirt. On July 9, 2026, multiple observations and interviews were conducted with the Maintenance Supervisor (MS); a. At 1:42 p.m., during an interview, the Maintenance Supervisor (MS) stated that individual room air conditioners (AC) with thermostats are not available. He stated that he monitors each resident's room temperature daily and provides fans upon request or if the room is too hot. In addition, he stated each hallway has a swamp cooler to keep the hallway cool;b. At 1:57 p.m., the MS measured the temperature using a handheld infrared thermometer gun (a device that measured an object's temperature) in the 40's hallway and the thermometer gun recorded a reading of 85 degrees Fahrenheit. The MS stated the acceptable temperature range for the facility was 68 to 85 degrees Fahrenheit. He stated room temperatures were taken by pointing the temperature laser gun at the wall near the resident's bed, the floor, and the vent above the room door; c. At 2:10 p.m., the MS checked the temperature in Resident 2's room by pointing the thermometer gun at the wall above Resident 2's bed and the handheld infrared thermometer gun recorded a reading of 82 degrees Fahrenheit; d. At 2:11 p.m., the MS checked the temperature in Resident 4's room by pointing the thermometer gun at the wall above Resident 4's bed and the handheld infrared thermometer gun recorded a reading of 84 degrees Fahrenheit; e. At 2:14 p.m., the MS checked the temperature in Resident 5's room by pointing the thermometer gun at the wall above Resident 5's bed, and the handheld infrared thermometer gun recorded a reading of 82 degrees Fahrenheit; f. At 2:15 p.m., the MS checked the temperature in Resident 6's room by pointing the thermometer gun at the wall above Resident 6's bed, and the handheld infrared thermometer gun recorded a reading of 84 degrees Fahrenheit; g. At 2:16 p.m., the MS checked the temperature in Resident 7's room by pointing the thermometer gun at the wall above Resident 7's bed, and the handheld infrared thermometer gun recorded a reading of 85 degrees Fahrenheit; h. At 2:18 p.m., the MS checked the temperature in Resident 11's room by pointing the thermometer gun at the wall above Resident 11's bed, and the handheld infrared thermometer gun recorded a reading of 82 degrees Fahrenheit; i. at 2:23 p.m., the MS checked the temperature in Resident 10's room by pointing the thermometer gun at the wall above Resident 10's bed, and the handheld infrared thermometer gun recorded a reading of 82 degrees Fahrenheit; j. At 3:29 p.m., the MS checked the temperature in Resident 9's room by pointing the thermometer gun at the wall above Resident 9's bed, and the handheld infrared thermometer gun recorded a reading of 84 degrees Fahrenheit; k. At 3:30 p.m., the MS checked the temperature in Resident 3's room by pointing the thermometer gun at the wall above Resident 3's bed, and the handheld infrared thermometer gun recorded a reading of 83 degrees Fahrenheit; l. At 4:08 p.m., the MS stated he conducts daily room temperature check every morning around 8:30 a.m., using a thermometer laser gun. He stated the facility has 14 AC units, seven units for each half of the building; m. At 5:42 p.m., the MS checked the temperature in Resident 8's room by pointing the thermometer gun at the wall above Resident 8's bed, and the handheld infrared thermometer gun recorded a reading of 88 degrees Fahrenheit; n. At 5:43 p.m., the MS checked the temperature in Resident 13's room by pointing the thermometer gun at the wall above Resident 13's bed, and the handheld infrared thermometer gun recorded a reading of 87 degrees Fahrenheit; and o. At 5:44 p.m., the MS checked the temperature in Resident 12's room by pointing the thermometer gun at the wall above Resident 12's bed, and the handheld infrared thermometer gun recorded a reading of 88 degrees Fahrenheit. On July 9, 2026, at 3:35 p.m., during an interview, Certified Nursing Assistant (CNA) 1 stated the residents appeared hot with some residents removing their shirts. CNA 1 expressed concern that rising temperatures as the sun set made room less safe for those with respiratory issues which could potentially worsen their symptoms. On July 9, 2026, at 4:37 p.m., during a concurrent interview and record review of the regulation and the facility policy and procedure, the Administrator (ADM) and the MS, were made aware that the room temperature had exceeded 81 degrees Fahrenheit, and the ADM stated the resident's room temperature was not in compliance with the regulations. On July 9, 2026, at 4:56 p.m., an interview was conducted with CNA 2. CNA 2 stated Resident 8 had complained twice that his room was too hot. CNA 2 stated she reported to MS. A review of residents' records indicated the following: a. Resident 2 was admitted to the facility on [DATE], with diagnoses which included insomnia (a common sleep disorder characterized by difficulty falling asleep, staying asleep or waking up too early). Resident 2's Minimum Data Set (MDS - an assessment tool), dated June 11, 2026, indicated a BIMS (Brief Interview for Mental Status) score of 15 (cognitively intact). b. Resident 3 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD-a long-term lung condition that makes it hard to breathe) and shortness of breath. Resident 3's MDS, dated [DATE], indicated a BIMS score of 14 (cognitively intact). c. Resident 4 was admitted to the facility on [DATE], with diagnoses which included paraplegia (paralysis from the waist down) and urinary tract infection (an infection in any part of the urinary system). Resident 4's MDS, dated [DATE], indicated a BIMS score of 15 (cognitively intact). d. Resident 5 was admitted to the facility on [DATE], with diagnoses which included COPD and anxiety. Resident 5's MDS, dated [DATE], indicated a BIMS score of 12 (moderate cognitive impairment). e. Resident 6 was admitted to the facility on [DATE], with diagnoses which included COPD and anemia (a blood condition where the body lacks enough healthy red blood cells). Resident 6's MDS, dated [DATE], indicated a BIMS score of 12 (moderate cognitive impairment). f. Resident 7 was admitted to the facility on [DATE], with diagnoses which included COPD and seizures (a sudden, uncontrolled burst of electrical activity in the brain). Resident 7's MDS, dated [DATE], indicated a BIMS score of 13 (cognitive function intact). g. Resident 8 was admitted to the facility on [DATE], with diagnoses which included venous insufficiency chronic peripheral (occurs when leg veins struggle to send blood backup to the heart) and insomnia. Resident 8's MDS, dated [DATE], indicated a BIMS score of 15 (cognitively intact). h. Resident 9 was admitted to the facility on [DATE], with diagnoses which included sinus tachycardia (a faster-than-normal heartbeat) and syncope and collapse (fainting). i. Resident 10 was admitted to the facility on [DATE], with diagnoses which included osteoarthritis of hip (protective cartilage on the joint slowly wears down) and anemia. Resident 10's MDS, dated [DATE], indicated a BIMS score of 15 (cognitively intact). j. Resident 11 was admitted to the facility on [DATE], with diagnoses which included hypotension (low blood pressure) and anxiety. Resident 11's MDS, dated [DATE], indicated, Memory problem.cognitive skills for daily decision making.severely impaired. k. Resident 12 was admitted to the facility on [DATE], with diagnoses which included COPD and shortness of breath. Resident 12's MDS, dated [DATE], indicated a BIMS score of 14 (cognitively intact). l. Resident 13 was admitted to the facility on [DATE], with diagnoses which included palliative care (extra medical support for anyone living with a serious illness) and basal cell carcinoma of skin (skin cancer). Resident 13's MDS, dated [DATE], indicated a BIMS score of 13 (cognitive function intact). A review of the facility's policy and procedure titled, Air Temperature Readings, dated April 2017, indicated, .Air temperature readings are taken.in response to air temperature complaints.prompt response to air temperature complaints is essential for maintaining acceptable levels of temperature, humidity, and ventilation.investigate air temperature complaints.the acceptable range for air temperature is 68 degrees - 85 degrees F (Fahrenheit) .

Based on observation, interview, and record review, the facility failed to ensure resident's bedroom window blinds were maintained in good working order for 14 of 63 rooms reviewed (rooms 9, 11, 16, 23, 29, 31, 33, 34, 41, 52, 54, 57, 58, and 61) when missing and broken blinds were observed for rooms facing a residential street, the facility courtyard, and the visitor/employee parking lot.This failure affected Resident 2, 3, 4, and 5's privacy, comfort, and ability to regulate natural lighting and privacy within their rooms (16, 41, and 57), and had the potential to affect the privacy of the other residents residing in rooms 9, 11, 23, 29, 31, 33, 34, 52, 54, 58, and 61.On July 1, 2026, at 10:32 am, a facility tour was conducted. An observation of rooms 9, 11, 31, 41, 57, 58, and 61, that face the facility's courtyard, had missing vertical blind slats; rooms 16, 29, 33, and 34, that face a residential street, had missing vertical blind slats and broken horizontal blinds; and room [ROOM NUMBER], 54, and 56, that face the facility's visitor/employee parking lot, had missing vertical blind slats and broken horizontal blinds.On July 1, 2026, at 11:57 am, a concurrent observation and interview was conducted with Resident 2 and Resident 3. Residents 2 and 3 were observed alert, oriented, and conversing with one another in room [ROOM NUMBER]. Resident 2 stated that the blinds had been missing slats since her admission to the facility. Resident 3 stated the blinds had been missing slats since her admission to the facility in October 2025. Resident 2 and Resident 3 stated the missing blind slats concern them since their room faces a residential street.On July 1, 2026, at 12:07 pm, a concurrent observation and interview was conducted with Resident 4. Resident 4 was observed exiting room [ROOM NUMBER]. Resident 4 stated he resides in room [ROOM NUMBER]. Resident 4 stated the blinds look bad and people on the other side of the courtyard can watch me.On July 1, 2026, at 12:21 pm, a concurrent observation and interview was conducted with Resident 5. Resident 5 was observed in room [ROOM NUMBER], sitting on the edge of his bed watching his iPad. Resident 5 stated he has an issue with the missing slats since his bed is closest to the window and other people across the courtyard can see him.On July 2, 2026, a review of the maintenance logbooks located in nurse station 1, 2, and 3 were reviewed.On June 3, 2026, there was documentation the blinds were replaced in rooms [ROOM NUMBERS].There was no documented evidence for the months of May or June 2026 of a request to repair the blinds in room [ROOM NUMBER], 11, 16, 29, 34, 41, 52, 54, 56, 57, 58, and 61.On July 2, 2026, at 11:42 am, a concurrent observation and interview was conducted with the maintenance supervisor (MS). The MS stated the facility process for requesting repairs are for staff to document their request in the maintenance logbook located at each nurse station and maintenance staff will check the maintenance logbooks daily for repair requests. A concurrent observation was conducted of rooms 9, 11, 16, 29, 31, 33, 34, 41, 52, 54, 56, 57, 58, and 61. The MS stated there were missing vertical blind slats and broken horizontal blinds in all of the rooms observed. A concurrent record review was conducted of the maintenance logbooks located at nurse station 1, 2, and 3. The MS stated there was no documented evidence of requests for blind repairs for rooms 9, 11, 16, 29, 34, 41, 52, 54, 56, 57, 58, and 61. The MS stated the facility staff did not follow the facility process for requesting repairs.On July 2, 2026, at 12:06 pm, a concurrent observation and interview was conducted with the Director of Nursing (DON). The DON stated the facility process for requesting repairs is for facility staff to document their request in the maintenance logbook located at each nurse station and maintenance staff will check the maintenance logbook daily for repair requests. A concurrent observation was conducted of rooms 9, 11, 16, 29, 31, 33, 34, 41, 52, 54, 56, 57, 58, and 61. The DON stated there should be no missing or damaged blinds in resident rooms. The DON stated it is the facility's responsibility to the resident to provide privacy and a homelike environment and the facility did not fulfill that responsibility. The DON further stated the facility did not follow their process for requesting repairs.A review of the facility policy titled, Homelike Environment, dated January 2018, indicated .Residents are provided with a safe, clean, comfortable and homelike environment.The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a .homelike setting.

Based on observation, interview, and record review, the facility failed to ensure the medical record accurately reflected care and services provided for one of three residents (Resident 1) when Resident 1's meal assistance and meal intake tasks had multiple missing entries.This failure resulted in incomplete medical records and had the potential to result in ineffective communication between staff members in monitoring Resident 1's nutritional status and response to care.Findings:A review Resident 1's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses which included stroke (loss of blood flow to a part of the brain) with right-sided weakness and dysphagia (difficulty swallowing).A review of Resident 1's History and Physical dated April 30, 2026, indicated the resident has the capacity to understand and make decisions.A review of Resident 1's Care Plan Report dated May 1, 2026, indicated, .The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) .cerebral infarction (stroke) with hemiplegia (weakness) right side (sic) .interventions included .EATING: The resident is totally dependent on 1 (one) staff for eating .A review of Resident 1's Documentation Survey Report for the month of May 2026, indicated the assistance for eating and nutrition-amount eaten tasks had missing entries on May 5, 6, 7, 11, 19, 2026, for breakfast and lunch; on May 8 and 9, 2026 for lunch; and on March 21, 2026 for dinner.On May 26, 2026, at 12:22 p.m., during a concurrent observation and interview, Resident 1 was in her room, lying in bed, turned to her left side, alert and awake. Resident 1 stated she was admitted to the facility due to a stroke that left her with right-sided weakness. Resident 1 stated she needs assistance to eat.On May 26, 2026, at 1:16 p.m., during a concurrent interview with Certified Nurse Assistant (CNA 1) and a record review of Resident 1's medical record, CNA 1 stated she assisted Resident 1 all the time with eating. CNA 1 stated Resident 1 ate 60 % of her meals and she documented it in the electronic charting. CNA 1 confirmed she was assigned to Resident 1 on May 7, 2026, for the 7-3 (morning) shift. When asked to explain why there were no entries for breakfast and lunch on May 7, 2026, CNA 1 stated it was because the computer was not working and the facility did not have any Wi-Fi ( a wireless networking technology that enables electronic devices to connect seamlessly to a network) for three days.On May 26, 2026, at 3:08 p.m., during an interview with the Director of Staff Development (DSD) and record review of Resident 1's medical record, the DSD stated CNAs document on the POC (Point of Care - an electronic charting tool) ADL Task how the resident was assisted with eating and how much they consumed for meals, and these should be documented daily for breakfast, lunch, and dinner. The DSD stated the ADL Tasks for assistance in eating and nutrition-amount eaten had incomplete documentation for the month of May 2026. The DSD stated there is no evidence that Resident 1 ate meals on multiple dates. The DSD stated the CNAs should document daily and accurately complete their charting.On May 27, 2026, at 2:53 p.m., during an interview with the Director of Nursing (DON), the DON stated anything that is not documented is not done. The DON stated for Resident 1, how would they know if the resident was eating when there is no documentation.A review of the facility's policy and procedure titled, Charting and Documentation dated January 2018 indicated .All services provided to the resident .shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary [NAME] regarding the resident's condition and response to care .

Based on interview and record review, the facility failed to ensure a physician's order of one-to-one sitter (1:1 sitter - a person who can provide continuous observation) was consistently implemented for one of three residents, Resident 2.As a result, Resident 2 was left unsupervised which may have contributed to Resident 2 having another fall incident on May 14, 2026, where Resident 2 sustained a skin tear to his left elbow. In addition, this failure had the potential for Resident 2 to sustain major injury such as a fracture (break in the bone).Findings:A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses which included prostate cancer (a growth of cells that starts in the prostate, a part of the male reproductive system).A review of Resident 2's Fall Assessment dated May 12, 2026, indicated the resident was a high risk for fall.A review of Resident 2's SBAR (Situation, Background, Assessment, Recommendation - a structured communication framework) and Progress Note indicated he had fall incidents on May 12, 2026 at 4:00 a.m., on May 13, 2026 at 12:50 p.m., and on May 14, 2026 at 1:20 a.m. A review of Resident 2's Order Summary Report indicated .1:1 sitter . was ordered on May 13, 2026.On May 27, 2026, at 10:02 a.m., during a telephone interview with Certified Nurse Assistant (CNA) 2, she stated she was familiar with Resident 2. CNA 2 stated she was assigned to Resident 2 twice for the night (11-7) shift in the past. CNA 2 stated they had to watch Resident 2 every 30 minutes the last time (May 13, 2026) she was assigned to him because he had fallen in the facility more than once. CNA 2 stated there was an order for Resident 2 to have a 1:1 sitter but there was no sitter for him that night, she was told that the facility tried to get a sitter but did not get approved for one. CNA 2 stated if there was 1:1 sitter, the sitter is supposed to sit right next to the patient, some would sit outside the resident's room by the door.A record review of the facility document titled Nursing Staff Assignment and Sign-in Sheet (assignment sheet - a document that outlines which staff members are caring for which residents on a given day or shift) dated May 13, 2026 indicated CNA 2 was assigned to Resident 2. On May 27, 2026, at 10:45 a.m., during a telephone interview with Registered Nurse (RN) 1, RN 1 stated Resident 2 had fallen during her shift on the early morning hours of May 14, 2026. RN 1 stated Resident 2's medical doctor (MD) ordered a 1:1 sitter but the sitter assignment was removed due to a miscommunication between the higher ups (management), staffing concerns that having a 1:1 sitter would result in overstaffing. RN 1 stated she notified the Director of Nursing (DON) about Resident 2's fall and the DON told her that there was a plan for CNAs to alternate every 30 minutes in providing the 1:1 sitter but RN 2 did not communicate this to her. RN 1 stated Resident 2 did not have a 1:1 sitter during the night shift beginning at 11:00 p.m. on May 13, 2026.On May 27, 2026, at 11:11 a.m., during a concurrent interview with Licensed Vocational Nurse (LVN) 1 and record review of Resident 2's medical record, LVN 1 stated Resident 2 was very confused and was a fall risk, so they placed his bed in a low position and provided floor mats. LVN 1 stated the following:-Resident 2 had an unwitnessed fall on May 12, 2026, at 4:00 a.m., he was on the floor and had a red bump on the right side of his forehead. The MD and family were notified. Resident 2's vital signs were monitored, and a neurological check (repeated, quick assessments used by healthcare professionals to monitor brain and nervous system function) was initiated;-Resident 2 had an unwitnessed fall on May 13, 2026, at 12:50 p.m., a CNA found him on the floor in his room. LVN 1 stated she was the charge nurse that shift, and the CNA had just placed the resident in his wheelchair in his room, the CNA left the room and when the CNA returned, Resident 2 was on the floor. LVN 1 stated Resident 2 was moved to a room closer to the nurses' station and the RN (RN 2) got an order from the MD for a 1:1 sitter which was initiated right away; and-Resident 2 had an actual suspected fall on May 14, 2026, at 1:20 a.m., he was found on the floor mat and had a skin tear on his left elbow which treatment was provided. The MD and family were notified.On May 27, 2026, at 11:55 a.m., during a concurrent interview with the Staffing Coordinator (SC) and record review of the facility's assignment sheet for May 13, 2026, the SC stated a CNA was initially assigned to be the 1:1 sitter for Resident 2 for the night shift of May 13, 2026, but was cancelled due to overstaffing. The SC stated the facility's plan was for the CNAs to alternate every 30 minutes in providing the 1:1 sitter.On May 27, 2026, at 12:09 p.m., during a telephone interview with RN 2, she stated she obtained the order of a 1:1 sitter for Resident 2 from the MD on May 13, 2026, after he fell, and she followed up with the SC to have extra staffing. RN 2 stated Resident 2 needed a 1:1 sitter for safety because even if he is in the wheelchair or in a low bed, he was still able to get himself on the floor. RN 2 stated during the morning shift (7am-3pm) on May 14, 2026, the DON asked her to notify Resident 2's MD that a 1:1 sitter was not necessary and the order was discontinued.On May 27, 2026, at 2:53 p.m., during an interview, the DON stated Resident 2 needed a 1:1 sitter due to his fall risk. The DON stated they removed the 1:1 sitter for Resident 2 on May 14, 2026, and had CNAs alternate every 30 minutes instead. The DON stated Resident 2 should have had a sitter on the night shift of May 13, 2026, as ordered.A review of the facility's policy and procedure titled Fall Prevention Program dated December 2016, indicated .the staff, with the input of the attending physician, will identify appropriate interventions to reduce the risk of falls.A review of the facility's policy and procedure titled Safety and Supervision of Residents dated January 2018 indicated .Our individualized, resident-centered approach to safety addresses safety and accident hazards for individuals residents .The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices .Implementing intervention to reduce accident risks and hazards shall include the following .communicating specific interventions to all relevant staff; assigning responsibility for carrying out interventions .ensuring the interventions are implemented .Monitoring the effectiveness of interventions shall include the following .ensuring that interventions are implemented correctly and consistently .

Based on interview and record review, the facility failed to ensure a secure environment for personal funds for four of five residents reviewed (Residents 7, 10, 11, and 12), when the facility changed the residents to private pay and removed $16,197.50 from the residents trust account (a bank account utilized to manage residents' finances) on [DATE], for Private Room & Board without the residents and/or Responsible Party (RP- primary point of contact that manages the resident's finances) consent.This failure had the potential for the residents and/or RP to experience mental anguish and/or confusion regarding the balance in their trust account.Findings:On [DATE], Resident 7's medical record was reviewed.The admission record indicated Resident 7 was re-admitted to the facility on [DATE], with diagnoses which included Dementia (decline in mental ability), Schizophrenia (severe brain disorder) and Bipolar (extreme mood swings). The admission record further indicated Resident 7 was self-responsible.The BIMS (Brief Interview for Mental Status- standardized tool used to screen cognitive impairment) score for Resident 7 dated [DATE], indicated a score of 07 severe cognitive impairment. A review of the document provided by the facility Business Office Manager (BOM) titled, (Named of Facility) Trust - Transaction History, dated [DATE], indicated Resident 7's trust account received a debit for Private Room & Board for the month of [DATE] in the amount of $16,197.50.A review of the document provided by the facility BOM titled, Eligibility Response (a real-time electronic response sent by insurance payers confirming a patient's coverage status) dated [DATE], indicated Resident 7 had Medi-cal (California need-based program covering long-term room, board, and nursing care for eligible residents who meet specific income/asset limits) covered benefits for the month of [DATE].A review of the document provided by the facility BOM titled, (Name of Facility) Payer Setup Information, (the formal process of identifying the primary payer and setting up billing parameters to align with requirements for reducing denied claims and managing cash flow) dated [DATE], indicated Resident 7 was billed as Private Pay for the month of [DATE]. The document further indicated on February 1, 2026, Resident 7 was changed from being billed private pay to billing Medi-Cal-IEHP (IEHP-Inland Empire Health Plan).A review of the document provided by the facility BOM titled, (Name of Facility) Activity Report, (financial document that tracks the inflows and outflows of financial resources over a specific period) dated [DATE], at 11:40 a.m., indicated Resident 7's trust account was debited $16,197.50 for Private Room & Board for the month of [DATE].There was no documented evidence that Resident 7 was notified and consented to being changed to private pay when the facility removed $16,197.50 from the residents trust account on [DATE].On [DATE], Resident 10's medical record was reviewed.The admission record indicated Resident 10 was admitted into the facility on [DATE], with diagnoses which include Dementia, and Psychotic Disorder (loss of touch with reality). The admission record further indicated Resident 10 was self-responsible.The history and physical dated [DATE], indicated Resident 10 had fluctuating capacity to understand and make decisions.The BIMS score for Resident 10 dated [DATE], indicated a score of 14 cognitively intact.A review of the document provided by the facility BOM titled, (Name of Facility) Trust - Transaction History, dated [DATE], indicated Resident 10's trust account received a debit for Private Room & Board for the month of [DATE] in the amount of $16,197.50.A review of the document provided by the facility BOM titled, Eligibility Response dated for the months of [DATE], and February 1, 2026, indicated Resident 10 had Medi-cal covered benefits for the months of [DATE] and February 2026.A review of the document provided by the facility BOM titled, (Name of Facility) Payer Setup Information, dated [DATE], and February 2026, indicated Resident 10 was billed as Private Pay for the month of [DATE]. The document further indicated on February 1, 2026, Resident 10 was changed from being billed private pay to billing Medi-Cal-IEHP.There was no documented evidence that Resident 7 was notified and consented to being changed to private pay when the facility removed $16,197.50 from the residents trust account on [DATE].On [DATE], Resident 11's medial record was reviewed.The admission record indicated Resident 11 was readmitted to the facility on [DATE], with diagnoses which include Metabolic Encephalopathy (brain dysfunction), and Dementia. The admission record further indicated Resident 11 was self-responsible.The history and physical dated [DATE], indicated Resident 11 had the capacity to make decisions.A review of the document provided by the facility BOM titled, (Name of Facility) Trust - Transaction History, dated [DATE], indicated Resident 11's trust account received a debit for Private Room & Board for the month of [DATE] in the amount of $16,197.50.A review of the document provided by the facility BOM titled, Eligibility Response dated [DATE], indicated Resident 11 had Medi-cal covered benefits for the month of [DATE].A review of the provided by the facility BOM titled, (Name of Facility) Activity Report, dated [DATE], at 11:40 a.m., indicated Resident 11's trust account was debited $16,197.50 for Private Room & Board for the month of [DATE].There was no documented evidence that Resident 11 was notified and consented to being changed to private pay when the facility removed $16,197.50 from the residents trust account on [DATE].On [DATE], Resident 12's medical record was reviewed.The admission record indicated Resident 12 was re-admitted to the facility on [DATE], with diagnoses which included Metabolic Encephalopathy, Dementia, and Altered Mental Status (change in baseline cognition from mild confusion to coma).The admission record also indicated that Resident 12's daughter was her RP.The BIMS score for Resident 12 dated February 9, 2026, indicated a score of 0 severe cognitive impairment. A review of the document provided by the facility BOM titled, (Name of Facility) - Trust Transaction History, dated [DATE], indicated Resident 12's trust account received a debit for Private Room & Board for the month of [DATE] in the amount of $16,197.50.A review of the document provided by the facility BOM titled, Eligibility Response, dated [DATE], and February 1, 2026, indicated Resident 12 had Medi-cal covered benefits for the month of [DATE] and February 2026.A review of the document provided by the facility BOM titled, (Name of Account) Payer Setup Information, dated [DATE], indicated Resident 12 was billed as Private Pay for the month of [DATE]. The document further indicated on February 1, 2026, Resident 10 was changed from being billed private pay to billing Medi-Cal-IEHP.A review of the document provided by the facility BOM titled, (Name of Facility) Activity Report, dated [DATE], at 11:40 a.m., indicated Resident 12's trust account was debited $16,197.50 for Private Room & Board for the month of [DATE].There was no documented evidence that Resident 12's RP was notified and consented to being changed to private pay when the facility removed $16,197.50 from the residents trust account on [DATE].On [DATE], at 10:08 a.m., an observation was conducted of Resident 12. Resident 12 was observed alert and uninterviewable.On [DATE], at 10:32 a.m., an observation and interview was conducted with Resident 7. Resident 7 was observed alert, oriented, and in the facility back dining room sitting in a wheelchair watching television. Resident 7 stated he did not have a bank account with the facility. Resident 7 stated that if he did have a bank account and someone withdrew a large amount of money without his knowledge he would report it to the bank and law enforcement.On [DATE], at 10:36 a.m., an observation and interview was conducted with Resident 10. Resident 10 was observed alert, oriented, and in the facility back dining room sitting at a table near the door playing chess with staff. Resident 10 stated he was not sure if he had a bank account with the facility. Resident 10 stated If someone took my money from my bank account without me knowing it would anger me.On [DATE], at 10:42 a.m., an observation and interview was conducted with Resident 11. Resident 11 was observed alert, oriented, and in the facility front dining room sitting in a wheelchair watching TV. Resident 11 stated he was not sure if he had a bank account with the facility. Resident 11 stated if he did have a bank account he would be pissed if someone took money from his account.On [DATE], at 3:03 p.m., a phone interview was conducted with the Accounts Receivable Director (ARD). The ARD stated Residents 10, 11, and 12 had a billable Medi-Cal benefit in the month of [DATE]. The ADR stated Resident 7, 10, 11, and 12's trust account was debited $16,197.50 on [DATE], for Private Room & Board for the month of [DATE], and there was no documented evidence that Resident 7, 10, and 11 were notified and/or consented to their trust account being debited $16,197.50 for the month of [DATE]. The ADR stated there was no documented evidence that Resident 12's RP was notified and/or consented to Resident 12's trust account being debited $16,197.50 for the month of [DATE].The ADR stated Resident 7, 10, and 11 did not request to be changed from billable Medi-Cal to Private Pay for the month of [DATE], it was the decision of the facility. The ADR stated Resident 12's RP did not request for Resident 12 to be changed from billable Medi-cal to Private Pay for the month of [DATE], it was also the decision of the facility.On [DATE], at 11:19 a.m., a concurrent interview and record review was conducted with the BOM. The BOM stated the facility process for transferring a resident to private pay only occurred when the resident did not have secondary insurance (Medi-Cal). The BOM stated if the resident did not have Medi-Cal as a secondary insurance when their Medicare days expired the resident will be switched from Medicare to private pay holding the resident financially responsible for the cost of their long term stay.The BOM stated on [DATE], Residents 7, 10, 11, and 12 were switched from Medi-Cal pay to private pay. The BOM stated there was documented evidence that Resident 7, 10, 11, and 12 had billable secondary (Medi-Cal) insurance benefits for the month of [DATE]. The BOM stated Resident 7, 10, 11, 12's trust account should not have been charged $16,197.50 for Private Room & Board when the residents were eligible for Medi-Cal benefits. The BOM stated there was no documented evidence that Resident 7, 10, and 11 were notified and/or consented to being changed to private pay for the month of [DATE]. The BOM further stated there was no documented evidence Resident 12's RP was notified and/or consented to being changed to private pay for the month of [DATE].The BOM further stated there was no documented evidence that Resident 7, 10, 11, and 12's RP consented to a withdrawal from their trust account in the amount of $16,197.50 for Private Room & Board for the month of [DATE].On [DATE], at 12:34 p.m., a concurrent interview and record review was conducted with the Administrator (ADM). The ADM stated residents are not supposed to be charged for Medi-Cal covered benefits. A review of Resident 7, 10, 11, and 12's financial records were conducted. The ADM stated the residents should not have been switched to private pay to cover Medi-Cal covered benefits. The ADM stated there was no documented evidence that Residents 7, 10, 11, or 12's RP consented to being changed to private pay for the month of [DATE]. The ADM further stated there was no documented evidence that Resident 7, 10, 11, and 12's RP consented to their trust accounts being debited $16, 197.50 for Private Room & Board for the month of [DATE]. The ADM further stated there should be no charges for Medi-Cal covered benefits when the resident is Medi-cal eligible.On [DATE], at 9:32 a.m., a phone interview was conducted with Resident 12's RP. Resident 12's RP stated she never knew Resident 12's trust account carried a balance and thought Resident 12's social security income was absorbed for Resident 12's room and board at the facility. The RP stated she had never been notified by the facility or consented to Resident 12's being changed to provide pay for the month of [DATE]. Resident 12's RP further stated she was never informed by the facility that Resident 12's trust account carried balance and had never consented to Resident 12's trust account being debited for private pay.On [DATE], a review of the facility census for the dates [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE], indicated the following:-On [DATE], Resident 7 was in a three bed room, Resident 10 was in a three bedroom with two roommates, Resident 11 was a three bedroom with two roommates, and Resident 12 was in a three bedroom with two roommates;-On [DATE], Resident 7 was in a three bed room, Resident 10 was in a three bedroom with two roommates, Resident 11 was a three bedroom with two roommates, and Resident 12 was in a three bedroom with two roommates.-On [DATE], Resident 7 was in a three bed room, Resident 10 was in a three bedroom with two roommates, Resident 11 was a three bedroom with two roommates, and Resident 12 was in a three bedroom with two roommates;-On [DATE], Resident 7 was in a three bedroom with two roommates, Resident 10 was in a three bedroom with two roommates, Resident 11 was a three bedroom with two roommates, and Resident 12 was in a three bedroom with two roommates;-On [DATE], Resident 7 was in a three bedroom with two roommates, Resident 10 was in a three bedroom with two roommates, Resident 11 was a three bedroom with two roommates, and Resident12 was in a three bedroom with two roommates; and-On [DATE], Resident 7 was in a three bed room with two roommates, Resident 10 was in a three bedroom with two roommates, Resident 11 was a three bedroom with two roommates, and Resident 12 was in a three bedroom with two roommates.A review of the facility policy and procedure titled, Abuse Prevention Program, dated [DATE], indicated .Our residents have the right to be free from.misappropriation of resident property.As part of the resident abuse prevention, the administration will.Protect our residents from abuse by anyone.

Based on interview and record review the facility failed to ensure residents who have trust accounts (a bank account utilized to manage residents' finances) managed by the facility received quarterly statements, for five of five residents reviewed (Resident 7, 9, 10, 11, and 12).This failure had the potential to prevent residents and/or resident's representatives from verifying resident account balances, identifying potential discrepancies, and tracking interest earned.Findings:On April 16, 2026, at 2:46 p.m., Resident 7 was observed alert, oriented, and watching TV. Resident 7 stated he did not have a bank account nor did he receive mail at the facility.On April 16, 2026, at 2:50 p.m., Resident 9 was observed alert, oriented in bed viewing her cell phone. Resident 9 stated that her Social Security checks are sent directly to the facility. Resident 9 stated she has a share-of-cost (monthly amount a Medi-Cal recipient must pay out-of-pocket for care before Medi-Cal begins covering expenses) obligation but was unable to specify the amount. Resident 9 stated the facility did not provide her with quarterly statements to track deposits and withdrawals.On April 16, 2026, at 3:00 p.m., Resident 10 was observed alert, oriented, and playing chess with another resident in the dining room. Resident 10 stated he had not received quarterly statements for a trust account.On April 16, 2026, at 4:03 p.m., Resident 11 was observed in bed alert and oriented watching TV. Resident 11 stated he was unaware if he had a trust account. Resident 11 stated he had not received a quarterly trust account statement. On April 16, 2026, at 4:13 p.m., Resident 12 was observed in bed covered with a blanket alert, nonresponsive, and uninterviewable.On May 4, 2026, at 8:39 a.m., a phone interview was conducted with Resident 12's RP. The RP stated since her mother's admission into the facility she he had never received quarterly statement for Resident 12's trust account. On April 20, 2026, Resident 7's medial record was reviewedThe admission record indicated Resident 7 was re-admitted to the facility on [DATE], with diagnoses which included Dementia (decline in mental ability), Schizophrenia (severe brain disorder) and Bipolar (extreme mood swings).The BIMS (Brief Interview for Mental Status- standardized tool used to screen cognitive impairment) score for Resident 7 dated April 16, 2026, indicated a score of 07 severe cognitive impairment. A review of the document provided by the facility Business Office Manager (BOM) titled, (Named Facility) Trust - Transaction History, indicated Resident 7's trust account with the facility was opened November 26, 2025.On April 20, 2026, Resident 9's medical record was reviewed.The admission record indicated Resident 9 was readmitted to the facility on [DATE], with diagnoses which included , Schizophrenia, Bipolar, and Major Depressive Disorder (persistent feeling of sadness).The history and physical dated July 31, 2025, indicated Resident 9 had the capacity to make decisions.A review of the document provided by the facility BOM titled, (Name of Facility) Care Trust - Transaction History, indicated Resident 9 opened a trust account with the facility on August 1, 2024.On April 20, 2026, Resident 10's medical record was reviewed.The admission record indicated Resident 10 was admitted into the facility on July 8, 2016, with diagnoses which include Dementia, and Psychotic Disorder (loss of touch with reality).The history and physical dated March 7, 2025, indicated Resident 10 had fluctuating capacity to understand and make decisions.A review of the document provided by the facility BOM titled, (Named Facility) Trust General Notes Report, indicated Resident 10 opened a trust account with the facility on November 30, 2018.The BIMS score for Resident 10 dated April 3, 2026, indicated a score of 14 cognitively intact.On April 20, 2026, Resident 11's medial record was reviewed.The admission record indicated Resident 11 was readmitted to the facility on [DATE], with diagnoses which include Metabolic Encephalopathy (brain dysfunction), and Dementia.The history and physical dated March 12, 2025, indicated Resident 11 had the capacity to make decisions.A review of the document provided by the facility BOM titled, (Named of Facility) Care Trust - Transaction History, indicated Resident 11 opened a trust account with the facility September 15, 2025.On April 20, 2026, Resident 12's medical record was reviewed.The admission record indicated Resident 12 was re-admitted to the facility on [DATE], with diagnoses which included Metabolic Encephalopathy, Dementia, and Altered Mental Status (change in baseline cognition from mild confusion to coma).The admission record also indicated that Resident 12's daughter was her Responsible Party (RP- primary point of contact that manages the resident's finances).The BIMS score for Resident 12 dated February 9, 2026, indicated a score of 0 severe cognitive impairment. A review of the document provided by the facility DON titled, (Named of Facility) Trust - Transaction History, indicated Resident 12 opened a trust account with the facility September 1, 2024.On April 20, 2026, at 9:27 a.m., a concurrent interview and record review was conducted with the BOM. The BOM stated the facility process for providing resident's or the RP with quarterly trust account statements are by demand request (formal request made by the resident or RP) only. The BOM stated since his start of employment with the facility (February 17, 2026), the business office had never provided quarterly trust account statements to the residents or the RP.On April 24, 2026, at 12:34 p.m. an interview was conducted with the Administrator (ADM). The ADM stated quarterly statements are automatically mailed to the residents or the RP from the facility business office. The ADM stated the facility did not have a procedure in place to ensure that the residents or the RP received quarterly trust statements. The ADM further stated he verified with the corporate office Director of Accounts Receivable that the resident or RP should have been receiving quarterly trust accounts statements and was not sure why the BOM was not mailing out the quarterly trust account statements.Policies were requested for resident trust accounts and quarterly statements. The requested policies were not provided by the facility.

Based on interview and record review, the facility failed to ensure the personal funds for four of five residents reviewed (Resident 7, 10, 11, and 12) were not charged for services covered by their Medi-Cal (California need-based program covering long-term room, board, and nursing care for eligible residents who meet specific income/asset limits) healthcare benefits.This failure resulted in an improper reduction of Residents 7, 10, 11, and 12 personal funds.Findings:On April 20, 2026, Resident 7's medical record was reviewed.The admission record indicated Resident 7 was re-admitted to the facility on [DATE], with diagnoses which included Dementia (decline in mental ability), Schizophrenia (severe brain disorder) and Bipolar (extreme mood swings).The BIMS (Brief Interview for Mental Status- standardized tool used to screen cognitive impairment) score for Resident 7 dated April 16, 2026, indicated a score of 07, severe cognitive impairment. A review of the document provided by the facility Business Office Manager (BOM) titled, (Name of Facility) Trust - Transaction History, dated December 31, 2025, indicated Resident 7's trust account (a bank account utilized to manage residents' finances) received a debit for Private Room & Board for the month of January 2026 in the amount of $16,197.50.A review of the document provided by the facility BOM titled, Eligibility Response (a real-time electronic response sent by insurance payers confirming a patient's coverage status) dated January 1, 2026, indicated Resident 7 had Medi-cal covered benefits for the month of January 2026.A review of the document provided by the facility BOM titled, (Name of Facility) Payer Setup Information, (the formal process of identifying the primary payer and setting up billing parameters to align with requirements for reducing denied claims and managing cash flow) dated January 1, 2026, indicated Resident 7 was billed as Private Pay for the month of January 2026.A review of the document provided by the facility BOM titled, (Name of Facility) Activity Report, (financial document that tracks the inflows and outflows of financial resources over a specific period) dated January 2, 2026, at 11:40 a.m., indicated Resident 7's trust account was debited $16,197.50 for Private Room & Board for the month of January 2026.On April 20, 2026, Resident 10's medical record was reviewed.The admission record indicated Resident 10 was admitted into the facility on July 8, 2016, with diagnoses which include Dementia, and Psychotic Disorder (loss of touch with reality).The history and physical dated March 7, 2025, indicated Resident 10 had fluctuating capacity to understand and make decisions.The BIMS score for Resident 10 dated April 3, 2026, indicated a score of 14 cognitively intact.A review of the document provided by the facility BOM titled, (Name of Facility) Trust - Transaction History, for December 31, 2026, indicated Resident 10's trust account received a debit for Private Room & Board for the month of January 2026 in the amount of $16,197.50.A review of the document provided by the facility BOM titled, Eligibility Response dated January 1, 2026, indicated Resident 10 had Medi-cal covered benefits for the month of January 2026.A review of the document provided by the facility BOM titled, (Name of Facility) Payer Setup Information, for January 1, 2026, indicated Resident 10 was billed as Private Pay for the month of January 2026.On April 20, 2026, Resident 11's medial record was reviewed.The admission record indicated Resident 11 was readmitted to the facility on [DATE], with diagnoses which include Metabolic Encephalopathy (brain dysfunction), and Dementia.The history and physical dated March 12, 2025, indicated Resident 11 had the capacity to make decisions.A review of the document provided by the facility BOM titled, (Name of Facility) Trust - Transaction History, dated December 31, 2025, indicated Resident 11's trust account received a debit for Private Room & Board for the month of January 2026 in the amount of $16,197.50.A review of the document provided by the facility BOM titled, Eligibility Response dated January 1, 2026, indicated Resident 11 had Medi-cal covered benefits for the month of January 2026.A review of the provided by the facility BOM titled, (Name of Facility) Activity Report, dated January 2, 2026, at 11:40 a.m., indicated Resident 11's trust account was debited $16,197.50 for Private Room & Board for the month of January 2026.On April 20, 2026, Resident 12's medical record was reviewed. The admission record indicated Resident 12 was re-admitted to the facility on [DATE], with diagnoses which included Metabolic Encephalopathy, Dementia, and Altered Mental Status (change in baseline cognition from mild confusion to coma).The admission record also indicated that Resident 12's daughter was her Responsible Party (RP- primary point of contact that manages the resident's finances).The BIMS score for Resident 12 dated February 9, 2026, indicated a score of 0 severe cognitive impairment. A review of the document provided by the facility BOM titled, (Name of Facility) Trust - Transaction History, for December 31, 2025, indicated Resident 12's trust account received a debit for Private Room & Board for the month of January 2026 in the amount of $16,197.50.A review of the document provided by the facility BOM titled, Eligibility Response, dated January 1, 2026, indicated Resident 12 had Medi-cal covered benefits for the month of January 2026.A review of the document provided by the facility BOM titled, (Name of Facility) Payer Setup Information, for the following dated January 1, 2026, indicated Resident 12 was billed as Private Pay for the month of January 2026.A review of the document provided by the facility BOM titled, (Name of Facility) Care Activity Report, dated January 2, 2026, at 11:40 a.m., indicated Resident 12's trust account was debited $16,197.50 for Private Room & Board for the month of January 2026.On April 24, 2026, at 11:19 a.m., a concurrent interview and record review was conducted with the BOM.The BOM stated the facility process for residents health insurance is when a resident enters the facility; the facility recommends that the resident enroll in Medi-Cal as a secondary insurance so that the resident is not responsible for private pay rates when their Medicare insurance runs out of covered days. The BOM stated that Medi-Cal is used for long term custodial billing and Medicare is used for three day or more hospital admissions. The BOM stated Medicare only covers 100 days of long term custodial care once a resident has been discharged from a three night or more hospital admission. The BOM stated once the Medicare 100 days expires the resident needs to have Medi-Cal (secondary insurance) in place to cover the cost of a long term custodial stay. The BOM stated if the resident does not have Medi-Cal when their Medicare 100 days expires the resident will be switched from Medicare to private pay, holding the resident financially responsible for the cost of their long term stay.The BOM stated a resident is only transferred to private pay when the resident does not have a secondary insurance. The BOM stated on January 1, 2026, Resident 7 was switched from Medi-Cal to private pay. The BOM stated there was documented evidence that Resident 7 had billable secondary (Medi-Cal) insurance benefits for the month of January 2026 that would have covered Resident 7's January 2026 long term stay. The BOM stated Resident 7 should not have been changed from Medi-Cal to private pay when Resident 7 had a billable secondary insurance. The BOM stated Resident 7's trust account should not have been charged $16,197.50 for Private Room & Board when resident 7 was eligible for Medi-Cal benefits. The BOM stated on January 1, 2026, Resident 10 was switched from Medi-Cal pay to private pay. The BOM stated there was documented evidence that Resident 10 had billable secondary (Medi-Cal) insurance benefits for the month of January 2026 that would have covered Resident 10's January 2026 long term stay. The BOM stated Resident 10 should not have been changed from Medi-Cal to private pay when Resident 10 had a billable secondary insurance. The BOM stated Resident 10's trust account should not have been charged $16,197.50 for Private Room & Board for the month of January 2026 when Resident 10 was eligible for Medi-Cal benefits. The BOM stated on January 1, 2026, Resident 11 was switched from Medi-Cal pay to private pay. The BOM stated there was documented evidence that Resident 11 had billable secondary (Medi-Cal) insurance benefits for the month of January 2026 that would have covered Resident 11's January 2026 long term stay. The BOM stated Resident 11 should not have been changed from Medi-Cal to private pay when Resident 11 had a billable secondary insurance. The BOM stated Resident 11's trust account should not have been charged $16,197.50 for Private Room & Board when resident 11 was eligible for Medi-Cal benefits. The BOM stated on January 1, 2026, Resident 12 was switched from Medi-Cal pay to private pay. The BOM stated there was documented evidence that Resident 12 had billable secondary (Medi-Cal) insurance benefits for the month of January 2026 that would have covered Resident 12's January 2026 long term stay. The BOM stated Resident 12 should not have been changed from Medi-Cal to private pay when Resident 12 had a billable secondary insurance. The BOM stated Resident 12's trust account should not have been charged $16,197.50 for Private Room & Board for the month of January 2026 when Resident 12 was eligible for Medi-Cal benefits. On April 24, 2026, at 12:34 p.m., a concurrent interview and record review was conducted with the Administrator (ADM). The ADM stated residents are not supposed to be charged for Medi-Cal covered benefits. Resident 7, 10, 11, and 12's records were reviewed. The ADM stated Resident 7, 10, 11, and 12 should not have been switched to private pay to cover Medi-Cal covered benefits.A review of the document provided by the facility BOM titled, California Standard admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities, undated, indicated .page 9.YOU SHOULD BE AWARE THAT NO FACILITY THAT PARTICIPATES IN THE MEDI-CAL PROGRAM MAY REQUIRE ANY RESIDENT TO REMAIN IN PRIVATE PAY STATUS FOR ANY PERIOD OF TIME BEFORE CONVERTING TO MEDI-CAL COVERAGE.Policies for Medi-Cal billing were requested. The policies were not provided by the facility.

Based on interview and record review, the facility failed to notify the resident's representative (RP - primary point of contact that manages the resident's finances) for one of 5 residents reviewed (Resident 12), when Resident 12's trust account (a bank account utilized to manage residents' finances) balance approached the Supplemental Security Income (SSI) resource limit.This failure had the potential to place Resident 12 at risk of losing Medicaid (government program covering long-term care for low-income residents, including room and board, nursing care, therapies, and medications) eligibility.Findings:On April 20, 2026, Resident 12's medical record was reviewed.The admission record indicated Resident 12 was re-admitted to the facility on [DATE], with diagnoses which included Metabolic Encephalopathy (brain dysfunction), Dementia (decline in mental ability), and Altered Mental Status (change in baseline cognition from mild confusion to coma).The admission record also indicated that Resident 12's daughter was her RP.The BIMS (Brief Interview for Mental Status- standardized tool used to screen cognitive impairment) for Resident 12 dated February 9, 2026, indicated a score of 0 (severe cognitive impairment).A review of the document titled, (Name of Facility) Trust - Transaction History, dated April 6, 2026, indicated Resident 12's trust account balance was $14,545.99.On April 22, 2026, at 3:03 p.m., a phone interview was conducted with the Director of Accounts Receivable (DAR). The DAR stated residents that have a trust account balance greater than $2000 are at risk of losing their Medi-cal/Social Security (SSI) benefits (Medicaid program covering long-term care for low-income residents, including room and board, nursing care, therapies, and medications). The DAR stated the facility process for resident trust accounts greater than $2,000 is to notify the resident or the resident's representative that a spend down (the process of reducing an individual's excessive income) needs to occur so that the balance of the resident's trust account does not affect the residents eligibility for Medicaid /SSI benefits. The DAR stated it is the facility process for the Business Office Manager (BOM) to speak with the resident and/or RP to inform them of the necessary spend down amount to continue to be eligible for Medicaid/SSI benefits. The DAR stated as of April 22, 2026, Resident 12's trust account balance was $14,545.99. The DAR stated there was no documented evidence that the BOM had notified Resident 12's RP of Resident 12's trust account balance. The DAR stated the facility should have notified Resident 12's RP of Resident 12's trust account balance and the potential of losing eligibility for Medicaid /SSI benefits.On April 24, 2026, at 11:19 a.m., a concurrent interview and record review was conducted with the BOM. The BOM stated any trust account with an amount greater than $2000 is at risk of losing Medi-Cal and Social Security benefits. The BOM stated the facility process for trust accounts over $2,000 would be to arrange an IDT (Interdisciplinary - a collaborative group of healthcare professionals who work together to create, implement, and review comprehensive, person-centered care plan for residents) Team Meeting with the resident and/or RP to discuss the residents trust account balance, reason for the spend down, and amount of the spend down. The BOM stated Resident 12's trust account balance as of April 24, 2026, was $14,545.99. The BOM stated there was no documented evidence Resident 12's RP had been notified of Resident 12's trust account balance. The BOM stated the RP should have been notified of Residents 12's trust account balance and possible need to spend down.On May 4, 2026, at 9:32 a.m., a phone interview was conducted with Resident 12's RP. Resident 12's RP stated she never knew Resident 12's trust account carried a balance and thought Resident 12's social security income was absorbed for Resident 12's room and board at the facility. The RP stated the facility had never informed her of Resident 12's trust account balance and/or how the balance may affect Resident 12's eligibility for Medi-Cal and Social Security benefits.Policies were requested for notification of account balance and eligibility account limits for Medi-Cal/Social Security. The requested policies were not provided by the facility.

Based on observation, interview, and record review, the facility failed to ensure seven of 39 residents reviewed (Residents 118, 106, 8, 153, 163, 108, and 69) were free from significant medication error when:1.Resident 118 did not receive her medication Lacosamide (anticonvulsant medication used to treat seizures) from December 17, 2025, to January 15, 2026.This failure had the potential to place Resident 118 at high risk for seizure and other complications;2. Resident 106 did not receive five doses of the medication Acyclovir (antiviral medication to treat infection) from February 22 to February 23, 2026.This failure had the potential to jeopardize Resident 106's health status by leaving a skin infection untreated, leading to delayed healing and increased risk of viral spread;3. Resident 8 did not receive the medications Atorvastatin (medication used to lower bad cholesterol), Olanzapine (medication used to treat mental disorder), Risperdal (medication used to treat mental disorder) , Allopurinol (medication used to lower uric acid level in the blood), on multiple occasions in January 2026 and February 2026.This failure had the potential to jeopardize Resident 8's health and safety for not managing and treating the medical conditions, overall long-term health, and well-being of the resident.4. Resident 153 did not receive her medication Lacosamide in December 1 and 2, 2025.This failure had the potential to place Resident 153 at high risk for seizure and its complications;5. Resident 108 did not receive the medication Methimazole (medication used to reduce thyroid hormone production in the body) on multiple occasions in December 2025, and January 2026.This failure had the potential to jeopardize Resident 108's health and safety by not managing and treating the medical condition, overall long-term health and well-being of the resident;6. Resident 163 did not receive the medication Glipizide (medication used to diabetes {treat high blood sugar}) on multiple occasions in December 2025.This failure had the potential to jeopardize Resident 163's health and safety for not managing and treating the diabetes that could result to unmanaged high blood sugar levels and even death; and7. Resident 69 did not receive the medications Divalproex sodium, Gabapentin, Buspirone, Keppra (medication used to treat epilepsy), Xarelto (blood thinning medication), Levothyroxine ( medication used to replace thyroid hormones), and Atorvastatin on multiple occasions in December 2025, and January 2026.This failure had the potential to jeopardize Resident 69's health and safety for not managing and treating the medical conditions, overall long-term health and well-being of the resident;On March 2, 2026, at 5:39 p.m., the facility Administrator and Director of Nursing were verbally notified of the system failure which resulted in an Immediate Jeopardy (IJ). The system failure resulted in a delay in receiving necessary medications to manage epilepsy, diabetes, treat infection, and to treat other medical condition of the residents.On March 3, 2026, at 1:31 p.m., the Administrator presented an acceptable plan of action which included the following:- Residents 118, 106, 8,153,163,108, and 69's primary physicians were notified of the missed medication doses, physician recommendations were implemented, such as laboratory orders, and resident care plans were updated to address any adverse effects of the missed medications;- Residents 118, 106, 8,153,163,108, and 69's medication were checked and all medications were available for administration;- A triple medication check was conducted by the pharmacist to ensure that residents' medication was available for medication administration; and-An in-service was provided to licensed nurses on how to communicate missing medications to the pharmacy and the Attending Physician; complete medication errors report when medication is passed late and proper documentation of medication administration.On March 3, 2026, at 3:45 pm, the immediate jeopardy was removed in the presence of the Administrator, upon verification and implementation of the plan of actions. The facility was notified an extended survey would be conducted due to substandard quality of care issues.Noncompliance for F760 remained at the lower scope and severity of E no actual harm with potential for more than minimal harm.Findings:1.On February 24, 2026, at 11:01 a.m., an observation with a concurrent interview was conducted with Resident 118. Resident 118 was in bed, alert, and interviewable. Resident 118 stated that she ran out of her seizure medication about a month ago.On February 24, 2026, Resident 118's medical records were reviewed. Resident 118 was admitted to the facility on [DATE], with diagnoses including epilepsy (chronic neurological disorder manifested by recurrent, unprovoked seizures caused by sudden, excessive electrical discharges in the brain).The document titled, ANNUAL HISTORY AND PHYSICAL, dated March 19, 2025, indicated Resident 118 had intermittent (fluctuating) capacity to make decisions.The physician's order dated March 19, 2024, indicated to give two tablets of Lacosamide Oral Tablet 50 milligrams (mg- unit of measurement) by mouth two times a day for seizure.The electronic Medication Administration Record (eMAR) dated December 1, 2025, to December 31, 2025, indicated the physician's order to give two tablets of Lacosamide Oral Tablet 50 milligrams by mouth two times a day at 9 a.m., and 5 p.m., for seizure. The eMAR indicated the medication Lacosamide was signed by the licensed nurses as not administered from December 17 to 31, 2025.The document titled, .Orders-Administration Note . dated December 17, 2025, signed by a licensed nurse, indicated, .Lacosamide Oral Tablet 50 MG .Give 2 tablet oral by mouth two time a day for .SEIZURE .med not in cart, already ordered .The document titled, .Orders-Administration Note . dated December 18, 2025, signed by the licensed nurse, indicated, .Lacosamide Oral Tablet 50 MG .Give 2 tablet oral by mouth two time a day for .SEIZURE .med not in cart. already called pharmacy, stating need to get order from Dr to refill .There was no documented evidence between December 17 to 31, 2025 that Resident 118's physician was notified of the missed doses and that the medication Lacosamide needed a refill medication order.The eMAR dated January 1 to 31, 2026, indicated a physician's order to give two tablets of Lacosamide Oral Tablet 50 milligrams by mouth two times a day at 9 a.m. and 5 p.m. for seizure. The eMAR indicated the medication Lacosamide was signed by the licensed nurses as not administered from January 1 to 15, 2026. The care plan dated March 20, 2024, indicated, .Focus .(Name of Resident) has a seizure disorder .Goal .The resident will be/remain free of seizure activity .Intervention/Tasks .Give medication Lacosamide Oral Tablet 50 MG .as ordered .Monitor effectiveness and side effect .There was no documented evidence Resident 118's physician was notified of the Lacosamide missed doses from January 1 to 15, 2026. In addition, there was no documented evidence Resident 118 has been monitored for change of condition or seizure activity between December 17, 2025, to January 15, 2026. On February 25, 2026, at 2:25 p.m., an interview with a concurrent record review was conducted with the Director of Nursing (DON). The DON stated:-Resident 118's medication Lacosamide Oral Tablet 50 mg by mouth two times a day for seizure was not administered as ordered by the physician from December 17, 2025, to January 15, 2026, because the medication was not available;-The medication was ordered from the pharmacy, but since it was considered a narcotic medication (controlled drug) the pharmacy needed a physician's signature first before they can refill the medication;-The licensed nurses failed to contact the primary physician regarding the medication refill for Lacosamide, which required a physician's signature. The DON stated the licensed nurses should have followed up with Resident 188's physician;- Resident 118's physician was only notified of the missed Lacosamide doses in January 15, 2026. The DON stated the licensed nurses should have notified the physician after the initial missed dose on December 17, 2025, and monitored the resident since it was considered as COC (Change of Condition).-Resident 118 was not monitored for possible seizure activity or COC since she started missing the dose on December 17, 2025, until January 15, 2026. The DON stated this should have been done; and- Resident 118 was at high risk to experience seizure activities due to the missed Lacosamide medication doses.The facility's policy and procedure titled, .Administering Medications ., dated January 2018, indicated .Medications are administered in accordance with prescriber orders, including any required time frame .The facility's policy and procedure titled, .Change of Condition . dated August 2017, indicated, .It is the facility's policy that it shall promptly notify the resident, his or her Attending Physician, and representative .of changes in the resident's medical/mental condition and/or status .PROCEDURE .Acute medical changes or any sudden or serious change in condition manifested by a marked change in physical, mental and psychosocial status .Licensed nurse will notify physician .If unable to contact attending physician or alternate physician, notify the Medical Director . 2. On February 25, 2026, Resident 106's record was reviewed. Resident 106 was admitted to the facility on [DATE].The physician's order dated February 19, 2026, indicated to give Acyclovir Oral Tablet 800 milligrams (mg - unit of measurement) one tablet by mouth four times a day for shingles (painful, blistering rash caused by a virus) for seven days to start February 19, 2026.The electronic Medication Administration Record (eMAR) dated February 1 to 28, 2026, indicated the medication Acyclovir was documented as not administered by the licensed nurses on February 22 at 8 p.m., February 23 at 8 a.m., 12 p.m., 4 p.m., and 8 p.m.The eMAR progress notes indicated the following entries by the licensed nurses:- February 23, 2026 at 12:36 a.m., .Acyclovir Oral Tablet 800 mg .Pharmacy did not send enough .I faxed pharmacy .;-February 23, 2026, at 8:34 a.m., .Acyclovir Oral Tablet 800 mg .Medication not on hand. Did not give. Contacted pharmacy .;-February 23, 2026, at 12:35 p.m., .Acyclovir Oral Tablet 800 .Medication not on hand. Did not give. Contacted pharmacy .; and-February 23, 2026, at 9:59 p.m., .Acyclovir Oral Tablet 800 .awaiting delivery from pharmacy .The care plan dated February 18, 2026, indicated, Focus .The resident has infection of the skin R/T (related to) fluid filled vesicles to the left back and hip .Intervention .Administer anti-viral as ordered .On February 25, 2026, at 2:27 p.m., an interview with concurrent record review of Resident 106's medical record was conducted with the Director of Nursing (DON). The DON stated the following:-Resident 106's medication Acyclovir was not administered on February 22, 2026, at 8 a.m., and February 23, 2026, at 8a.m., 12 p.m., 4 p.m., and 8 p.m.,;- The medication was not administered by the licensed nurses because it was not available. The DON stated the pharmacy did not deliver enough Acyclovir medication to complete the seven days order;- The pharmacy was notified to deliver the rest of the medications but it was not delivered until February 24, 2026.-Resident 106's missed antibiotic doses meant his medication regimen treatment was incomplete and this may not effectively treat the current infection.3.On March 2, 2026, Resident 8's record was reviewed. Resident 8 was admitted to the facility on [DATE], with diagnoses including diabetes (high blood sugar), schizophrenia (type of behavioral disorder), gout (type of arthritis caused by high level of uric acid in the blood forming needle-like crystals in joints causing pain), hyperlipidemia (having high level of cholesterol in the blood), and Congestive Heart Failure (CHF - chronic condition where the heart muscle is too weak to pump blood efficiently).The facility document titled, .HISTORY AND PHYSICAL NOTE . dated July 10, 2024, indicated Resident 8 had fluctuating capacity to make decisions.The physicians' order indicated to give:-Allopurinol tablet 100 milligrams (mg- unit of measurement) by mouth one time a day for gout, date ordered February 4, 2026;-Atorvastatin Calcium Tablet 40 mg one tablet by mouth at bedtime for hyperlipidemia, date ordered June 20, 2025;-Risperdal Oral Tablet 1 mg one tablet by mouth two times a day for schizophrenia, date ordered June 20, 2025, discontinued February 3, 2026, and re-ordered on February 3, 2026; and-Olanzapine Oral Tablet 2.5 mg one tablet at bedtime for schizophrenia, ordered January 12, 2026 and discontinued January 20, 2026.The care plans dated:-December 13, 2024, indicated, Focus .AT RISK FOR (acute/chronic pain) r/t (related to) .GOUT .Interventions .Adminsiter (sic.) Allopurinol per MD (Medical Doctor) orders for gout .;-July 8, 2025, indicated, Focus .The resident uses psychotropic medications (risperdal) r/t Schizophrenia m/b (manifested by) episode of visual hallucination .Interventions .Administer PSYCHOTROPIC medications as ordered by physician .';and-September 7, 2025, indicated, Focus .The resident has hyperlipidemia .Interventions .Administer statin drug(Atorvastatin) per MD orders .The electronic Administration Record (eMAR) dated January 1 to 31, 2026, indicated the following physician's order were not signed as administered by the licensed nurses:- Atorvastatin Calcium Tablet 40 mg one tablet by mouth at bedtime for hyperlipidemia on January 12, 15, 16, 17, 18, and 20, 2026, at 9:00 p.m.;-Olanzapine Oral Tablet 2.5 mg one tablet at bedtime for schizophrenia on January 12, 13, 14, 15, 16, 17, and 18, 2026, at 9:00 p.m.; and-Risperdal Oral Tablet 1 mg one tablet by mouth two times a day for schizophrenia, on January 28 and 31 at 9:00 a.m., and on January 8, 9, 12, 15, 17, and 18, 2026, at 5:00 p.m.;The eMAR dated February 1 to 28, 2026, indicated the following physician's order were not signed as administered by the licensed nurses:-Allopurinol tablet 100 mg by mouth one time a day for gout on February 6, 7, 8, 11, and 15, 2026, at 9:00 a.m.; and-Risperdal Oral Tablet 1 mg one tablet by mouth two times a day for schizophrenia on February 2, 3, 6, and 8, 2026, at 9:00 a.m.On March 2, 2026, at 3:05 p.m., an interview with a concurrent record review of Resident 8's medical record was conducted with the Assistant Director of Nursing (ADON). The ADON stated:- Resident 8's medications Atorvastatin, Olanzapine, Risperdal, and Allopurinol, were not administered as ordered by the physician on multiple occasions in January 2026 and February 2026; and-The licensed nurses did not administer these medications because they were unavailable. The ADON stated these medications should have been available and administered as ordered by the physician; and-Resident 8 was not getting the desired therapeutic effect of the medications to address the diagnosis or health condition because of the missed doses.On March 2, 2026, at 4:20 p.m., an interview was conducted with the Pharmacy Consultant (PC), The PC stated:- She conducted review of the residents' medical records including the residents' eMAR monthly in December 2025 and January 2026. Included in her monthly review was to review the residents' eMAR to identify and report medication discrepancies such medications not administered as ordered by the physician;-She did not identify and report the medication discrepancies in the residents' eMAR when the licensed nurses documented that medications were not administered as ordered due to unavailability for Residents 153, 163, 108, 69, 8, 118, and 106;-The expectation from the licensed nurses was to notify the residents' physician as soon as possible and report the missed medication dose and monitor the residents for a change in condition or adverse effects from the missed medication.4. On March 2, 2026, Resident 153's medical record was reviewed. The licensed nurses documented in the eMAR Resident 153 did not receive her medication Lacosamide (medication used to treat seizures) on December 1 and 2, 2025, for the 9 a.m. and 5 p.m. doses.Resident 153 was admitted to the facility on [DATE], with diagnoses which included epilepsy (a brain disorder characterized by seizures) with simple partial seizures (convulsions, altered consciousness). - The medication was not administered by the licensed nurses because it was not available. - Resident 153's missed Lacosamide doses meant her medication regimen treatment was incomplete and this had the potential to place Resident 153 at high risk for seizure and its complications. 5. On February 26, 2026, at 3:01 p.m., an interview was conducted with Resident 108 inside her room. Resident 108 stated that she did not receive her thyroid medication for more than two days.On February 26, 2026, Resident 108's medical records were reviewed. Resident 108 was admitted to the facility on [DATE], with past medical history of hyperthyroidism (an overactive thyroid condition).The facility document titled, HISTORY AND PHYSICAL, dated March 28, 2025, indicated Resident 108 had the capacity to make decisions.A review of the physicians order indicated, .Methimazole oral tab 5 MG (milligram- unit of measurement) give 0.5 tablet by mouth one time a day for Hyperthyroidism .A review of the electronic Medication Administration Record (eMAR) for December 2025 and January 2026 indicated multiple doses of Methimazole 5 mg were documented by the licensed nurses not administered according to the physicians order on the following dates:-December 20, 2025, med not on hand;-December 21, 2025, pending delivery;-December 22, 2025, med not in cart;-December 27, 2025, med not on hand;-December 28, 2025, med not in cart;-December 29, 2025, med not in cart;-January 2, 2026, med not in hand;-January 3, 2026, med not in hand;-January 4, 2026, med not in cart; and-January 5, 2026, med not in cart.Further review of the Resident 108's medical record did not indicate documentation nursing staff had reordered the medication or contacted the pharmacy or physician to ensure the medication was available for administration.On March 2, 2026, at 5:20 p.m., a concurrent interview and record review was conducted with the DON. The DON stated if the medication was not available in the medication cart, then the licensed nurse would be responsible for following up with the pharmacy and to find out the reason why the medication was not delivered, notify the physician for the missed doses, document a change of condition, and initiate a care plan. The DON further stated Resident 108's health and safety was affected for not managing and treating her medical condition.6. On March 2, 2026, Resident 163's record was reviewed. Resident 163 was admitted to the facility on [DATE], with diagnoses which included Type 2 Diabetes Mellitus (high blood sugar).The facility document titled, .Brief Interview for Mental Status (BIMS- a cognitive assessment tool) . dated December 12, 2025, indicated Resident 163 had a score of 15 (cognitively intact).A review of the physician order for Resident 163 indicated, .Glipizide oral tablet 2.5mg, give 1 tablet by mouth three times a day for DM 2 administer with meals .A review of the eMAR for December 2025 indicated multiple doses of Glipizide were documented by the licensed nurses as not administered according to the physician's orders on the following dates:-December 6, 2025, med not on hand;-December 7, 2025, med not on hand;-December 11, 2025, med not on hand;-December 12, 2025, med not on hand; and-December 14, 2025, awaiting delivery from pharmacy.Further review of the medical record did not indicate documentation that the nursing staff had reordered the medication or contacted the pharmacy or physician to ensure the medication was available for administration.On March 2, 2026, at 5:20 p.m., a concurrent interview and record review was conducted with the DON. The DON stated if the medication was not available in the medication cart, then the licensed nurse was responsible for following up with the pharmacy to find out the reason why the medication was not delivered, notify the physician regarding the missed doses, document a change of condition, and initiate a care plan. The DON further stated Resident 163 not receiving the ordered Glipizide, may result in unmanaged high blood sugar levels.7. On March 2, 2026, Resident 69's record was reviewed. Resident 69 was admitted to the facility on [DATE], with diagnoses which included schizoaffective disorder (severe, chronic mental disorder that interfere with a person's ability to think clearly, manage emotions, make decisions and relate to others), bipolar disorder (chronic mental health condition characterized by extreme, long-lasting mood swings that ranges from high-energy mania to low depressive episodes), and atrial fibrillation (heart rhythm disorder characterized by a rapid, irregular heartbeat).A review of Physician's Order, indicated the following:- Atorvastatin Calcium Oral tablet 20mg (milligrams - a unit of measurement), give one tablet in the evening for peripheral vascular disease, hyperlipidemia and diabetes;- Levothyroxine Sodium Oral tablet, 100 mcg (micrograms - a unit of measurement), give 1 tablet by mouth one time a day for hypothyroidism;- Xarelto oral tablet, 20mg, give one tablet by mouth at bedtime for acute embolism and thrombosis of left popliteal vein;- Keppra oral tablet, 500 mg, give one tablet by mouth two time a day for seizures;- Buspirone Hydrochloride oral tablet 10 mg, give one tablet by mouth three times a day for anxiety M/B (manifested by) angry outburst towards others AEB (as evidenced by) being verbally abusive;- Divalproex Sodium oral tablet Delayed Release 500mg, give one tablet by mouth three times a day for Schizo-affective disorder, bipolar type M/B mood swings of being calm and then getting angry; and- Gabapentin oral capsule 300mg, give one capsule by mouth three times a day for neuropathy.A review of the eMAR for December 2025 and January 2026 indicated Atorvastatin Calcium oral tablet 20mg was not available and not administered on the following dates:- December 15, 16, 17, 22, 23, 24, 25, 26, 27, 28, 29,; and- January 1, 2, 3, 4.A review of the eMAR for December 2025 and January 2026 indicated Levothyroxine Sodium oral tablet 100mcg was not available and not administered on the following dates:- December 19, 20, 21, 22, 24, 26, 28, 29, 30, 31; and- January 1, 2, 3, 4.A review of the eMAR for December 2025 and January 2026 indicated Xarelto oral tablet 20mg was not available and not administered on the following dates:- December 22, 23, 24, 26, 27, 28, 29, 30; and- January 1, 2, 3, 4, 5, 12, 13, 18,19.A review of the eMAR for December 2025 and January 2026 indicated Keppra 500mg was not available and not administered on the following dates:- December 5 (5 p.m. dose), 9 (9 a.m. dose); and- January 3 (5 p.m. dose), 4 (5 p.m. dose).A review of the eMAR for December 2025 and January 2026 indicated Buspirone 10mg tablet was not available and not administered on the following dates:- December 4, 11, 12, 15, 16, 17, 18, 22, 23, 24, 26, 27, 28, 29 (5 p.m. dose); and- January 1, 2, 3 (for 5 p.m. dose), 4 (9 a.m. and 5 p.m. doses).A review of the eMAR for December 2025 and January 2026 indicated Divalproex 500mg tablet was not available and not administered on the following dates:- December 5 (5 p.m. dose); and- January 10, 11 (9 a.m. doses).A review of the eMAR for December 2025 and January 2026 indicated Gabapentin oral capsule 300mg was not available and not administered on the following dates:- December 16, 17, 18, 23, 24, 25, 26, 27, 28, 29 (5 p.m. dose); and- January 1, 2, 3, 4 (5 p.m. dose) 10 (9 a.m. dose).On March 2, 2026, at 5:18 p.m., during an interview with the Director of Nursing (DON), she stated when a medication was not available the licensed nurse should call the pharmacy and check if the medication had been ordered. She stated the licensed nurse should notify the physician when the medication is not available. She also stated the license staff could call the medical director if the attending physician would not call back. She stated there could be possible adverse effects when a resident did not receive the medication.On March 3, 2026, at 3:28 p.m., during an interview with Licensed Vocational Nurse (LVN) 1, she stated when a medication was not available, the licensed nurse should call the pharmacy or send a fax to the pharmacy to re-order the medication. She stated that some medications were not always available even when the licensed nurse called. On March 3, 2026, at 3:48 p.m., during an interview with the Quality Assurance (QA) nurse, he stated the facility process was for the licensed nurse to call and notify the pharmacy when there was only five doses left of the medication. He also stated the physician should be notified when the resident missed doses when the medication was not available for possible change in medication order.The facility's policy and procedure titled, .Administering Medications ., dated January 2018, was reviewed. The policy indicated, .Medications are administered in accordance with prescriber orders, including any required time frame .Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include .enhancing optimal therapeutic effect of the medication .preventing potential medication or food interactions .Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training .Medications are administered within one (1) of their prescribed time, unless otherwise specified .The facility's policy and procedure titled, .Pharmacy Services .Role of Provider Pharmacy . dated January 2018, indicated, .The facility shall have a written agreement with the provider pharamcy to provide regular and reliable pharmacy services to residents, including medications, services .The provider pharmacy shall agree to provide services that comply with applicable facility policies and procedures; accepted professional standards of practice, and laws and regulations, including but not limited to .Supply the facility with approved medications, biologicals, and supplies, as well as any compounded medications or investigational drugs that are needed .Help the facility identify needed supplies and services related to medications .Help the facility comply with its legal and regulatory requirements related to medications and medication management .Establish a reliable way to notify the facility in a timely fashion of issues and concerns related to medication prescriptions .Deliver medications to the facility, and help the facility ensure that all deliveries are correct and proper documentation related to delivery is provided .The facility's policy and procedure titled, .Medication and Treatment Orders . dated January 2018, indicated, .Drugs and biologicals that are required to be refilled must be re-ordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure the refills are readily available .The undated facility policy and procedure titled, MEDICATION ORDERING AND RECEIVING FROM PHARMACY, was reviewed. The policy indicated, .If not automatically refilled by the pharmacy, repeat medications (refills) are .ordered as follows .Reorder medication (three to four) days in advance of need to an adequate supply is on hand. When ordering medications that requires special processing .order at least (seven days) in advance of need .The facility's undated policy and procedure titled, .CONSULTANT PHARMACIST SERVICES PROVIDER REQUIREMENTS . indicated, .Regular and reliable consultant pharmacist services are provided to residents .The consultant pharmacists agrees to render the required service in accordance with local, state, and federal laws, regulations, and guidelines; facility policies and procedures; community standards of practice; and professional standards of practice .Assisting in identification and evaluation or medication-related issues, including prevention and reporting of medication errors .Collaborating with facility leadership in setting standards and developing, implementing, and monitoring policies and procedures for the safe and effective distribution, control, and use of medications .Developing mechanisms for communicating, addressing, and resolving issues related to pharmaceutical services

Based on interview and record review, the facility failed to ensure equipment in the kitchen was maintained in a safe operating condition when the kitchen steam table (appliance designed to hold prepared food at safe, hot serving temperatures using heated water or steam) was not fully functional from December 19, 2025, to February 3, 2026.This failure had the potential to place vulnerable population of residents who receive food from the kitchen at risk for not receiving quality food.Findings:On February 24, 2026, at 1:06 p.m., Resident 89 was observed lying in bed, awake and alert. In a concurrent interview with Resident 89, he stated he received his food cold and believed the food would come out of the kitchen cold.Resident 89's record was reviewed. Resident 89 was admitted to the facility on [DATE], with diagnosis which includes diabetes (high blood sugar). Resident 89's history and physical, dated July 21, 2025, indicated Resident 89 had the capacity to understand and make decisions. On February 26, 2026, at 3 p.m., during an interview with the Registered Dietician (RD), she stated she conducted monthly audits. The RD stated she did not send her monthly audit reports on time as expected. She stated the fourth steam table wells were not fully functional in her December 2025 and January 2026 kitchen audits. She stated the expectation was to always maintain all kitchen equipment fully functional. She also stated hot foods should stay hot so when delivered to the residents it will remain hot. A review of the two-month kitchen audit by the RD indicated the following:- December 19, 2025, indicated, .98 degrees Fahrenheit (F - a unit of measurement) of the fourth well of the steam table (an equipment used for holding hot food).; and- January 23, 2026, indicated, .Steam well #3 does not reach the appropriate temperature, 180(F) to ensure food meets and stays at temp (temperature) during serving.The RD's email sent to the Administrator (ADM) and the Director of Nursing on February 6, 2026, was reviewed. The email indicated, .The main, most important finding is the temperature, >180F. This did impact my test tray as two items did not reach the appropriate temperature.On February 26, 2026, at 3:44 p.m., during an interview with the Maintenance Director (MND), he stated he was not aware of the steam table problem in the kitchen until late January 2026.The facility policy and procedure, titled, SANITATION, dated 2023, indicated, .The Food & Nutrition Services Department shall have equipment of the type.for the preparation, serving, and storing of food.All equipment shall be maintained as necessary and kept in working order.Employees are to alert the FNS (Food and Nutrition Services) Director immediately to any equipment needing repair.Correct temperatures for the storage and handling of foods are used.The facility policy and procedure, titled, Maintenance Service, dated January 2026, indicated, .The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

Based on interview and record review, the facility failed to have a written Quality Assurance Performance Improvement (QAPI - a systematic, interdisciplinary, comprehensive, and data-driven approach to maintain and improve safety, quality of care, and quality of life of the residents) plan in place to address the facility's systemic process issues related to timely response to call lights. This failure resulted in delayed response to residents' call lights and placed residents at risk of not achieving their highest physical, mental, psychosocial well-being.A recertification survey was conducted between February 23, 2026, and March 3, 2026. During the survey, systemic issues were identified with timely response to residents' call lights (Cross Reference F725). On February 27, 2026, at 2:26 p.m., an interview and a concurrent record review was conducted with the Administrator (ADM) and the Director of Nursing (DON) to discuss facility's QAPI program. The ADM stated the QAPI committee consists of the ADM, DON, Medical Director, Infection Preventionist, Director of Staff Development and the heads of the facility departments. The ADM stated he was aware of the late response to residents' call lights from the residents' council meetings. The ADM stated the facility did not have a QAPI program which identified, corrected, and improved the issues related to timely response to call lights for their residents. A review of the facility document titled, Quality Assurance and Performance Improvement (QAPI) Plan, dated August 2017, indicated, .It is the policy of the facility to establish and maintain an ongoing, systematic and proactive facility wide process and data driven information to plan to measure and assess as well as to carry out the plan and improve resident care, outcomes and safety based on its mission, strategic goals and objectives .The QAPI program is also designed to provide an integrated collaborative and comprehensive program that will monitor, assess and improve the quality of resident care delivered at this facility .

Based on interview and record review, the facility failed to ensure, 10 of 39 residents reviewed for Advance Directive (AD - written statement of a person's wishes regarding medical treatment) (Residents 1, 10, 14, 15, 30, 57, 89, 106, 156, and 176) the resident or their resident representative (RP) had been provided follow up information regarding the formulation of an AD.These failures had the potential to result in the ADs for Residents 1, 10, 14, 15, 30, 57, 89, 106, 156, and 176, not being readily accessible to staff and physicians, which could lead to the residents' wishes regarding medical treatment being unknown and ultimately not honored.Findings:1. On February 24, 2026, at 8:39 a.m., an interview was conducted with Resident 14. Resident 14 stated that she was unsure of having been asked by the facility about formulating an AD and that she would like to know more. Resident 14's record was reviewed. Resident 14 was admitted to the facility on [DATE]. The History and Physical Examination, (H&P) dated, February 20, 2024, indicated Resident 14 had the capacity to understand and make decisions. A review of the Social Services Quarterly form, dated September 2, 2025, indicated, .Advance Directive.describe.'blank'. A review of the Social Service Assessment dated, February 18, 2026, indicated, .Does resident have advance directives? .NO.reason for no advance directive.resident would like to formulate an Advance Directive for healthcare. Ombudsman emailed on December 3, 2024.Resident responsible party involvement.name of son listed. There was no documented evidence the resident or RP was provided follow up information about the right to formulate an AD from December 2024 to February 2026. 2. On February 24, 2026, at 4:45 p.m., an interview was conducted with Resident 156. Resident 156 stated she was unsure of any follow up from the facility regarding an AD. On February 27, 2026, Resident 156's record was reviewed. Resident 156 was admitted to the facility on [DATE]. The H&P dated, January 26, 2026, indicated Resident 156, .can make needs known but can not make medical decision. A review of the Social Service Quarterly dated, October 1, 2025, indicated, .Advance Directive. Resident currently does not have capacity . and is unable to formulate an Advance Directive at this time. Writer made contact aware that if they would wish to be residents legal decisions maker they would need to contact the Superior Court of California, County of Riverside.(phone number and address listed). A review of the Social Service Assessment dated, October 16, 2025, indicated, .relative/responsible party.husband.Does resident have advance directives? .YES.if yes, is the Advance Directive present if so please upload to Electronic Health Record (EHR).currently awaiting ombudsman visit to complete Advance Directive form.referral made to ombudsman. There was no documented evidence the resident or RP was provided follow up information about the right to formulate an AD, and there was no documented evidence a follow up correspondence was made with the ombudsman from October 2025 to February 2026. 3. On February 24, 2026, at 9:12 a.m., an interview was conducted with Resident 176 in his room. When asked about an AD, he stated he would like to know more about it because he had not spoken to any staff members in the facility regarding his right to formulate an AD.Resident 176's record was reviewed. Resident 176 was admitted to the facility on [DATE]. A review of the H&P dated, March 6, 2025, indicated, Resident 176 had the capacity to understand and make decisions. A review of the Social Service Quarterly dated, August 8, 2025, indicated, .Advance Directive .changes over past quarter.describe.N/A. A review of the Social Service Assessment dated, February 17, 2026, indicated, .relative/responsible party.father.Does resident have advance directives? .NO.reason for no advance directive.Resident would like to formulate an Advance Directive for Healthcare. Ombudsman emailed December 2, 2024. There was no documented evidence the resident or RP was provided follow up information about the right to formulate an AD, and there was no documented evidence a follow up correspondence was made with the ombudsman from December 2024 to February 2026. 4. Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE]. A review of the Advance Healthcare Directive dated April 17, 2025, indicated Resident 1 would like more information, and the social service director sent a referral to Ombudsman on April 17, 2025. A review of the H&P dated September 9, 2025, indicated Resident 1's decision making capacity was intact. A review of the Social Service Assessment, dated February 21, 2026, indicated, .Does resident have advance directives? .YES. There was no documented evidence that the resident or the RP was provided follow up information about the right to formulate an AD, and there was no documented evidence that a follow up correspondence was made with the ombudsman from April 12, 2025, to February 27, 2026. 5. Resident 89's record was reviewed. Resident 89 was admitted to the facility on [DATE]. A review of the Social Service Assessment, dated July 10, 2025, indicated, .Does resident have advance directives? .NO. A review of the Advance Healthcare Directive, dated July 10, 2025, indicated Resident 89 would like more information and a referral was sent to the Ombudsman on July 10, 2025. A review of the H&P dated July 21, 2025, indicated Resident 89 had the capacity to understand and make decisions. A review of the Social Services Quarterly Assessment, dated October 10, 2025, indicated, .current Advance Directive wishes, Resident wants to move forward with executing an Advance Directive. Currently awaiting ombudsman visit to complete Advance Directive form. There was no documented evidence that the resident or the RP was provided follow up information about the right to formulate an AD, and there was no documented evidence that a follow up correspondence was made with the ombudsman from July 10, 2025, to February 27, 2026. 6. Resident 106's record was reviewed. Resident 106 was admitted to the facility on [DATE]. A review of the History and Physical dated December 4, 2025, indicated the resident 106 decision-making capacity was intact. A review of the Social Services Quarterly assessment, dated September 24, 2025, indicated resident wished to formulate advance directive for Resident 106. A review of the Social Services Assessment, dated February 11, 2026, indicated, .Does the resident have advance directives? . NO.and .The assessment indicated the resident would like to formulate an Advance Directive for Healthcare. 7. On February 26, 2026, Resident 30's record was reviewed. Resident 30 was admitted to the facility on [DATE], with diagnosis which included Encephalopathy (altered brain function). A review of Resident 30's Minimum Data Set (MDS), dated [DATE], indicated, .Cognitive Skills for Daily Decision Making . severely impaired- never/rarely made decisions. A review of the Advance Healthcare Directive form, dated April 14, 2025, indicated, .I have not executed any advance directives.Per H&P, resident does not have capacity to make healthcare decisions. A review of the Social Service Quarterly dated, August 7, 2025, indicated, .Advance Directive. changes over past quarter.describe.N/A. A review of the Social Service Assessment dated, September 24, 2025, indicated, .relative/responsible party.son (name listed) .cousin (name listed) .Does resident have advance directives? NO.reason for no advance directive.resident does not have capacity to formulate. There was no documented evidence that the resident or (RP) was provided with follow up information about the right to formulate an AD. 8. Resident 10's record was reviewed. Resident 10 was admitted to the facility on [DATE], with diagnosis which included Cerebral Infraction due to embolism of left middle cerebral artery (stroke). A review of Resident 10's MDS, dated [DATE], indicated Resident 10 had BIMS score of 0 ( severe cognitive impairment). A review of the Social Service Assessment dated, February 9, 2026, indicated, .relative/responsible party.son (name listed) .daughter (name listed) .Does resident have advance directives? NO.Per H&P resident has no capacity to make healthcare decisions or low BIMS. A review of the Social Service Quarterly dated, December 19, 2025, indicated, .Advance Directive. changes over past quarter.describe.no changes. There was no documented evidence that the resident or (RP) was provided with follow up information about the right to formulate an AD from December 15, 2025- February 9, 2026. 9. Resident 15's record was reviewed. Resident 15 was admitted to the facility on [DATE] with diagnosis which included Dementia (decline in brain function). A review of Resident 15's History and Physical, dated February 9, 2026, indicated Resident 15 has fluctuating capacity to understand and make decisions. A review of the Advance Healthcare Directive form, dated August 19, 2025, indicated, .requested AD, and referred to ombudsman . A review of the Social Service Assessment dated, December 24, 2025, indicated, .relative/responsible party.daughter (name listed) .self (name listed) .Does resident have advance directives? NO.reason for no advance directive.(Blank). There was no documented evidence that the resident or (RP) was provided with follow up information about the right to formulate an AD from August 19, 2025- February 9, 2026. 10. Resident 57's record was reviewed. Resident 57 was admitted to the facility on [DATE]. The H&P dated September 24, 2025, indicated Resident 57 can make needs known but cannot make medical decisions. A review of the Social Services Quarterly form, dated August 2, 2025, indicated, .Advance Directive.describe.'N/A (not/applicable)'. There was no documented evidence the resident or RP was provided follow up information about the right to formulate an AD from August 2025 to February 2026. On February 27, 2026, at 10:14 a.m. an interview was conducted with the Social Service Director (SSD) and the Social Service Assistant (SSA). The SSA stated the process for establishing an advance directive (AD) is that during admission if the resident can make decisions they would be asked if an AD was available and if they were not cognitively able then the RO would be asked. She stated if an AD was available then a physical copy would be available in the medical record. If there was no AD available then the facility would offer to assist the resident or representative in formulating one. The SSA stated AD requests would be sent to the ombudsman for verification. The SSA stated the Ombudsman was inconsistent with following up regarding the AD's. The SSA stated that she conducted a monthly audit to evaluated those residents interested in formulating an AD. The SSD stated the social service assessment would be conducted upon admission, then quarterly as well as annually and that the assessment would include updates regarding the AD. The SSD stated it was important to have an AD available so the facility could determine the resident needs and honor their medical care wishes. In a concurrent record review the SSA stated the following for all sampled residents, (Residents 1, 10, 14, 15, 30, 57, 89, 106, 156, and 176). For Resident 1, the SSA stated the social service assessment dated [DATE], was incorrect. The SSA stated Resident 1 did not formulate an AD. The SSA stated she could not identify any documentation that she submitted the AD requests to the Ombudsman for all sampled residents reviewed. The SSA stated the Ombudsman had not completed the AD requests since the first request made on December of 2024, and could not provide any email correspondence that would indicate the ombudsman was aware of the need for all sampled residents to formulate the AD. The SSA stated she did not follow up for all sampled residents to honor their requests for the right to formulate an AD and she should have. The SSA further stated there was a risk if residents did not have an AD then there was the potential for their rights for treatments to not be honored. A review of the facility policy and procedure titled, Advance Directives dated January 2018, indicated, .upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the residents' legal representative.information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.if the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives.the resident will be given the option to accept or decline the assistance.staff will document the resident's decision to accept or decline assistance.an ongoing review of the resident's decision-making capacity and communicate significant changes to the resident's legal representative.review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded.inquiries concerning advance directives should be referred to the.social service director.

Based on observation, interview, and record review the facility failed to provide sufficient nursing staff to be able to provide for care and services for the residents of the facility. This failure caused delays in the response to multiple residents' (Residents 19, 39, 43, 62, 108, 121, 124, 128, 183, 148, 150, 97, 13, 87, 108, and 162) call lights which had the potential to put residents at risk for falls, accidents, late provision of care or care not being rendered at all.Findings: On February 24, 2026, Resident council meetings (independent, resident-led groups that typically meet monthly to discuss concerns, improve quality of life, and influence care) minutes for December 2025, January 2026, and February 2026 were reviewed. The minutes indicated residents complained to the facility that call lights were not being answered in a timely manner. On February 24, 2026, at 3:10 p.m., an interview was conducted with the residents who attended the residents' council. All residents who attended the residents' council (Resident 19, 39, 43, 62, 108, 121, 124, 128, 183, 148, and 150) stated it took too long for nursing to respond to residents' call light, on average 25 minutes or more. On February 26, 2026, at 3 p.m., an interview with Certified Nursing Assistant (CNA) 5 was conducted. CNA 5 stated facility was short staffed of CNAs, and it affected her being able to respond timely to residents' call lights. On February 26, 2026, at 3:18 p.m., a concurrent observation and interview was conducted with Resident 97. Resident 97 was observed in bed. Resident 97 was alert and oriented. Resident 97 stated she was dependent on nursing and needed total care. Resident 97 stated it took too long to get help after she pressed the call light. She stated one instance she wanted some fresh water and the CNA responded to her call light one hour later. Resident 97 stated facility was short staffed. Resident 97's record was reviewed. Resident 97 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke), contracture of right and left ankle, and left artificial hip joint (hip replacement). On February 26, 2026, at 3:38 p.m., a concurrent observation and interview was conducted with Resident 13. Resident 13 was observed in bed. Resident 13 was alert and oriented, and stated she was dependent on nursing for her care. Resident 13 stated she had to wait a long time to get help after she pressed the call light. Resident 13 stated one time she was incontinent (involuntary leakage) of urine, needed help for cleaning and waited about 30-45 minutes to get help after she used the call light. Resident 13 stated facility was short staffed. Resident 13's record was reviewed. Resident 13 was admitted to the facility on [DATE], with diagnoses which included parkinsonism (a disease causing slow movement, poor balance, tremors and stiffness), cerebral infarction (stroke), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) affecting right side. On February 27, 2026, at 9:22 a.m., an interview was conducted with CNA 6. CNA 6 stated facility was short staffed for CNAs at times, and short staffing affected his timely response to residents' call lights. On February 27, 2026, at 11:04 a.m., a concurrent interview and record review was conducted with the Director of Staff Development (DSD) and the Staffing Coordinator (SD). The DSD stated she was aware of residents' council staffing issue that came up in relation to call light response. The DSD stated she brought up the issue of using registry (staff personnel provided by a placement service on a temporary basis) to the Administrator (ADM) but was not allowed to use registry when short staffed. The SD stated facility needed both CNAs and Licensed Vocational Nurses (LVN) from registry to help with short staffing. On February 27, 2026, at 2:54 p.m., a concurrent interview and record review was conducted with the ADM and Director of Nursing (DON). The ADM stated facility did not use registry since he started as an Administrator. The ADM stated facility was not going to use registry when short staffed. On February 27, 2026, at 6:45 p.m., a concurrent interview and record review was conducted with the ADM. The ADM verified the staffing hours and stated the facility was short staffed on January 4, January 10, February 8, February 14, and February 15 of 2026. On February 23, 2026, at 1:34 p.m., a concurrent observation and interview was conducted with Resident 108. Resident 108 was observed sitting in her wheelchair. Resident 108 was alert and oriented. Resident 108 stated that there is not enough staff to do their job and felt that the CNAs could not do all their job. Resident 108 stated it took too long to get help after she pressed the call light. Resident 108's record was reviewed. Resident 108 was admitted to the facility on [DATE], with diagnoses which included anxiety disorder (mental disorder) and paraplegia (paralysis of legs and lower body). On February 24, 2026 at 12:50 p.m., a concurrent observation and interview was conducted with Resident 162. Resident 162 was observed in bed, yelling for help and stated that she needed help, and it takes them too long to come help her. Resident 162's record was reviewed. Resident 162 was admitted to the facility on [DATE], with diagnoses which included blindness and generalized anxiety disorder (mental disorder). On February 25, 2026, at 12:41 p.m., a concurrent observation and interview was conducted with Resident 87 in his room. Resident 87 was observed lying in bed and asked for help to get changed. Resident 87 stated that he could not find his call light and staff took too long to respond. Resident 87's record was reviewed. Resident 87 was admitted to the facility on [DATE], with diagnoses which included muscle weakness and anxiety disorder. On February 27, 2026, at 1:40 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 5. CNA 5 stated that she was asked to work extra hours multiple occasions when the facility was short staffed. CNA 5 further stated that she was assigned too many residents to provide safe and adequate care. On February 27, 2026, at 1:50 p.m., a concurrent observation and interview was conducted with the Registered Nurse (RN) 2. RN 2 was observed passing medications to the residents. In a concurrent interview, RN 2 stated that it was difficult to perform her role efficiently as a nurse supervisor if she was assigned medication cart to administer medications to the residents. The facility document titled Facility Assessment Tool, dated August 2025, was reviewed. The facility assessment indicated, .The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs .Position Based on Average Census .171 .Licensed Vocational Nurses Providing Direct Care .Days: 8; Evening: 6; Nights: 5 .Certified Nursing Assistant .Days: 22; Evening: 17; Nights: 14 . The staffing schedule for February 2026 was reviewed. The staffing schedule indicated a shortage of staff for February 8, 2026, when there were 7 LVNs scheduled for day shift, 16 CNAs scheduled for day shift, 15 CNAs scheduled for evening shift, and 7 CNAs scheduled for night shift; for February 14, 2026, when there were 5 LVNs scheduled for day shift, 17 CNAs scheduled for day shift, 12 CNAs scheduled for evening shift, and 6 CNAs scheduled for night shift; and for February 15, 2026, when there were 5 LVNs scheduled for day shift, 17 CNAs scheduled for day shift, 15 CNAs scheduled for evening shift, and 8 CNAs scheduled for night shift. The facility policy titled Answering the Call Light, dated January 2018, was reviewed. The policy indicated, .The purpose of this procedure is to ensure timely response to the resident's requests and needs . The facility policy titled Staffing, dated January 2018, was reviewed. The policy indicated .Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents.

Based on observation, interview, and record review, the facility failed to ensure pharmacy services were provided in a timely manner, for 14 of 39 residents reviewed (Residents 118, 106, 8, 153, 13, 163, 108, 69, 182, 185, 184,186, 176, and 167) for pharmacy services, when:1. For Resident 118, 106, 8, 153, 13, 163, 108, and 69, medications were not administered as ordered by the physician on multiple occasions between December 2025, January 2026, and February 2026, due to medication unavailability. (Cross Reference F760).2. Residents 182, 185, 184, and 186, did not receive the PPD skin test (test to detect Tuberculosis {contagious lung infection}) as scheduled due to unavailability of the PPD solution;3. For Residents 176 and 167, the facility did not establish a system for receiving and ensuring Over-The Counter (OTC) medications are readily available for residents' use; and4. For Resident 106, the medication Albuterol Sulfate Inhalation (drug used for treat shortness of breath by relaxing airway muscles) was available when needed in the medication cart.These failures resulted in residents not receiving medications as ordered by the physician to manage and treat medical conditions, and over-all long-term health and well-being of the residents. Findings: 1.On February 24, 2026, Resident 118's medical record was reviewed. The licensed nurses documented in the electronic Medication Administration Record (eMAR) that Resident 118 did not receive her medication Lacosamide (anticonvulsant medication used to treat seizures) from December 17, 2025, to January 15, 2026.(Cross Reference F760 Finding #1). On February 25, 2026, at 2:49 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated: -Resident 118's Lacosamide medications were not administered as ordered by the physician from the period of December 17, 2025, to January 15, 2026, due to unavailability of the medication. -There was an issue with the ordering of the medication refill with the pharmacy and it was not identified and addressed until January 15, 2026. This resulted in Resident 118 not receiving the medication from December 17, 2025, to January 15, 2026. -Resident 118's missed Lacosamide medication doses were not discussed with the pharmacy or pharmacy consultant. The DON stated they had been encountering issues with the pharmacy delivery service, and the facility management was made aware; and -All residents' medication should be available and administered as ordered by the physician. On February 25, 2026, Resident 106's medical record was reviewed. The licensed nurses documented in the electronic Medication Administration Record (eMAR) that Resident 106 did not receive five doses of the medication Acyclovir (antiviral medication to treat infection) from February 22 to February 23, 2026.(Cross Reference F760 Finding #2). On February 26, 2026, at 3:19 p.m., the Pharmacy Owner (PO) was interviewed. The PO stated their pharmacy technician made a refill balance error for Resident 106's Acyclovir, causing the delivery of medication delay and five missed doses. The PO stated their pharmacy technician did not follow the proper procedure for refilling medication at the facility, and this practice was unacceptable. On March 2, 2026, Resident 8's medical record was reviewed. The licensed nurses documented in the eMAR that Resident 8 did not receive the medications Atorvastatin (medication used to lower bad cholesterol), Olanzapine (medication used to treat mental disorder), Risperdal (medication used to treat mental disorder) , and Allopurinol (medication used to lower uric acid level in the blood), on multiple occasions in January 2026 and February 2026. (Cross Reference F760 Finding #3). On March 2, 2026, Resident 153's medical record was reviewed. The licensed nurses documented in the eMAR Resident 153 did not receive her medication Lacosamide on December 1 and 2, 2025. (Cross Reference F760 Finding #4). On March 2, 2026, Resident 13's medical record was reviewed. The licensed nurses documented in the eMAR Resident 13 did not receive the medication Duloxetine (medication used to treat depressions) on December 16 and 23, 2026. On March 2, 2026, Resident 108's record was reviewed. The licensed nurses documented in the eMAR Resident 108 did not receive the medication Methimazole (medication used to reduce thyroid hormone production in the body) on multiple occasions in December 2025, and January 2026. (Cross Reference F760 Finding #5). On March 2, 2026, Resident 163's record was reviewed. The licensed nurses documented in the eMAR Resident 163 did not receive the medication Glipizide (medication used to treat diabetes {high blood sugar}) on multiple occasions in December 2025. (Cross Reference F760 Finding #6). On March 2, 2026, Resident 69's record was reviewed. The licensed nurses documented in the eMAR Resident 69 did not receive the medications Divalproex sodium, Gabapentin, Buspirone, Keppra (medication used to treat epilepsy), Xarelto (blood thinning medication), Levothyroxine ( medication used to replace thyroid hormones), and Atorvastatin on multiple occasions in December 2025, and January 2026. (Cross Reference F760 Finding #7). On March 2, 2026, at 4:20 p.m., an interview was conducted with the Pharmacy Consultant (PC). The PC stated the missed medication doses due to unavailability for Residents 118, 106, 8, 153, 13, 163, 108, and 69, should have been identified and reported during her Drug Regimen Review for these residents in December 2026 and January 2026. The PC stated she was unaware that these residents missed their medications due to unavailability, as she had not received any reports from the facility about medication delivery issues. 2. On February 24, 2026, a concurrent interview and record review for Resident 182 was conducted with the Director of Nursing (DON). Resident 182 was admitted to the facility on [DATE]. The Physician's Order dated February 19, 2026, indicated to give the Step 1 PPD skin test 0.1 milliliter (ml- unit of measurement) intradermally (deliver medication or vaccine in the dermis{layer of skin}) on the evening of February 20, 2026. The eMAR progress notes, dated February 20, 2026, indicated the licensed nurse did not administer the Step 1 PPD test on Resident 182 because the PPD solution was not available. During a concurrent interview, the DON stated Resident 182 did not receive the Step 1 PPD skin test as ordered and scheduled on February 20, 2026 evening shift, due to the facility's lack of available PPD solution. On February 24, 2026, at 5:35 p.m., a concurrent interview and record review was conducted with the Infection Preventionist Nurse (IPN). The following resident records were reviewed: -Resident 185 was admitted to the facility on [DATE]. A Physician's Order dated February 20, 2026, indicated to give the Step 1 PPD skin test 0.1 ml intradermally on the evening shift (from 3:00 p.m. to 11:00 p.m.) of February 21, 2026. The eMAR dated February 21, 2026, evening shift indicated the licensed nurse did not administer the Step 1 PPD test due to medication unavailability. -Resident 184 was admitted to the facility on [DATE]. A Physician's Order dated February 20, 2026, indicated to give the Step 1 PPD skin test 0.1 ml intradermally on the evening shift of February 21, 2026. The eMAR dated February 21, 2026, evening shift indicated the licensed nurse did not administer the Step 1 PPD test due to medication unavailability; and - Resident 186 was admitted to the facility on [DATE]. A Physician's Order dated February 18, 2026, indicated to give the Step 1 PPD skin test 0.1 ml intradermally on the evening shift on February 19, 2026. The eMAR dated February 19, 2026, evening shift was blank and did not indicate if the licensed nurse administered the Step 1 PPD skin test as scheduled. In a concurrent interview, the IPN stated, Resident 186's licensed nurse probably did not administer the step 1 PPD Skin test to Resident 186 as scheduled because there was no PPD solution available. The IPN stated, she was notified by the licensed nurses on February 21, 2026, that the facility did not have PPD solution available to give to the residents. The IPN stated she ordered the PPD solution from the pharmacy on February 21, 2026, and it was still pending delivery until February 24, 2026. The IPN stated the facility should have a PPD solution supply readily available for the residents. 3. On February 24, 2026, at 9:12 a.m. an interview was conducted with Resident 176. Resident 176 stated he took melatonin for sleep and the facility had been out for several days and that he had a hard time sleeping. Resident 176's record was reviewed. Resident 176 was admitted to the facility on [DATE] with a diagnosis which included generalized anxiety disorder (uncontrollable fear or worry that impairs daily functioning). A review of the Physicians order summary indicated, .Melatonin (medication used to help with sleep) Oral Tablet 3 MG (milligrams - a unit of measurement), Give 3 tablet (sic) by mouth at bedtime for supplement. A review of the eMAR progress note indicated, .February 19, 2026 at 8:43 p.m .administration note.Melatonin oral tablet 3 mg give 3 tablet (sic) by mouth at bedtime for supplement medication not on hand, awaiting facility stock. A review of the eMAR for February 2026, indicated code 9 for the 8 p.m., administration time on February 19, 2026. The eMAR indicated a 9 code was for a missed dose. Resident 167's record was reviewed. Resident 167 was admitted on [DATE] with a diagnosis which included chronic pain syndrome. A review of the Physicians order summary indicated, .Melatonin Oral tablet 10 mg Give 1 tablet by mouth at bedtime for inability to sleep. A review of the eMAR progress note dated February 19, 2026 orders administration note indicated, .Melatonin Oral Tablet 10 MG Give 1 tablet by mouth at bedtime for inability to sleep med not on hand, awaiting facility stock. A review of the eMAR for February 2026, indicated code 9 for the 8 p.m., administration time February 19, 2026. The eMAR indicated a 9 code was for a missed dose. On February 26, 2026 at 8:21 a.m. an observation and interview was conducted with the IPN . Observed medication administration for Resident 167. The IPN indicated she could not locate one eye drop and one nasal spray which were considered over the counter (OTC) medications and should have been readily available. On February 26, 2026, at 8:29 a.m. the IPN indicated she could not locate the OTC medication for Resident 167 in the OTC stock room and would have to ask for assistance to find the medications as they were noted to have been administered on February 24, and 25, 2026. On February 26, 2026, at 12:30 p.m. a follow up interview was conducted with the IPN regarding OTC medication availability of Melatonin. The IPN indicated Melatonin was an OTC medication and that two forms of the doses of 3mg and 5mg were available on each medication cart. The IPN was asked to review the eMARs for both Residents 176 and 167. The IPN confirmed a missed of dose of Melatonin for each resident on February 19, 2026. An observation of the OTC stock room with the IPN revealed a shelf labeled 3mg/5mg. The IPN stated there was no melatonin in the OTC stock room. She stated she would need to order new stock if the shipment delivered this week did not have any and that she did not check the recent shipment received this week. The IPN stated Melatonin 3mg was not available in the medication cart but there was 5mg bottle available. The IPN stated she could not speak for the evening nurse who documented the missed dose of 3mg for Resident 176 and 5mg for Resident 167 on February 19, 2026. The IPN further stated she was made aware the OTC stock delivery was received but could not account for any staff as to when or if it was stocked. On February 26, 2026, at 2:43 p.m. an interview and record review was conducted with staff coordinator/central supply (SC) ordering clerk. She stated she was in charge of ordering central supply stock only and that a Certified Nursing Assistant (CNA) 7 performed the stocking of the items received weekly. She stated the process was that the staff would endorse to her the supplies needed by Monday of each week so that the orders could be placed by Tuesday. The SC indicated ordered items included OTC medications. The SC stated she would only order from the list that was provided to her by the corporate office and that she did not have a list that kept an active inventory of the supplies ordered. The SC stated she assumed the CNA assigned to restock would ensure that all supplies were made available. A review of the supply inventory list was conducted with the SC. The supply inventory list read the following: Supply Inventory list indicated, .item Melatonin.Restock level.5. SC stated the number 5 indicated the amount of OTC bottles that where received which included both 3mg and 5 mg. The SC stated she did not review the packing slips to match the inventory list provided but only ordered what was on the inventory list weekly and that she would add any additional needs communicated to her by the staff. A review of the Packing slip dated February 19, 20206, indicated the following stock items were delivered to the facility: Melatonin tab 3mg.shipped 5. Melatonin tab 5mg.shipped 5. A review of the Packing slip dated February 25, 2026, indicated the following stock items were delivered to the facility. Melatonin, tab 3mg.shipped 6.to follow.3. Melatonin, tab 5mg.shipped 10. A review of the Supply Inventory list, undated, indicated, .item Melatonin.Restock level.5. On February 26, 2026, at 12:55 p.m. an interview was conducted with the Registered Nurse (RN) 1. RN 1 stated was asked to provide access to the OTC stock room to review the medication storage. RN 1 identified one empty drawer labeled 'eye drops' and another empty shelf labeled Melatonin 3mg/5mg. RN 1 stated if the OTC stock was not available on the shelf, then it would be in the medication carts available for the licensed nurse (LVN) in each station. RN 1 was asked how she would ensure enough stock of OTC was available. RN 1 stated she would ask the staff in charge of central supply to provide it and that there were orders delivered each week. RN 1 stated she would not regularly check the OTC stock but check the medication carts and that her expectation was that the LVN's assigned to medication pass would also check for any needs or shortages and if found any missing items to communicate with central supply. RN 1 stated there was no designated person assigned to check the OTC stock in the medication storage. On February 26, 2026, at 3:17 p.m. a follow up interview was conducted with the IPN at medication cart number one. The IPN was asked to check to see if there was any Melatonin stocked in the OTC medication storage and if she was aware of any restocked OTC medications received. The IPN checked the shelf and there was no Melatonin. The IPN stated the CNA assigned to restocking had gone home for the day and did not communicate to her that any stock was available or needed to be distributed regarding OTC medications. On February 27, 2026, at 1:14 p.m. an observation and interview was conducted with CNA 7. CNA 7 stated she was assigned the duty to restock items received from central supply which included OTC medications. CNA 7 indicated there was no staff that communicated with her any inventory list and that she would put out the supplies for the CNA's such as diapers and that she would communicate with the LVN's and RN's when the OTC medications were delivered so that they could open up the OTC supply room to place them in the designated spot because she did not have a key to access the area. CNA 7 stated there was no designated nurse who would account for the supplies delivered weekly from central supply and that she would tell who ever the supervisor was when central supply orders were received. CNA 7 stated the most recent shipment was received on February 25, 2026, and that the box of OTC medications were still in the supply room awaiting distribution and that it should be stocked by nursing. CNA 7 pointed to a large box in the supply room that was unlabeled that had another box stacked on top of it labeled diapers. CNA 7 was asked how the nurses would know where to find the OTC medications if the boxes were not labeled. CNA 7 responded, that is a good question. On February 27, 2026, at 1:54 p.m., an interview was conducted with the Pharmacy Consultant (PC). The PC was asked how she would ensure OTC oversight as it was identified to be on the pharmacist checklist during monthly medication regimen reviews. The PC stated she would randomly select a medication cart and look for expired medications and open dates and if one cart was found to have an issue she would check another one. The PC stated the spot checks conducted did not include inventory and that the facility did not communicate any concerns regarding a lack of OTC medications. The PC stated she was not made aware of any missing medications by the facility during her last visit in January. The PC further stated if there were any missing OTC's then the nurses should communicate with the pharmacy so that a quick resolution could be reached. On February 27, 2026, at 2:34 p.m. an interview was conducted with the DON regarding inventory for stock supplies and OTC meds. The DON Stated there was no system in place to keep inventory for OTC medications and there should be. The DON indicated there was one staff who ordered from a list provided to her from the corporate office but that there was no assigned person to track, monitor, or evaluate the stock needs for OTC medications. The DON further stated there was one CNA who was the designated staff assigned to distributing the central supply stock weekly and that the shipment was received, but that it was the responsibility of the nurses to obtain any OTC stock for their medication carts as the CNA did not have a key to access the medication cart or the medication stock room. 4. On February 25, 2026, at 1:50 p.m., an inspection of the medication cart with a concurrent record review of Resident 106's record was conducted with Registered Nurse (RN) 1. Resident 106 had a physician's order to give Albuterol Sulfate Inhalation, two puffs inhale orally every four hours as needed for shortness of breath or wheezing (high pitched whistling sound caused by narrowed or obstructed airways). RN 1 was observed to check the medication cart for Resident 106's medication Albuterol Sulfate Inhalation and stated it was not available in the medication cart. On February 25, 2026, at 1:55 p.m., an observation with a concurrent interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated: - She was the licensed nurse assigned to give medication to Resident 106. LVN 1 stated, Resident 106's medication Albuterol Sulfate Inhalation, was taken out of the medication cart this morning because it was empty and it needed to be re-ordered; -She was not aware when the medication supply ran out or whether a reorder had been placed. She stated the licensed nurse should have ordered the medication before it ran out; -Resident 106 will not have a medication to use in case he will experience SOB or wheezing. LVN 1 stated no resident should be running out of medication. On February 25, 2026, Resident 106's medical record was reviewed. Resident 106 was admitted to the facility on [DATE], with diagnoses including heart failure, dyspnea (shortness of breath), pleural effusion (abnormal accumulation of excess fluid in the pleural space between the lungs and chest wall often causing shortness of breath, chest pain, and coughing); and asthma (chronic disease that causes inflammation, swelling, and narrowing of the airways in the lungs making it difficult to breathe). The physician's order dated January 28, 2026, indicated to give Albuterol Sulfate Inhalation Aerosol Powder Breath Activated 108 (90 Base) MCG (Microgram – unit of measurement) two puff inhale orally every four hours as needed for shortness of breath and wheezing. Resident 106's electronic Medication Administration Record ( eMAR), dated February 1 to 28, 2026, indicated the medication Albuterol was last administered by the licensed nurse on February 20, 2026, at 1:04 a.m. The Care Plan dated December 9, 2024, indicated, Focus .The resident has asthma .Potential for ineffective breathing pattern .Goal .The resident will remain free from complications of asthma .Intervention .Give medications as ordered . The Care Plan dated, August 16, 2025, indicated, .Focus .The resident has diagnosis of Chronic Obstructive Pulmonary Disease .Ineffective Airway Clearance .Impaired Gas Exchange .Ineffective Breathing Pattern .Goal .The resident will display optimal breathing patterns .Interventions .Give aerosol or bronchodilators as ordered .

Based on observation, interview and record review, the facility failed to ensure four of 39 residents (Resident 5, 30, 87, and 162), had the call light within reach.This failure resulted in Resident 5, 30,87, and 162 not to have a means of contacting the staff for assistance.Findings: 1.On February 24, 2026, at 12:50 p.m., an observation and interview was conducted with Resident 162 inside her room. Resident 162 was yelling .help, help, help me please, please help me. Resident 162 was found lying in bed and stated that she needed to be changed. Resident 162 further stated that she could not see her call light. On February 24, 2026, at 12:55 p.m., a concurrent observation and interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated Resident 162's call light button was not within reach. CNA 3 further stated the call light should be within Resident 162's reach so she could call for help if she needed to. A review of Resident 162's record was conducted. Resident 162 was admitted to the facility on [DATE], with diagnoses which included dementia (a set of symptoms that can affect memory, language, and behavior), and blindness. Resident 162's care plan dated August 3, 2023, indicated, . Resident is at risk for falls r/t (related to) confusion, incontinence, poor communication/comprehension, blindness . be sure call light is within reach . the resident needs prompt response to all request for assistance. On February 27, 2026, at 3:25 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident 162's call light should be within reach to be able to ask for assistance. 2. On February 25, 2026, at 12:41 p.m., an observation and interview was conducted with Resident 87 inside his room. Resident 87 stated that he had diarrhea and needed help. Resident 87 further stated he tried to press the call light but couldn't reach it. Resident 87's call light was observed hanging on the rail on the right side of his bed, out of his reach. On February 25, 2026, at 12:43 p.m., a concurrent observation and interview was conducted with Certified Nursing Assistant (CNA) 1. CNA1 stated Resident 87's call light was not within reach. CNA 1 further stated, the call light should be within Resident 87's reach so he could call for help. A review of Resident 87's medical record was conducted. Resident 87 was admitted to the facility on [DATE], with diagnoses which included anxiety disorder, and muscle weakness. A review of Resident 87's care plan dated, January 25, 2024, indicated, . Resident has an ADL (Activities of Daily Living) self-care performance deficit . be sure call light is within reach . encourage the resident to use bell to call for assistance. On February 27, 2026, at 3:25 p.m., an interview was conducted with the DON. The DON stated Resident 162's call light should be within reach to be able to ask for assistance. 3. On February 26, 2026, at 11:15 a.m., an observation was conducted inside Resident 30's room. Resident 30 attempted to speak but could not be understood. Resident 30's call light was observed to be on top of a suction machine on his bedside drawer, not within reach. On February 26, 2026, at 11:20 a.m., a concurrent observation and interview was conducted with the Quality Assurance Nurse (QA). The QA stated Resident 30's call light was not within reach. The QA further stated, the call light should be close to Resident 30 so he could call out for help. A review of Resident 30's record was conducted. Resident 30 was admitted to the facility on [DATE], with diagnoses which included vascular dementia (a decline in thinking, memory, and reasoning skills). On February 27, 2026, at 3:25 p.m., an interview was conducted with the DON. The DON stated Resident 162's call light should be within reach to be able to ask for assistance. 4. The following observations were conducted in Resident 5's room: On February 23, 2026, at 9 a.m., and 2:46 p.m., Resident 5's call light was not within reach and underneath the resident's bed; On February 24, 2026, at 12:30 p.m., the call light button was not within reach of Resident 5 and was underneath the resident's bed; On February 25, 2026, at 8:45 a.m., Resident 5 was observed sitting on her bed for breakfast. The call light was observed on the floor underneath the resident's bed; and On February 25, 2026, at 8:58 a.m., the surveyor observed the resident sitting for breakfast. The call light was observed on the ground underneath the resident's bed. On February 25, 2026, at 9:05, a.m., an interview was conducted with Resident 5. Resident 5 stated she was unaware of how to reach and/or call the nurse from her room. Resident 5 stated she had to go to the hallway to locate a nurse if she needed assistance. On February 26, 2026, at 10:46 a.m., an interview was conducted with DON. The DON stated facility policy required the call light to be within reach of the resident. The DON stated staff were expected to conduct rounds at the beginning of their shift to ensure residents' call lights were within reach. The DON further stated if a resident cannot reach the call light during an emergency, staff could not be notified, which could result in a potential negative outcome for the resident. On February 26, 2026, at 10:55 a.m., an interview and a concurrent observation was conducted with CNA 3. CNA 3 stated at the beginning of the shift she goes from room to room to check call light placement ensuring it was within reach of residents. CNA 3 stated if a resident did not have the call light within reach to call for assistance a serious injury could occur, and staff may not be aware. On February 26, 2026, Resident 5's record was reviewed. The resident's admission record indicated an admission date of May 28, 2025, which included diagnoses of chronic ulcer (a long-lasting open sore on the skin) to left foot, venous insufficiency (poor blood flow in the veins of the legs), muscle wasting and atrophy (loss of muscle strength and size) and dementia (a condition that causes memory loss and problems with thinking and decision-making). On February 26, 2026, a review of Resident 5's care plan dated July 26, 2020, indicated an ADL self-care deficit related to dementia, impaired balance, limited mobility and indicated the resident . requires assistance with activities of daily living including bathing, dressing, and bed mobility. The History and Physical dated September 24, 2025, indicated that the resident can make needs known but cannot make medical decisions. The facility policy titled Answering the Call Light, dated January 2018, was reviewed. The policy indicated that the purpose of the procedure is to ensure timely responses to residents' requests and needs. The policy further indicated .be sure the call light is plugged in and functioning at all times. and .when the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident.

Based on observation, interview, and record review, the facility failed to ensure staff knocked and received permission prior to entering multiple resident rooms for six out of 14 sampled residents (Residents 15,18, 87, 67, 81, and 183). This failure had the potential to compromise resident's rights to dignity, respect, and privacy for Residents 15, 18, 87, 67,81, and 183 .Findings: On February 24, 2026, at 1:10 p.m., a concurrent observations and interview were conducted with Certified Nursing Assistant (CNA). CNA1 was observed entering Resident 15 and Resident 18's rooms without knocking and/or obtaining permission prior to entry. CNA1 stated that he should have knocked prior to entering the resident's room for privacy, to let them know, and for dignity. On February 24, 2026, at 1:12 p.m., a concurrent observation and interview was conducted with CNA 2. CNA 2 was observed entering Resident 87's room without knocking and/or obtaining permission prior to entry. CNA 2 stated that she should have knocked prior to entering the resident's room. On February 25, 2026, 1:20 p.m., a concurrent observation and interview was conducted with Maintenance Director (MND). The MND was observed entering the rooms of Resident's 67, 81, and 183 without knocking and/or obtaining permission prior to entry. The MND stated that he should have knocked prior to entering the resident's room for respect and privacy. On February 26, 2026, at 3:57 p.m., an interview was conducted with Resident 81 in his room. Resident 81 stated that he did not like that the MND entered his room earlier without knocking. He further stated that the MND did not respect his privacy. On February 27, 2026, at 2:01 p.m., an interview was conducted with the Director of Staff Development (DSD). The DSD stated it was the facility's expectation that staff knock and obtain permission before entering a resident's room for respect and dignity. The facility policy and procedure titled, Resident Rights, dated January 2018, indicated, .employees shall treat all residents with kindness, respect and dignity.

Based on observation, interview, and record review, the facility failed to ensure the call light system (a communication system that allow the residents to call for staff assistance) was fully functional when the call light system panel did not have an audible sound. This failure had the potential for the residents in the facility not to receive assistance from the staff in a timely manner. Findings: On February 25, 2026, at 12:48 p.m., while standing in the hallway at Station 3, between rooms [ROOM NUMBERS], the Maintenance Director (MND)was observed to approach room [ROOM NUMBER] and asked the resident if he needed help. The call light for room [ROOM NUMBER]A was observed on, without an audible sound. The call light panel located on the wall in Station 3 was observed with the light on for room [ROOM NUMBER] with no audible sound. There was no staff member present at the nurse's station. On February 25, 2026, at 12:50 p.m., the Maintenance Director (MND) was interviewed. He stated he worked at the facility for one year and was not aware if the call light system should have an audible sound. He stated he would check the call light panel to see if there was a problem with the wiring or why the call light system did not have the functionality for the sound. On February 25, 2026, at 1:03p.m., Certified Nursing Assistant (CNA) 10 was interviewed. CNA 4 stated she did not hear any sound coming from the call light panel since she started working at the facility. She stated she would respond to the call because she could see the light was on but there was no sound. On February 25, 2026, at 2:20 p.m., the Administrator (ADM) was interviewed. He stated the call light system should have both visual and audible notification, and was not aware that the call light system did not have an audible sound. On February 25, 2026, at 2:50 p.m., during an interview with the Director for Staff Development (DSD), she stated she did not hear any audible sound coming from the call light system when the call light was on since she started working at the facility in August 2025. On February 25, 2025, at 4:45 p.m., during an interview with the MND, he stated the call light panel wirings were fixed and the call light system panel now had sound when the light was on. The facility policy and procedure, titled, Maintenance Service, dated January 2026, indicated, .The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

Based on observation, interview, and record review, the facility failed to ensure proper infection control measures were implemented when:1.For Resident 66, there was no EBP (Enhanced Barrier Precaution - an infection control strategy in nursing homes requiring staff to wear gowns and gloves during high-contact resident care, such as bathing, dressing, or device care) signage posted at the door outside Resident 66's room who had a urinary catheter (a flexible tube used to drain urine); 2. A kitchen staff was observed to touch the kitchen floor and continued with food handling without washing hands and changing gloves; 3. For Resident 106, the CNA attempted to reapply resident 106's nasal cannula after it had been on the floor; 4. The staff failed to hand sanitize in between meal tray pass; and 5. For Resident 30, the facility did not label his suction machine and discard the contents inside the canister in accordance with the facility policy. These failures had the potential to result in cross-contamination, increasing the spread of infection to an already vulnerable population of residents in the facility. Findings: 1. On February 23, 2026, at 2:02 p.m., Resident 66 was observed lying in bed awake and alert. Resident 66 was observed to have a urinary catheter. There was no EBP signage posted at the door outside Resident 66's room. On February 23, 2026, at 3:20 p.m., Registered Nurse (RN) 2 was observed to sanitize her hands with the alcohol-based hand rub (ABHR), don a pair of gloves and entered Resident 66's room, to administer an IV (Intravenous – administering fluids, nutrients, or medication directly into a vein) antibiotic (medication that fight bacterial infections). On February 23.2026, at 3:28 p.m., CNA 8 was interviewed in front of Resident 66's room. CNA 8 stated Resident 66 had a urinary catheter and there was no EBP signage posted at the door outside Resident 66's room. On February 23, 2026, at 3:33 p.m., RN 2 was observed to exit Resident 66's room, removed her gloves and sanitized her hands. In a concurrent interview with RN 2 she stated she hung IV antibiotic for Resident 66. RN 2 stated Resident 66 had a urinary catheter. RN 2 stated an EBP signage should have been posted at the door outside Resident 66's room. Resident 66's record was reviewed. Resident 66 was admitted to the facility on [DATE], with diagnoses which included extended spectrum beta lactamase (ESBL – a type of infection that is resistant to many common antibiotics) resistance, paraplegia (impairment or total loss of voluntary movement and sensation in the lower half of the body, including both legs and sometimes the abdomen). The facility document titled, Physician's Order, dated January 18, 2026, indicated, .Indwelling Catheter.for NEUROMUSCULAR DYSFUNCTION OF BLADDER loss of bladder control caused by nerve damage from diseases or injuries). On February 27, 2026, at 9:14 a.m., during an interview with the Infection Preventionist (IPN), she stated any resident with a medical device such as central line catheter, indwelling catheter (foley), feeding tubes and wounds should be placed on EBP. The IPN stated an EBP signage should have been posted at the door outside Resident 66's room because he had a urinary catheter The facility policy and procedure titled, Enhanced Barrier Precaution, dated, June 2022, indicated, .The purpose of this policy is to establish and provide guidelines for isolation precautions as well as to prevent transmission of infectious agents in the facility.Enhanced Barrier Precautions can be applied.to residents with any of the following.Wounds or indwelling medical devices, regardless of MDRO colonization status such as but not limited to central line, urinary catheter, feeding tubes.Infection or colonization with an MDRO.Post clear signage at the door or wall outside the resident room. 2. On February 26, 2026, at 1:04 p.m., during tray line observation, the Dietary Aide (DA), assisting in food handling, stated There was no meal ticket for this tray. The DA slightly pushed the meal cart, kneeled onto the kitchen floor, touched the floor with both hands with gloves on and looked under the meal cart. The DA got up on his feet and went back to continue to assist with food handling without removing his gloves and performing hand washing. On February 26, 2026, at 1:09 p.m., in a concurrent interview with the DA, the DA was immediately stopped before he could assist with food handling and was asked by the surveyor if he changed his gloves. The DA stated he did not change his gloves and had been using the same gloves from the start of the tray line. On February 26, 2026, at 3 p.m., during an interview with the RD, she stated all kitchen staff should perform handwashing and change gloves in-between tasks. She stated the DA should have removed his soiled gloves, performed handwashing, and don a new pair of gloves before he went back to assist with food handling. According to Food and Drug Administration (FDA – agency responsible for protecting public health by ensuring the safety of food supply) Food Code 2022, Section 2-301.14(I), titled. When to Wash, indicated, .FOOD EMPLOYEES shall clean their hands and exposed portions of their arms.After engaging in other activities that contaminate the hands. and Section 3-304.15 (A), titled, Gloves, Use Limitation, indicated, .If used, single used gloves shall be used for only one task.and discarded when damaged or soiled, or when interruptions occur in the operation. 3. On February 24, 2026, at 9:35 a.m., an observation with a concurrent interview was conducted with Certified Nursing Assistant (CNA) 2. A nasal cannula was observed laying on the floor next to Resident 106's bed. CNA 2 was then observed to attempt to place the nasal cannula tubing that had been on the floor back on Resident 106. The resident refused the attempt. CNA 2 then placed the nasal cannula tubing that had been on the floor onto the resident's headboard for storage. On February 24, 2026, at 9:40 a.m., an interview was conducted with CNA 2. CNA 2 stated she was assigned to Resident 106 that day. CNA 2 stated according to facility policy the nasal cannula found on the floor should have been reported to the LVN, thrown away in the trash, and replaced with a new nasal cannula. CNA 2 stated the new nasal cannula per facility policy should be labeled with the resident's name and the date and time it was opened. CNA 2 also stated if the nasal cannula was not in use, it should be placed in a clean bag labeled with the resident's name and date/time and stored near the resident's headboard. CNA 2 further stated it was wrong to attempt to place the nasal cannula that had been on the floor back onto the resident because it could increase the risk of infection (illness caused by germs). On February 26, 2026, at 10:44 a.m., an interview was conducted with the IPN. The IPN stated according to facility policy, a nasal cannula found on the ground must be discarded (thrown away) and a new nasal cannula must be obtained. The IPN stated the new nasal cannula should be labeled with the resident's name and date and time of opening. If the nasal cannula was not in use, it should be stored in a clean bag labeled with the date and time near the resident's headboard. The IPN stated the outcome of placing a contaminated nasal cannula back on Resident 106 placed the resident at risk for infection. On February 26, 2026, Resident 105's record was reviewed. Resident 106 was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure (long-term breathing problem), chronic obstructive pulmonary disease or COPD (lung disease that makes it hard to breathe), asthma (condition that causes swelling and narrowing of airways), hemiplegia (paralysis on one side of the body), atrial fibrillation (irregular heart rhythm), and heart failure (heart cannot pump blood effectively). On February 26, 2026, Resident 106's clinical record was reviewed. A physicians order dated January 5, 2026, indicated staff were to administer oxygen at two liters per minute via nasal cannula. The facility's policy and procedure titled, Cleaning and Disinfection of Environmental Surfaces, dated January 2018, indicated . environmental surfaces will be cleaned and disinfected according to CDC recommendations for disinfection of healthcare facilities and OSHA bloodborne pathogen standards.and .items that come in contact with contaminated surfaces must be cleaned and disinfected. The facility's policy and procedure titled, Oxygen Administration, dated January 2018, indicated .assess the equipment and supplies as needed. and .check the tubing connected to the oxygen cylinder to assure that it is free of kinks, discard used supplies in designated containers. 4. On February 24, 2026, at 1:10 p.m., a concurrent observation and interview with Certified Nursing Assistant (CNA ) 1 was conducted. CNA 1 was observed passing meal trays to multiple residents without performing hand hygiene (Residents 15, 18 and 87). CNA 1 stated that he should have sanitized his hands for infection control. A review of Resident 15's medical record was conducted. Resident 15 was admitted to the facility on [DATE], with diagnoses which included immunodeficiency (condition where the immune system is weakened, compromised, or absent). A review of Resident 18's medical record was conducted. Resident 18 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (paralysis of one side of the body). A review of Resident 87's medical record was conducted. Resident 87 was admitted to the facility on [DATE], with diagnoses which included bacteremia (presence of bacteria in the bloodstream). On February 27, 2026, at 9:20 a.m., an interview with the IPN was conducted. The IPN stated her expectation was for all staff to hand sanitize in between while passing meal trays, to prevent cross contamination and prevent spread of infections. 5. On February 26, 2026, at 11:15 a.m., during an observation inside Resident 30's room, a suction machine with tubing was observed without a resident identifier label. The suction canister attached to the machine contained fluid and secretions that had not been discarded. On February 26, 2026, at 11:20 a.m., a concurrent observation and interview was conducted with the Quality Assurance Nurse (QA) inside Resident 30's room. The QA acknowledged the suction machine was not labeled with the resident's identifier and confirmed contents in the suction canister should have been discarded. The QA further stated that it was an infection control issue. On February 27, 2026, at 9:20 a.m., an interview with the IPN was conducted. The IPN stated the suction machine tubing should have been labeled and dated and the fluid or bodily secretions inside the canister should have been discarded. The IPN further stated that this had the potential for cross contamination and infection control concerns. A review of the facility policy and procedure titled, Suctioning the Upper Airway (Oral Pharyngeal Suctioning, dated January 2018, indicated, .empty and rinse collection container if necessary or as indicated by facility protocol.

Based on observation, interview, and record review, the Pharmacy Consultant (PC) failed, for eight of 39 residents reviewed for pharmacy services (Residents 118,106, 8, 153, 63,108, and 69), to identify drug irregularities when multiple licensed nurses were documenting in the electronic medication Administration Record (eMAR) prescribed medications were not administered on multiple occasions between December 2025, January 2026, and February 2026, due to medication unavailability. (Cross Reference F760).This failure resulted in these residents not receiving medications as ordered by the physician to manage and treat medical conditions. Findings:On February 24, 2026, Resident 118's medical record was reviewed. The licensed nurses documented in the eMAR that Resident 118 did not receive her medication Lacosamide (anticonvulsant medication used to treat seizures) from December 17, 2025, to January 15, 2026.(Cross Reference F760 Finding #1).On February 25, 2026, Resident 106's medical record was reviewed. The licensed nurses documented in the eMAR that Resident 106 did not receive five doses of the medication Acyclovir (antiviral medication to treat infection) from February 22 to February 23, 2026.(Cross Reference F760 Finding #2).On March 2, 2026, Resident 8's medical record was reviewed. The licensed nurses documented in the eMAR that Resident 8 did not receive the medications Atorvastatin (medication used to lower bad cholesterol), Olanzapine (medication used to treat mental disorder), Risperdal (medication used to treat mental disorder) , and Allopurinol, on multiple occasions in January 2026 and February 2026. (Cross Reference F760 Finding #3).On March 2, 2026, Resident 153's medical record was reviewed. The licensed nurses documented in the eMAR Resident 153 did not receive her medication Lacosamide on December 1 and 2, 2025. (Cross Reference F760 Finding #4).On March 2, 2026, Resident 108's record was reviewed. The licensed nurses documented in the eMAR Resident 108 did not receive the medication Methimazole (medication used to reduce thyroid hormone production in the body) on multiple occasions in December 2025, and January 2026. (Cross Reference F760 Finding #5).On March 2, 2026, Resident 163's record was reviewed. The licensed nurses documented in the eMAR Resident 163 did not receive the medication Glipizide (medication used to diabetes {treat high blood sugar}) on multiple occasions in December 2025. (Cross Reference F760 Finding #6).On March 2, 2026, Resident 69's record was reviewed. The licensed nurses documented in the eMAR Resident 69 did not receive the medications Divalproex sodium, Gabapentin, Buspirone, Keppra (medication used to treat epilepsy), Xarelto (blood thinning medication), Levothyroxine ( medication used to replace thyroid hormones), and Atorvastatin on multiple occasions in December 2025, and January 2026. (Cross Reference F760 Finding #7).On March 2, 2026, at 4:20 p.m., an interview was conducted with the Pharmacy Consultant (PC), The PC stated:- She conducted review of the residents' medical records including the residents' eMAR monthly in December 2025 and January 2026. Included in her monthly review was to review the residents' eMAR to identify and report medication discrepancies such medications not administered as ordered by the physician;-She did not identify and report the medication discrepancies in the residents' eMAR when nurses documented that medications were not administered as ordered on multiple occasions due to unavailability for Residents 153,163,108, 69, 8,118, and 106, during the period between December 2025 to February 2026.;- The missed medication doses due to unavailability should have been identified and reported during her Drug Regimen Review for these residents in December 2026 and January 2026; and- She was unaware that Residents 118, 106, 8,153, 63,108, and 69) missed their medications due to unavailability, as she hadn't received any reports from the facility about delivery issues. The facility's undated policy and procedure titled, .CONSULTANT PHARMACIST SERVICES PROVIDER REQUIREMENTS . was reviewed. The policy indicated, .Regular and reliable consultant pharmacist services are provided to residents .The consultant pharmacists agrees to render the required service in accordance with local, state, and federal laws, regulations, and guidelines; facility policies and procedures; community standards of practice; and professional standards of practice .The consultant pharmacist provided consultation on all aspects of the provision of pharmacy services in the facility. In collaboration with facility staff, the consultant pharmacist help identify, communicate, address, and resolve concerns or issues related tot he provision of pharmaceutical services. This includes, but is not limited to .Working with the facility staff on the development, implementation, evaluation, and revision of pharmaceutical services procedures, helping assure that the procedures address the needs of the residents and reflect current standards of practice .Assisting in identification and evaluation or medication-related issues, including prevention and reporting of medication errors .Collaborating with facility leadership in setting standards and developing, implementing, and monitoring policies and procedures for the safe and effective distribution, control, and use of medications .Developing mechanisms for communicating, addressing, and resolving issues related to pharmaceutical services .Specific activities that the consultant pharmacist performs includes .Communicating to the responsible prescriber and the facility leadership potential or actual problems detected and other findings related to medication therapy .Reviewing medication administration record (MARs), treatment administration record (TARs) and physician orders (at least monthly) to ensure proper documentation of orders and administration of medication to residents .

Based on interview and record review, the facility failed to ensure an allegation of physical abuse was reported within two hours to the California Department of Public Health (CDPH - State Agency Licensing and Certification Program) for one of 39 residents reviewed (Resident 20).This failure had the potential to result in a delay in the investigation and reporting further allegations of abuse for Resident 20.Findings:On February 25, 2026, at 12:31 p.m., Resident 20 was observed lying in bed, awake and alert. In a concurrent interview with Resident 20, he stated he had a urinal hanging at the foot of his bed. Resident 20 stated his previous roommate, was in his wheelchair and asked him if the urinal was his and answered, yes. He stated his previous roommate took the urinal that was hanging at the foot of his bed and threw it at him. Resident 20 stated he got wet with urine, and did not report the incident to the nurse until the next day. He stated he could not recall the date of the incident. Resident 20 was asked if somebody saw what happened and he stated he had a sitter (a person who provides one-on-one supervision for residents) when the incident happened. Resident 20 stated Certified Nursing Assistant (CNA) 4 was the sitter when the incident happened.Resident 20's record was reviewed. Resident 20 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (total loss of motor function on one side of the body) and hemiparesis (neurological condition characterized by partial weakness, reduced coordination, or numbness on one entire side of the body).A review of the History and Physical (H&P), dated January 15, 2026, indicated Resident 20 had the capacity to make decisions.A review of the Minimum Data Set (MDS - an assessment tool), dated January 21, 2026, indicated a Brief Interview for Mental Status (BIMS - a cognitive assessment tool) score of 14 (cognitively intact).A review of the Physician's Order, dated January 17, 2026, indicated, .Pt (patient) must have 1 on 1 sitter until d/c (discharge) by MD (Medical Doctor) every shift for FALL RISK.A review of the Situation-Background-Assessment-Recommendation (SBAR - a structured, four-component communication technique used in nursing to improve patient safety) dated February 11, 2026, indicated.the resident came in the front of the nurses desk with his sitter and told the RN (Registered Nurse) supervisor that his roommate had thrown a urinal full of urine at him during the evening shift yesterday (February 10, 2026) while he was lying in bed, hitting his feet. The resident is alert and oriented x 3-4 (a medical term used to describe a patient's level of consciousness and cognitive awareness indicating the patient is awake, and responsive, and knows their name, current location, time/date, and situation) and able to express his needs .On February 11, 2026, at 9:51 p.m., CDPH received a voicemail from the facility RN supervisor reporting a resident-to-resident altercation without resident names provided.On February 12, 2026, at 8:53 a.m., CDPH received a written report from the facility.On February 25, 2026, at 1:20 p.m., during an interview with CNA 4, she stated she was the sitter when the incident happened between Resident 20 and his previous roommate. She stated Resident 20's previous roommate took the urinal that was hanging at the foot of bed and toss it at Resident 20's feet. She stated she did not report the incident because she did not think it was an abuse. CNA 4 stated she thought it was Resident 20's previous roommate's behavior and did not think it was an abuse.On February 25, 2026, at 2:50 p.m., during an interview with the Director for Staff Development (DSD), she stated CNA 4 should have reported the incident immediately to prevent the incident from happening again between Residents 20 and his previous roommate.On February 27, 2026, at 9 a.m., during an interview with the administrator (ADM), he stated he was informed of the incident after Resident 20 reported the incident to the RN. He stated there was a witness to the incident, who was the sitter, but did not report the incident because CNA 4 told him she did not think the incident was abuse. He stated he did not have any knowledge of the incident until February 11, 2026.A review of the Five Day Follow-up, dated February 16, 2026, indicated, .This correspondence shall serve as the facility's five-day written follow-up on a resident-to-resident physical altercation alleged to have occurred on February 10, 2026. The incident was first reported by the alleged Victim (Resident 20) on January 11, 2026.A review of the facility policy and procedure titled, Abuse prevention Program, dated January 2018, indicated, .Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse.A review of the facility policy and procedure titled, Abuse Investigation and Reporting, dated February 2024, indicated, .Reporting.All alleged violation of abuse, neglect, exploitation or mistreatment.will be reported to the proper agencies as guided per regulations.

Based on observation, interview, and record review, the facility failed to ensure that Resident 1 received necessary care and services in accordance with the resident's comprehensive assessment and professional standards of practice when the facility did not conduct a comprehensive interdisciplinary assessment of transportation needs to ensure safe and proper transport to and from dialysis appointments for 1 of 3 sampled residents (Resident 1) reviewed for dialysis.This failure resulted in Resident 1 being transported to dialysis (medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to) appointments via Uber three times a week, leading to unsafe and uncomfortable transfers from wheelchair to car every dialysis appointment and resulted in missed or delayed dialysis on September 23 and 24, 2025, hospital transfer for dialysis, and continued use of an unsafe transport method. On October 2, 2025, while being transported in a standard vehicle (Uber), the resident sustained a right chest-wall hematoma, soft-tissue swelling, and possible rib fractures, demonstrating that the unsafe practice caused actual serious harm and placed the resident at ongoing risk of further injury or death. The facility continued to use Uber transportation for dialysis through October 9, 2025, after the resident's injury, thereby exposing the resident to an ongoing risk of serious injury or death from missed or delayed dialysis or additional trauma during unsafe transfers. This constitutes Immediate Jeopardy to resident health and safety because the facility's noncompliance caused actual serious harm and presented a continued likelihood of serious injury, harm, or death. On October 10, 2025, the ADM presented an acceptable removal plan which included the following:1. Resident 1 was assessed by assigned licensed nurse for any adverse effects of being transferred to dialysis using Uber Health (helps patients and clinical staff arrange and schedule transportation services with independent third-party providers) transportation.2. Resident 1 was also assessed by PT (Physical Therapist) to determine whether Resident 1 can tolerate the car or wheelchair van transportation.3. The Care Plan was updated to reflect current transportation information for dialysis.4. A new contract for wheelchair transport was drawn up by the ADM.5. An ad hoc (impromptu tasks, meetings, or projects that arise suddenly in response to a particular situation) QAPI (Quality Assurance and Performance Improvement - a data-driven and proactive approach used in healthcare facilities to systematically improve the quality of care provided to residents) Committee meeting was held to discuss changes in contracted dialysis transportation services.6. Inservice training was conducted by DON and/or DSD (Director of Staff Development) with licensed staff regarding use of contracted dialysis transportation.On October 14, 2025, at 2:07 p.m., the immediacy was removed in the presence of the ADM and the DON upon verification of implementation of the removal plan.Noncompliance for F684 remained at the scope and severity of J actual harm that is immediate jeopardy to resident health and safety.Findings:A review of Resident 1's admission Record dated October 3, 2025, indicated Resident 1 was initially admitted to the facility on [DATE], with diagnoses which included type 2 diabetes (high blood sugar), end stage renal disease (permanent kidney failure that requires a regular course of dialysis).A review of Resident 1's Physical Therapy Evaluation and Plan of Treatment, dated September 18, 2025, indicated, .Precautions: fall risk .heel WB (weight bearing) only during transfers .S/P (status after) amputation (removal of the body part) of L (left) 2nd and 3rd toes .A review of Resident 1's Minimum Data Set (MDS - a standardized assessment tool) dated September 22, 2025, indicated the resident is cognitively intact (ability to think effectively) and requires substantial/maximal assistance with sit to stand and chair/bed-to-chair transfer and dependent with wheelchair mobility. A review of Resident 1's Order Summary Report dated October 3, 2025, indicated .Dialysis Center: (name, address and telephone number) Dialysis Days: T-Th-Saturday (Tuesday-Thursday-Saturday) Pick-up time 0415 (4:15 a.m.) chair time 0430 (4:30 a.m.) . was ordered on September 18, 2025.A review of Resident 1's Progress Notes indicated the following:-On September 23, 2025, at 6:30 a.m., Resident 1 missed her dialysis appointment due to transportation. No further explanation was documented.-On September 23, 2025, at 4:58 p.m., the SSD wrote she was informed Resident 1 missed dialysis due to transportation not arriving and she reached out to the transportation who stated that they are no longer transporting Resident 1 due to non-payment from the facility. The SSD reached out to the corporate office regarding non-payment, and she was informed that Resident 1's transportation needs to be provided by a straight Medi-cal (a type of health insurance plan) provider.-On September 24, 2025, at 6:38 a.m., Resident 1 missed the rescheduled dialysis appointment today due to transportation issues. At 9:27 a.m., the resident was transferred to the GACH and at 11:10 p.m., the resident returned to the facility after receiving dialysis.-On September 30, 2025, Resident 1 was picked up by Uber and accompanied by a (Certified Nursing Assistant) CNA.-On September 30, 2025, at 11:59 a.m., Resident 1 returned from her dialysis appointment at 11:45 a.m., with CNA escort via Uber.-On October 4, 2025, at 12:33 a.m., the Licensed Vocational Nurse (LVN) was notified that Resident 1 had large bruising on her right torso and small discoloration to her left underarm. The area was assessed, and discoloration and slight inflammation were noted. Resident 1 stated she had trouble getting into the transportation for dialysis and she got hurt. Resident 1's MD (Medical Doctor) and FM (family member) were notified.-On October 4, 2025, at 12:46 at 2:39 a.m., Resident 1 was transferred out to the GACH for the discoloration of her right torso.A review of Resident 1's IDT (Interdisciplinary Team - a group of healthcare professionals from different disciplines who collaborate to provide comprehensive and coordinated care for a patient) Care Conference with a review date of October 1, 2025, indicated that Resident 1's FM expressed concerns regarding dialysis transportation. It was explained to him that the facility has been paying for transportation and has not been authorized to schedule a wheelchair van, that is why the resident goes to dialysis via Uber.On October 3, 2025, at 10:14 a.m., during a concurrent observation and interview, Resident 1 was sitting in her wheelchair on the smoking patio and was wheeled by a staff member to the family room. Resident 1 stated she goes to dialysis three times a week on T-Th-Sat and leaves the facility at 3:30 a.m. Resident 1 stated the Social Service Director (SSD) quit paying her insurance to get her van transportation. Resident 1 stated the facility has been putting her in an Uber car and it is uncomfortable and awfully hard for her. Resident 1 stated the facility nurses transferred her to the car, but it's wrong and she should be going in a wheelchair van. Resident 1 stated the last time she had dialysis, she was at the dialysis center until 7:30 a.m., because the facility had to send a larger Uber car which took more time. Resident 1 stated she doesn't want to take Uber anymore because she may end up breaking a bone.On October 3, 2025, at 11:37 a.m., during a telephone interview with the Unit Secretary (US) of (name of dialysis center), she stated there had been issues with Resident 1's transportation and it started when her insurance changed. Initially, the facility transported Resident 1 to the dialysis center via Uber by herself and the dialysis staff had to transfer Resident 1 out of the car to her wheelchair. The US stated they requested for the facility to provide a staff member because according to the dialysis center's policy the dialysis staff cannot transfer residents from car to chair. The facility then provided staff to go with Resident 1 during her dialysis appointments. The US stated Resident 1 missed dialysis appointments in August and September 2025, due to a mix of transportation issues and her refusing to go to dialysis. The US stated the facility should have provided wheelchair van transportation for the resident.On October 3, 2025, at 11:41 a.m., during an interview, LVN 1 stated the SSD arranged non-emergency medical transportation for dialysis residents.On October 3, 2025, at 1:08 p.m., during an interview, the SSD stated dialysis residents are admitted to the facility with transportation and dialysis appointments already arranged and that she arranged transportation for any make up dialysis days. The SSD stated Resident 1's insurance is accepted by very few transportation companies. The SSD stated they were using a private wheelchair van transportation for Resident 1, but the facility stopped paying and she does not know why. The owner of the private wheelchair van transportation informed her that because he was not getting paid, he could not take Resident 1 to dialysis anymore. The SSD stated the Case Manager (CM) arranged recurrent trips for Resident 1's dialysis appointments via Uber which started the week of September 22, 2025. The SSD stated this was not discussed with Resident 1 nor her FM. The SSD stated it was the corporate office who determined to use Uber because they did not want to pay for wheelchair van transportation. The SSD stated if the resident's insurance does not cover transportation, the resident can pay privately, and if the resident cannot pay, the facility will pay for it.On October 3, 2025, at 2:49 p.m., during an interview, the DON stated the SSD coordinated the transportation. The DON stated non-emergent transportation should be provided by the facility to the residents including dialysis transportation. The DON stated that the corporate office told them to provide Uber transportation for Resident 1.On October 3, 2025, at 4:23 p.m. during a telephone interview with Resident 1's FM, the FM stated the facility was sending Resident 1 to her dialysis appointments via Uber. The FM stated Resident 1 had an operation on her feet and was not supposed to put pressure on her feet and that she needed a lifted van for a wheelchair transfer. The FM stated he had a meeting with the facility on October 1, 2025, and they said they would take care of the transportation, but he did not hear from them.On October 3, 2025, at 5:17 p.m., during a telephone interview, Registered Nurse (RN) 1 stated that there was an occasion when the transportation did not show up for Resident 1 and she informed the SSD. The SSD informed her it was an insurance thing. RN 1 stated Resident 1 is now going to dialysis via Uber with two CNAs, but the CNAs are stating they have trouble transferring her into the car. RN 1 stated Resident 1 used to have a wheelchair van that picked her up. RN 1 stated it was better and safer for Resident 1 to be transported in a wheelchair van than Uber.On October 6, 2025, at 2:53 p.m., during a telephone interview, RN 2 stated, on September 23, 2025, the transportation for Resident 1 did not show up and her dialysis appointment was rescheduled for the next day, September 24, 2025. On September 24, 2025, an Uber picked up Resident 1 to go to her dialysis appointment and she went by herself. When she arrived at the dialysis center, she did not get her dialysis treatment because she was in an Uber. RN 2 stated that it was the first time she had seen an Uber pick up Resident 1. RN 2 stated Uber was absolutely not an appropriate transportation for Resident 1 because it was hard for her to go in and out of the Uber and she needed help.On October 9, 2025, at 10:30 a.m., during an observation, Resident 1 was in her room, lying in bed and asleep, CNA 1 was sitting at the bedside. CNA 1 stated the resident returned from dialysis that morning between 7:30 a.m. to 8:00 a.m. CNA 1 stated two CNAs went with Resident 1 for her dialysis appointment via Uber.On October 9, 2025, at 10:39 a.m., during an interview, CNA 2 stated she started taking Resident 1 to her dialysis appointments on October 2, 2025, via Uber. CNA 2 stated another CNA helped her transfer Resident 1 into Uber. CNA 2 stated Resident 1 can stand with two-person assistance, and she is basically deadweight (a person who is physically unable to assist with their own movement). CNA 2 stated Resident 1 disliked Uber and she informed the SSD and the RN about it. CNA 2 stated Resident 1 kept calling her FM and told him he needed to pay for gurney transportation (catered to patients with limited mobility or require a stretcher to be moved) and that she got mad because her FM could not pay for it.On October 9, 2025, at 11:27 a.m., during an interview with the Director of Rehabilitation (DOR), she stated that Resident 1 did not have a weight-bearing status order from the GACH physician. However, due to her toe amputation, they placed her on heel weight-bearing status to allow wound healing. The DOR mentioned that their department was not consulted to assess Resident 1's transportation needs, which is typically their responsibility. On October 3, 2025, Resident 1 received car transfer training by two rehabilitation staff using a staff member's car.On October 9, 2025 at 12:31 p.m., during a follow-up interview, CNA 2 stated that on October 2, 2025, Resident 2 was leaning on her left side and was agitated during the Uber ride because her FM couldn't pay the wheelchair van transportation.On October 9, 2025, at 12:39 p.m., during a follow-up interview, the SSD stated she did not consult the rehabilitation or nursing departments before using Uber because the CM initiated it. She contacted rehabilitation on October 2, 2025, after speaking to Resident 1's FM. Despite this, Resident 1 continues to use Uber for dialysis appointments as the corporate office would not cover wheelchair van costs. The SSD emphasized that the facility is responsible for providing appropriate transportation for Resident 1 and meeting all her care needs.On October 9, 2025, at 12:56 p.m., during an interview, LVN 2 stated on October 3, 2025, during shift change, he received a report from a CNA that Resident 1 had a bruise on the right side of her torso, and he created a change of condition (recording any major or minor change in a resident's health status). LVN 2 stated he found out the next day that Resident 1 was transferred out to the GACH.On October 9, 2025, at 1:33 p.m., during a telephone interview, the Case Manager (CM) indicated that she arranged Resident 1's transportation to the dialysis center using Uber Health. The CM mentioned that she did not consult the rehabilitation or nursing department prior to booking the Uber, as she was following specific instructions. According to the CM, the Administrator (ADM) directed her to organize the Uber for Resident 1's dialysis appointments.On October 9, 2025, at 2:16 p.m., during an observation, Resident 1 was sitting in her wheelchair, with a smoking apron on, smoking a cigarette in the smoking patio, with a 1:1 sitter (a designated staff member who provides constant, one-to-one observation and care) nearby.On October 9, 2025, at 2:30 p.m., during an interview with Resident 1 in the family room, Resident 1 stated she did not like Uber because the cars that arrived were either too small or too high which was hard for her to get into. Resident 1 stated she was transferred into the car by the CNAs who put their arms under her armpits and scoot her backwards into the car.On October 9, 2025, at 3:17 p.m., during an interview, the Physical Therapist Aid (PTA) stated they were asked to conduct car transfer training with Resident 1 and the CNAs, but not an assessment to determine an appropriate mode of transportation. The PTA stated Resident 1 can transfer from bed to wheelchair and vice versa with two-person physical assistance, meaning she can transfer anywhere as long as there are two people helping her. The PTA stated it was the facility who decided to use Uber for Resident 1.On October 9, 2025, at 3:57 p.m., during an interview, the DON stated Resident 1 was transferred to the hospital because of her bruises. The DON stated that according to CNA 2, Resident 1 was getting agitated and was trying to get out of her seatbelt while they were inside the Uber and they sent her to the hospital for evaluation.On October 9, 2025, at 4:40 p.m., during a follow up interview with the DON, the DON was asked if she knew that Resident 1 disliked Uber. The DON stated she heard about it on October 3, 2025, when they found out about the bruises. The DON stated she does not have an answer when she was asked why Resident 1 was still going to her dialysis appointments via Uber.On October 9, 2025, at 4:56 p.m., during an interview, the ADM stated Resident 1 was going to dialysis via Uber with two CNAs for safety. The ADM stated the facility began paying for Resident 1's Uber transportation when her insurance changed and a decision was made to stop using the prior transportation, and he does not know why. The ADM stated they were having problems getting transportation that's reliable to come to the facility at 4:00 a.m. When asked if it was acceptable to transport a resident by Uber without first determining the appropriate mode of transportation, the ADM stated that doing so poses a risk or injury to the resident compared to a wheelchair van transportation.A review of Resident 1's GACH records titled, Physician Chart dated October 4, 2025, indicated Resident 1 arrived at the Emergency Department at 1:34 a.m., and on physical examination Resident 1 had bruising on the right and left side of her torso, between the lowest rib and the hip, with mild tenderness when touched.A review of Resident 1's Computed Tomography (CT) Scan (a diagnostic imaging test that created detailed pictures of the inside of the body) of the chest dated October 4, 2025, indicated Resident 1 had right breast and chest muscle hematoma (localized collection of blood) and soft tissue swelling, side right chest wall subcutaneous (under the skin) soft tissue swelling probable contusion (bruise), possible nondisplaced lateral right rib fractures (a type of bone fracture where the broken bone pieces remain in their original position).A review of the facility's policy titled, Transportation, Social Services dated January 2018, indicated .Our facility shall help arrange transportation for residents as needed .Social services will help the resident as needed to obtain transportation .

Based on observation, interview, and record review, the facility failed to, for one of three sampled residents (Resident 3): 1. Re-assess the blister on the right elbow of Resident 3, initially observed during re-admission to the facility on April 13, 2025, and 2. Administer treatment to Resident 3's right elbow blister, when it was observed on April 13, 2025. These failures resulted in the worsening of the right elbow blister to a Stage 4 pressure injury (bed sore-full thickness skin loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer). Findings: On April 23, 2025, at 9:34 a.m., during interview with Resident 3 in her room, Resident 3 stated she had wounds on her right elbow and left heel, and she acquired those in the facility. A review of Resident 3's admission Record medical record indicated the resident was re-admitted to the facility on [DATE], with diagnoses which included rheumatoid arthritis. A review of the General Acute Care Hospital (GACH) Notes indicated the following: - Wound Nurse Record, dated April 10, 2025, the resident has history of chronic wounds, and had pressure injuries on the right buttock, left buttock, coccyxx, right first toe, left heel, and purple bruising on BUE (bilateral upper extremity) with no open skin. -PA(Physician Assistant)/NP (Nurse Practitioner) Progress notes, dated April 13, 2025, discharged . Further review did not indicate open area in the right elbow. A review of Resident 3's Nursing admission Assessment, dated April 14, 2025, indicated Resident 3 did not have any pressure injury on her right elbow. Further review of the admission assessment included Braden Skin Risk Scale & Skin Assessment which indicated the following: a. Sensory Perception: Ability to respond meaningfuly to pressure-related discomfort- 4. No impairment (responds to verbal commands). b. Moisture: Degree to which skin is exposed to moisture. - 1. Constantly Moist (skin is kept moist almost constantly by perspiration, urine). c. Activity: Degree of physical activity- 2. Chairfast (ability to walk is severely limited or nonexistent). d. Mobility: Ability to change and control body position- 1. Completely immobile (does not make even slight changes in body or extremity position without assistance). e. Nutrition: Usual food intake pattern- 3. Adequate (Eats over half of most meals). f. Friction and Shear - 1. Problem (Requires moderate to maximum assistance in moving). A review of the Braden Skin Risk Assessment Scale dated April 14, 2025, has a total score of 12, which meant the resident is high risk of developing pressure injury. A review of Resident 3's Order Summary Report, active orders as of April 23, 2025, indicated, Right Elbow stage 4 pressure injury: Cleanse with Normal Saline, pat dry with gauze, apply MEDIHONEY AND CALCIUM ALGINATE, pad with ABD and wrap with kerlix for 21 days and PRN for soiled or dislodged dressing .Start date 4/15/2025 Further review of the Order Summary Report, active orders as of April 23, 2025, did not indicate any treatment orders for the blister on the right elbow, noted during re-admission on [DATE]. On April 23, 2025, at 10:38 a.m., during a concurrent wound care observation for Resident 3 and interview with Treatment Nurse (TN) 1 and Licensed Vocational Nurse (LVN) 3, TN 1 stated Resident 3 had a Stage 4 pressure injuries on her right elbow and left heel. Resident 3's right arm was offloaded on a rolled bed sheet. Resident 3 had an open wound on her right elbow, circular in shape, which measured approximately three centimeters (cm-a unit of measurement) in length and three cm in width, the wound bed was pink, and the bone was exposed. On April 23, 2025, at 12:55 p.m., during an interview, TN 1 stated he received a report from a Certified Nurse Assistant (CNA) on April 15, 2025, that Resident 3's right elbow was wrapped with a bandage. TN 1 stated he assessed Resident 3's right elbow after he removed the bandage and noted that Resident 3 had a Stage 4 pressure injury on her right elbow. TN 1 stated if Resident 3's right elbow was wrapped when she was re-admitted to the facility on [DATE], the staff should have assessed the skin underneath the bandage. On April 24, 2025, at 3:22 p.m. during a concurrent interview with Registered Nurse (RN) 4 and record review of Resident 3's medical record, RN 4 stated she was familiar with Resident 3. RN 4 stated Resident 3 was re-admitted to the facility on [DATE], and she stated the resident's right elbow was wrapped with kerlix and an ACE bandage (compression bandage). RN 4 stated Resident 3's right elbow had a blister on it, the size of a ping-pong ball. RN 4 stated she did not document it because the blister was intact. RN 4 stated she should have documented the presence of the blister, notified the doctor and she should have obtained a treatment order for the right elbow blister. On April 25, 2025, at 12:20 p.m., during an interview, RN 3 stated the licensed nurses are expected to assess residents from head to toe, upon admission or re-admission, and document skin issues. RN 3 stated if the assessment was not documented then it was not done. RN 3 stated RN 4 should have unwrapped Resident 3's bandage on the right arm, conducted an assessment, measured the pressure injury, notified the doctor, obtained a treatment order and documented in Resident 3's medical records. RN 3 stated wound care should have been provided to prevent the wound from worsening. On May 12, 2025, at 10:50 a.m., during a telephone interview, LVN 5 stated she was familiar with Resident 3. LVN 5 stated she was the TN after Resident 3 returned from the hospital. LVN 5 stated Resident 3's right arm was wrapped and had a sling, but Resident 3 did not want her to check her right elbow. On May 12, 2025, at 12:18 p.m., during a concurrent interview, TN 2 stated every licensed nurse should be able to document and describe any skin problems they identified, notify the doctor and obtain a treatment order. TN 2 stated it was important to document skin assessments to keep track of the progress of any wounds. On May 12, 2025, at 1:00 p.m., during an interview, the Director of Nursing (DON) stated if Resident 3 had a blister on her right elbow when she was re-admitted , there should be an assessment, a treatment order and a care plan. The DON stated a blister is cleansed with normal saline, patted dry and a dressing is placed over it to protect it from popping. A review of the facility's policy and procedure titled Initial Nursing Assessment and Re-Assessment dated August 2019 indicated .It is the policy to assess residents upon admission and re-admission to the facility .upon admission, the licensed nurse will conduct a head to toe assessment of resident .Any change in the patient's condition shall require an immediate reassessment with changes in the plan of care reflecting the change in condition .All data collected shall be recorded in the nursing assessment record and shall be available to all disciplines involved in the care of the patient . A review of the facility's policy and procedure titled Skin Breakdown, Prevention and Management dated December 2017 indicated .Upon admission or when a resident is identified to have a non-pressure skin discoloration or skin breakdown, the licensed nurse will contact the attending independent licensed practitioner .for any sites or area that requires any form of treatment .The licensed nurse assigned to the resident will assess, evaluate and initiated a change of condition nursing documentation .Initial wound assessment will be documented on the nursing admission assessment .

Based on interview and record review, the facility failed to provide and document sufficient preparation and orientation to ensure a safe and orderly discharge from the facility for two of six residents reviewed (Resident 1 and 2), when the residents were discharged to an undisclosed location, and there was no documentation in Resident 1's record of diabetic teaching and diabetic supplies being given to Resident 1 prior to discharge. This failure resulted in the unsafe discharge for Resident 1 and 2 back into the community. Findings: On September 18, 2023, at 12:10 p.m., an unannounced visit was conducted at the facility for an unsafe discharge. Review of the discharge list of residents dated September 1-18, 2023, indicated Resident 1 and Resident 2 were discharged home on September 13, 2023. Review of Resident 1's record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal sugar in the blood), and hypertension (elevated blood pressure). Resident 1's physician history and physical indicated Resident 1 had capacity to make decisions. Review of Resident 1's Physician Order Summary indicated, .May go home with meds (medication) . dated September 13, 2023.Blood Sugar checks three times a day before meals and Notify MD (medical doctor) if BS (blood sugar) less than 60 or greater than 300 . dated August 5, 2023, and .Insulin (diabetic medication used to help the body regulate sugar) Lispro Solution 100 UNIT/ML (milliliter- dosage) Inject 10 units subcutaneously (under the skin) before meals . dated July 8, 2023. Review of Resident 1's nursing progress note dated September 13, 2023, at 10 p.m., indicated, .MD ordered may go home with meds, he came in made the rounds today . Review of Resident 1's IDT (interdisciplinary team- a group of healthcare professionals who work together to coordinate resident care) Discharge Summary dated September 13, 2023, at 10:01 p.m., indicated a list of medication given to Resident 1. There was no documentation of insulin, diabetic supplies, or diabetic education given to Resident 1. Review of Resident 1's Notice of Transfer/discharge date d September 13, 2023, at 10:07 p.m., indicated Resident 1 discharged to his previous address. There was no further documentation in Resident 1's record indicating when, where, how, who accompanied Resident 1 when Resident 1 discharged , or an assessment done. There was no documented evidence Resident 1 received discharge instructions and/or diabetic teaching and supplies. Review of Resident 1's Psycho-social note undated, indicated, Wednesday September 13, 2023. (Name of Resident 1) made the decision to leave the facility, Dr. (name of physician) gave the orders .A bed at another facility was arranged for resident, resident waited too long in the day to be discharged so alternate accommodations were arranged and the bed at the other facility was available the next day .(Name of Resident 2) was discharged from the facility and told to contact the facility for assistance transportation the next day, if needed. Thursday September 14, 2023 .Resident reached out to this writer and decided he didn't want to go to the new facility until Friday Friday September 15, 2023 .Resident contacted this writer and he was now ready to go to the other facility . Review of Resident 2's record indicated Resident 2 was admitted on [DATE], with diagnoses which included altered mental status, umbilical hernia (weakening in the abdominal muscle wall), and history of alcohol (ETOH) abuse. Resident 2's physician history and physical indicated Resident 2 had capacity. Review of Resident 2's Physician Order Summary indicated, .May go home with meds . dated September 13, 2023. Review of Resident 2's IDT Discharge Summary dated September 13, 2023, at 7:26 p.m., indicated, .IF PROBLEMS ARISE DURING DISCHARGE, PLEASE CONTACT THE FOLLOWING INDIVIDUAL(S) AT THE NURSING FACILITY . There were no names or numbers were entered on the form. Review of Resident 2's nursing progress note dated September 13, 2023, at 9:28 p.m., indicated, .resident left facility at approx. (approximately) 9:15 pm . There was no further documentation in Resident 2's record indicating where, how, who accompanied Resident 2 when Resident 2 discharged , or an assessment done. Review of Resident 2 Psycho-social note undated, indicated, Wednesday September 13, 2023. (Name of Resident 2) made the decision to leave the facility, Dr. (name of physician) gave the orders .A bed at another facility was arranged for resident, resident waited too long in the day to be discharged so alternate accommodations were arranged and the bed at the other facility was available the next day .(Name of Resident 2) was discharged from the facility and told to contact the facility for assistance transportation the next day, if needed. Thursday September 14, 2023 .Resident reached out to this writer and decided he didn't want to go to the new facility until Friday Friday September 15, 2023 .Resident contacted this writer and he was now ready to go to the other facility . On September 18, 2023, at 3:09 p.m., an interview was conducted with the Social Service Assistance (SSA) and the Social Service Director (SSD) concurrently. The SSA and the SSD stated for a safe discharge, the resident must meet discharge criteria, have a discharge plan, and have an assessment to ensure the resident needs and requirements, such as home health and any medical equipment were addressed. The SSA and the SSD stated resident referrals needed to be made as well. The SSA and SSD stated education regarding medications, wound care, and any other resident needs, needed to be provided before discharge. The SSA and SSD stated residents who took insulin needed discharge education on fingerstick blood sugars and on the use of insulin, along with any medical equipment needed to perform the blood sugar checks. The SSA and the SSD stated documentation needed to be done regarding discharge teaching, medications and education done, transportation used, where the resident was discharged too, time the resident was discharged , who accompanied the resident, and who the resident's care takers would be. The SSD stated residents who were homeless should not be discharged without proper placement. During a concurrent record review of Resident 1's physician order summary, the SSA and the SSD stated Resident 1 required insulin three times a day with fingerstick blood sugars. They stated there was no documentation Resident 1 received discharge education regarding his diabetes, received diabetic supplies, or his insulin and/or a prescription for insulin. The SSA and the SSD stated the Notice of Transfer/Discharge indicated Resident 1 returned to his previous address, but they stated Resident 1 did not discharge to that address. The SSA and the SSD stated Resident 1's nursing progress note indicated he had an order to discharge but there was no documentation indicating Resident 1 was assessed prior to discharge, education or teaching done, when Resident 1 discharged , where Resident 1 was discharged , and how Resident 1 left the facility. The SSA and the SSD stated the psycho-social note indicated Resident 1 went to an alternate accommodation until a bed was available. The SSA and the SSD stated Resident 1 should not have discharged until the other arranged bed was available and he should have stayed in the facility. The SSA stated she was not sure where Resident 1 was discharged too and had not been able to contact him to verify he was safe. On September 18, 2023, at 3:15 p.m., Resident 2's record was reviewed with the SSA and the SSD. The SSA and the SSD stated the Transfer/Discharge notice indicated Resident 2 was discharged home. The SSA and the SSD stated Resident 2 was homeless, and there was no documentation where Resident 2 was discharged too. The SSA and the SSD stated Resident 2 should have not been discharged until the receiving facility confirmed the bed was available and Resident 2 should have remained at the facility. The SSA and SSD stated Resident 1 and Resident 2 were not discharged safely from the facility. On September 18, 2023, at 4:15 p.m., a telephone interview was conducted with the Registered Nurse Supervisor (RNS). The RNS stated resident discharge education began with the charge nurse when the discharge was discussed, usually the day before discharge. The RNS stated he was working the evening Residents 1 and 2 were discharged . The RNS stated he returned from his dinner break and was notified Residents 1 and 2 were being discharged . The RNS stated he did not provide any discharge education to Residents 1 and 2. The RNS stated the charge nurses provided him with Resident 1 and 2's medications, he reconciled it, and filled out the Discharge Summaries. The RNS stated he did not recall giving Resident 1 any insulin or equipment for monitoring his blood sugar. The RNS stated he did not provide any education to Resident 1 regarding his diabetes. The RNS stated when he questioned the residents as to where they were discharging, both stated home. The RNS stated he was unaware of where home was, and just put Resident 1's previous address and (name of city) for Resident 2 since Resident 2 was homeless. The RNS stated he was unaware of discharge plans for Resident 1 and 2's until the evening of September 13. The RNS stated he was notified of the discharges around 8 p.m. in the evening and was rushed to complete their discharges. The RNS stated he contacted the physician to verify the discharges were ordered. He stated when the physician confirmed Residents 1 and 2 were able to be discharged , he discharged the residents shortly after. The RNS stated he was not sure where Residents 1 and 2 were discharged too. On September 18, 2023, at 5:20 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated he provided care to Resident 2 on September 13, 2023. LVN 1 stated he noted Resident 2 packing up his belongings, when he questioned Resident 2, Resident 2 stated he was in the parking lot when the [NAME] President (VP) saw him at a visitor's car. LVN 1 stated Resident 2 told him the VP thought he was buying drugs and was discharging him home. LVN 1 stated he gathered Resident 2's medication and briefly educated him about them before he left. LVN 1 stated Resident 2 was homeless and did not have a home to return too. LVN 1 stated Resident 2 should not have been discharged without confirming his bed was available at the alternate location. LVN 1 stated he was unaware where Resident 2 was discharged too, what the alternate accommodations were, and what facility he was to transfer too when the bed was available. On September 18, 2023, at 5:45 p.m., an interview was conducted with LVN 2. LVN 2 stated she provided care for Resident 1 on September 13, 2023, until about 8 p.m., before she went home ill. LVN 2 stated Residents 1 and 2 were ordered to be discharged , and within 30 minutes were being sent out. LVN 2 stated she asked Resident 1 where he was discharging to, and Resident 1 stated he was being discharged to a local hotel. LVN 2 stated the discharge did not make sense to her, seemed fishy. LVN 2 stated she questioned the VP about it. LVN 2 stated the VP said there were physician orders to discharge the residents and they needed to be discharged now. LVN 2 stated the VP then stated to her that with the right amount of cash you can kick anyone out, no questions. LVN 2 stated she did not feel good about the discharges of Residents 1 and 2, and it was making her physically ill. LVN 2 stated she contacted the RNS and she went home before the residents were discharged . LVN 2 stated the discharges seemed rushed and were not safe. LVN 2 stated the VP would not indicate where the residents were being transferred to or why. LVN 2 stated Residents 1 and 2 had been previously accused of illicit drug activity. LVN 2 stated Residents 1 and 2 were given a large sum of money, and sent to a local hotel, with their medications, some of which were narcotics. LVN 2 stated she did not feel comfortable discharging the residents with a known drug history to a hotel, and with a large amount of cash and narcotics. On September 19, 2023, at 10:45 a.m., the investigation was continued at the facility. On September 19, 2023, at 11:40 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated discharge instructions needed to be specific and include; where the resident was discharging too, when the resident discharged , an assessment of the resident needs, current assessment of the resident's condition, and any needed medical equipment or referrals needed. The DON stated a planned discharge also included notification to the Ombudsman, the appeal process, along with an IDT discharge summary conducted within 72 hours before discharge, not at discharge. During a concurrent record review of Resident 1's record, the DON stated Resident 1 had no documentation where he was being discharged too. The DON stated Resident 1's Transfer/Discharge Notice stated Resident 1 was discharged to ' home on September 13, 2023. The DON stated there was no documentation where Resident 1 was discharged too, no address or location, when, how, discharge planning or education regarding his diabetes and insulin use, an assessment of his needs, outside referrals made, his right to appeal his discharge, or Resident 1's current condition. The DON stated Resident 1's IDT discharge summary was completed at his discharge. The DON stated Resident 1 used insulin three times a day and needed to check his blood sugars three times a day. The DON stated Resident 1 had the potential risk of hyperglycemia (elevated blood sugar) and/or hypoglycemia (low blood sugar) either could be very dangerous for Resident 1. The DON stated the psycho-social note for Resident 1 indicated ' alternate accommodations' were made until the bed was available at another facility. The DON stated Resident 1 should not have been discharged until the receiving facility bed was available for Resident 1. On September 19, 2023, at 11:45 a.m., Resident 2's record was reviewed. The DON stated Resident 2 was homeless and did not have a home to discharge too. The DON stated there were no outside referrals made for Resident 2, no address listed where Resident 2 discharged too, and how Resident 2 left the facility. The DON stated the discharge instructions were vague and did not address Resident 2's ETOH and drug addictions for referrals. The DON stated Resident 2's psycho-social note was the same as Resident 1's and did not indicate an address where the residents were discharging and why. The DON stated Resident 2 was being followed by psychology for his addiction and there was no documentation a referral or outside contacts were given to Resident 2. The DON stated Resident 2 should not have been discharged until the other facilities bed was available. The DON stated Resident 1 and Resident 2 were unsafely discharged from the facility. On September 19, 2023, at 1:25 p.m., a telephone interview was conducted with the Case Manager (CM). The CM stated to have a safe facility discharge, the facility must start the discharge planning 72 hours before. The CM stated residents needed outside referrals, medical equipment needed to be provided and/or arranged, home health services needed to be acquired if needed, family and support arranged, education regarding medication and home use, and notification of the appeals process. The CM stated when the resident discharged , documentation needed to include information regarding where the resident went with the address, how the resident discharged i.e . private car or transport, who accompanied the resident, an assessment of the resident, medication given along with education on use, medical equipment needed, and list of outside referrals made or needed. The CM stated she was notified around 5 p.m., on September 13, 2023, Residents 1 and 2 were being discharged . The CM stated she asked where the residents were being discharged too and was told Residents 1 and 2 were going home. The CM stated Resident 2 had no funds to provide for himself and was homeless. The CM stated the discharges were very chaotic and rushed. The CM stated when she left for the evening both residents were at the facility. The CM stated when she returned the next morning September 14, 2023, both residents were no longer at the facility and had been discharged during the night. The CM stated she was unaware of the location of Residents 1 and 2 and had not been able to contact them. The CM stated she had heard Residents 1 and 2 were sent to a local hotel when she returned to work on September 14. The CM stated the residents should not have been discharged to a hotel but rather stay at the facility until alternate accommodations were arranged with confirmation of acceptance of the residents. The CM stated Residents 1 and 2 were discharged unsafely. On September 19, 2023, at 1:57 p.m., during an interview with the Adm, an immediate jeopardy (IJ- a situation in which immediate corrective action is necessary) was called in the presence of the Administrator (Adm), DON, and the facility consultant, for unsafe discharge of Residents 1 and 2 to an undisclosed location with no discharge planning, assessments or outside referrals. Resident 1 was discharged without his needed insulin and/or medical supplies to check his blood sugar. On September 20, 2023, at 11:14 a.m., a telephone interview was conducted with Resident 2. Resident 2 stated a facility big wig approached him and told him that he could help transfer himself and Resident 1 to another ' better' facility. Resident 2 stated the ' big wig' offered him $2500 dollars to leave. Resident 2 stated the facility wrote him a check first, but he would be unable to cash it, so the facility gave him cash. Resident 2 stated he packed up his belongings and went to a local hotel in the area. Resident 2 stated he got his medication and left. Resident 2 stated this all happened ' quickly' on the night of September 13, 2023. Resident 2 stated he did not receive any referrals for outside counseling or drug addiction. Resident 2 stated once he got to the hotel, he went to the liquor store and bought alcohol and drugs. Resident 2 stated he got a call Thursday from ' someone at the facility' who said they (Resident 1 and 2) needed to transfer to Los Angeles (LA). Resident 2 stated he told the facility he was unable to transfer to LA because of his insurance. He stated the ' person' then said there would be a facility available for him to transfer to on Friday and a driver would contact him in the morning. Resident 2 stated he had not heard from the facility or anyone since. Resident 2 stated he and Resident 1 had checked out of the hotel and had moved to another because it was too expensive, and the money was almost gone. Resident 2 stated he had $60 left. Resident 2 stated he did not think it was smart for the facility to give a known drug addict $2500 cash and put him in a hotel where he had access to drugs and alcohol. Resident 2 stated he did not have anywhere to go now and would be homeless after tonight. On September 20, 2023, at 11:20 a.m., During the telephone interview with Resident 2, Resident 1 got on Resident 2's telephone. Resident 1 stated he was staying with Resident 2. Resident 1 stated he was approached by the big wig (someone who he thought was from the facility business office or corporate) on Monday September 11, 2023. Resident 1 stated the big wig told him he and Resident 2 were ' liabilities' to the facility and needed to discharge. Resident 1 stated he was willing to comply but wanted to wait until a medical prosthesis (a medical equipment used to help the body perform better) arrived for his leg. Resident 1 stated he was told the facility would give him money and set him up at another facility, similar to where he was. Resident 1 stated on Wednesday September 13, 2023, he and Resident 2 were told they were discharging today and were discharged to a local hotel with cash. Resident 1 stated it was in the evening sometime but was unsure when. Resident 1 stated he got his medications from the RNS and when he asked about his insulin, Resident 1 stated was told he could not have needles, due to the allegation of drug use. Resident 1 stated he did not get any insulin, medical supplies to monitor his sugar, or a prescription for insulin. Resident 1 stated he did not get any information for clinics to visit to help monitor his blood sugar. Resident 1 stated he knew if he got tired, he needed to eat, and could tell when his sugar was high but had no way to monitor his blood sugars or treat them. Resident 1 stated the facility called Thursday September 14, 2023, and offered to transfer him to LA, but Resident 1 stated he did not want to go to LA due to a prior history there and preferred to go somewhere locally. Resident 1 stated he was told someone would be picking himself and Resident 2 up Friday morning to transfer them to another facility, but no one ever called or showed up. Resident 1 stated he then called the ' new' facility they were to transfer too, and the facility had no record of them coming or being admitted . Resident 1 stated he kept his end of the deal with the facility and left, but the facility did not keep their end and left them with no place to go. Resident 1 stated he and Resident 2 would be homeless soon. On September 20, 2023, at 1:40 p.m., a telephone interview was conducted with Sales and Admissions from the number given by the facility as the potential location for Residents 1 and 2 to be transferred to on September 13, 2023. The Sales and Admissions stated they had not been in contact with any local facility for new admissions. The Sales and Admissions stated they would not accept residents without a thorough screening process and were a memory care unit for the elderly. The Sales and Admissions stated Resident 1's name was familiar, but they were contacted by a hospice looking for a potential bed, and not a skilled nursing facility. The Sales and Admissions stated they were not contacted to admit Residents 1 and 2 to their facility, no prices were discussed, and no contracts were drawn up. On September 20. 2023, at 2:20 p.m., a telephone interview was conducted with the owner from the number given as proposed facility number 2 for Residents 1 and 2 transfer. The owner stated he had not been contacted by any skilled nursing facility recently for admissions. The owner stated his facility was a room and board and had two beds available, until a few days ago. The owner stated he did receive a call about a potential admission maybe two weeks ago and a name was given (Resident 1). The owner stated no paperwork was started, no pricing was discussed, and no contracts were signed. The owner stated he would be the only contact person and no one else at his room and board. The owner stated he had one inquiry about a potential need for a bed, but no other information was given, and no further contact was done. Review of the facility policy titled, Transfer or Discharge Notice dated January 2018, indicated, .Our facility shall provide a resident and/or the resident's representative (sponsor) with a thirty (30)-day written notice of an impending transfer or discharge .The resident and/or representative (sponsor) will be notified in writing of the following information .The reason for the transfer or discharge .The effective date of the transfer of discharge .The location to which the resident is being transferred or discharged .A statement of the resident's right to appeal the transfer or discharge .The reasons for the transfer or discharge will be documented in the resident's medical record . On September 22, 2023, at 8:55 a.m. the corrective plan was submitted by the facility Adm and was accepted. The corrective plan indicated how the facility will ensure that no resident will be negatively affected by being discharged to a low level of care or to a community living situation: Implementation & Completion date: 09/21/2023. Started in-service 09/21/23, will be completed on 09/22/23. Upon admission to the facility the IDT team will attempt to evaluate the prior living situation of the resident and the resident's discharge potential. During the resident's stay here at the facility the IDT will ensure that the prior living situation is appropriately can meet the resident's needs and is the desired placement for discharge for the resident, and if the prior living situation is determined to not be able to appropriately meet the needs of the resident or is not the desired discharge location of the resident, then the facility will, o Upon determination of the resident's date of discharge the IDT team will evaluate and confirm that the resident's anticipated needs post-discharge. o This facility will reach out to the planned discharge location confirming the location can safely meet the resident's post-discharge needs. o This facility will ensure the name of the location, the address of the planned discharge location, the name of the receiving party, and the telephone number of the location are properly documented. o An appropriate receiving party/facility will be documented in the resident's medical record with the following information: Name of receiving party/facility, the name of the discharge location (if applicable), the address of the receiving party/facility, and the phone number of the receiving party/location. This will be documented by the SSD/SSA or the case manager of this facility. o This facility will ensure that an appropriate discharge order is received from the resident's physician and is charted in the resident's medical record and is carried out as ordered. o The IDT team will assess the resident's post-discharge care needs and care goals. o The IDT team will assess if resident needs any DME or home health services, and if needed, orders will be obtained from the resident's physician and documented in the resident's medical record by SSD/SSA or the case manager of this facility. o All medications will be reviewed prior to discharge and confirmed by this facility that the medication list is accurate the facility will ensure that appropriate medication administration teaching is offered and provided as requested to the resident/resident's representative or the receiving party prior to the discharge of the resident. o The facility nurse will document the list of medications provided to the resident upon discharge, listing the preferred pharmacy provided. o This facility will document in the resident's medical record that the education was offered to and given to the resident/resident representative or receiving party for all discharge medication. o The SSD/SSA and/or CM will make any follow-up appointments and/or referrals to the primary care physician. o The facility will assess and provide to the resident/resident's representative and receiving party any needed training for post-discharge care needed, and this will be documented in the resident's medical record. o The facility will arrange or verify safe and appropriate transportation for the resident and the resident's belongings and all pertinent information regarding discharge transportation will be documented in the resident's chart. o The facility will use the DISCHARGE CHECKLIST created and attached to ensure the process for discharge is carried out in compliance with the regulatory requirements and the administrator or designee will sign off on the document and it will be provided to the resident/resident's responsible party and receiving party placed in the resident's medical record prior to discharge. On September 22, 2023, at 8:55 a.m., a visit to the facility was conducted to ensure the corrective action plan was put into place and verified through observations, interviews, and record review. On September 22, 2023, at 3:43 p.m., the Adm and DON were informed that the IJ had been lifted.

Based on observation, interview, and record review, the facility failed to address the individualized needs related to substance use behavior, (SUB - continually using drugs or alcohol even though it is causing or adding to physical or psychological problems), for seven of 13 residents reviewed, (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 8, and Resident 9), who had history of substance use prior to admission and had been suspected of illegal drug use while at the facility. In addition, the facility failed to increase monitoring and supervision of the seven residents suspected of illegal drug use as well as the 136 residents not involved. These failures had the potential to cause serious harm such as accidental death to the seven residents and could seriously affect the health and safety of the facility's 136 vulnerable residents not involved in the illegal drug use. Findings: On August 15, 2023, at 2:58 p.m., an unannounced visit to the facility was initiated for two complaints regarding resident rights. A review of Resident 1's Facesheet indicated he was admitted to the facility on [DATE], with diagnoses of diabetes mellitus type 2, (a chronic condition that affects the way the body uses sugar. The body either resists the effects of insulin - a hormone that regulates the movement of sugar into the cells - or doesn't produce enough insulin to maintain normal sugar levels), benign prostatic hyperplasia, (BPH - enlargement of the prostate gland), stimulant dependence, and depression, (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 1's History and Physical dated July 28, 2022, indicated he had decision making capacity. A review of Resident 2's Facesheet indicated she was admitted to the facility on [DATE], with diagnoses of quadriplegia, (paralysis from the neck down, including the trunk, legs, and arms), major depressive disorder, and anxiety disorder, (a chronic condition characterized by an excessive and persistent sense of apprehension). A review of Resident 2's History and Physical dated May 11, 2023, indicated she had the capacity to understand and make decisions. A review Resident 3's Facesheet indicated he was admitted to the facility on [DATE], with diagnoses of psychoactive abuse with intoxication, depression, alcohol abuse with intoxication, and schizophrenia, (a mental illness that is characterized by disturbances in thought). A review of Resident 3's History and Physical dated September 20, 2022, indicated he had decision making capacity. A review of Resident 4's Facesheet indicated he was admitted to the facility on [DATE], with diagnoses of diabetes mellitus type 1, (a chronic, disease characterized by elevated levels of blood sugar), vascular 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), major depressive disorder, and stroke. A review of Resident 4's History and Physical dated January 10, 2023, indicated he had the capacity to understand and make decisions. A review of Resident 5's Facesheet indicated he was admitted to the facility on [DATE], with diagnoses of chronic pain syndrome, peripheral vascular disease, (PVD - is a slow and progressive circulation disorder), major depressive disorder, and cirrhosis of the liver, (a late stage of scarring of the liver). A review of Resident 5's History and Physical dated October 14, 2021, indicated decision making capacity was intact. A review of Resident 8's Facesheet indicated she was admitted to the facility on [DATE], with diagnoses of schizophrenia, chronic pain syndrome, anxiety disorder, and diabetes mellitus type 2. Resident 8's History and Physical dated June 22, 2023, indicated she had the capacity to make decisions. A review of Resident 9's Facesheet indicated she was admitted to the facility on [DATE], with diagnoses of HIV, dementia, anxiety, major depression, chronic pain. A review of Resident 9's History and Physical dated September 29, 2022, did not indicate if she had the capacity to make decisions. On August 15, 2023, at 3:52 p.m., an interview was conducted with the Social Services Assistant, (SSA). The SSA stated the facility Administrator and staff conducted a consented room search for Resident 3, Resident 8, and Resident 9. The police confiscated the drugs and paraphernalia and tested the substances to see what kind of drugs they had. The SSA stated On August 2, 2023, Resident 2 willingly opened the drawer and surrendered liquid speed, (methamphetamine) in syringes, (a medical device with a needle attached to a hollow cylinder that is fitted with a sliding plunger used to inject fluid into the body). The SSA stated on August 11, 2023, the facility did consented room searches with police present for Resident 1, Resident 2, Resident 4, and Resident 5. The SSA stated they found drugs, and drug paraphernalia. The SSA stated the police confiscated the drugs and paraphernalia and tested the substances to see what kind of drugs they had. On August 15, 2023, at 4:25 p.m., an interview was conducted with the facility Administrator, (ADMIN). The ADMIN stated the police have been coming out all week to confiscate the drugs and paraphernalia they found in resident rooms. The ADMIN stated that the Director of Nursing, (DON 1), was notified that Resident 1 was receiving drugs through his room window and distributed the drugs to certain residents. The ADMIN stated the room searches were consented and done on two separate occasions. The ADMIN stated the first search was conducted on August 2, 2023, and the police came out twice on August 2, 2023. The ADMIN stated on August 11, 2023, the room searches were conducted in front of police presence, and the drugs and drug paraphernalia were confiscated by the police. On August 15, 2023, at 5:45 p.m., an interview was conducted with Resident 1. Resident 1 stated he consented to the room search on August 11, 2023. Resident 1 stated the police were there, but the staff did the search. Resident 1 stated the staff found a pipe that wasn't his. Resident 1 stated the police were there and did not do anything. On August 21, 2023, at 1:09 p.m., an interview was conducted with the Director of Nursing, (DON 1). DON 1 stated on August 2, 2023, he got a report from staff that there were drugs in the facility. The DON 1 stated they got resident consent to search the rooms, and when they found drugs, the police confiscated the drugs. On August 21, 2023, at 1:50 p.m., an interview was conducted with Resident 2. Resident 2 stated her room was not searched; the drugs were sitting out. Resident 2 stated she was not offered substance abuse counseling, and that she was independent and did things for herself and did not require supervision. On August 21, 2023, at 2:27 p.m., an interview was conducted with the Certified Nursing Assistant, (CNA 4). CNA 4 denied that residents were caught with drugs in their rooms. On August 21, 2023, at 2:31 p.m., an interview was conducted with CNA 5. CNA 5 stated they did not supervise residents who go out on pass and denied that residents were caught with drugs in the facility. On August 30, 2023, at 12:08 p.m., observed that Resident 1 was not in his room, or in the facility. On August 30, 2023, at 12:11 p.m., an interview was conducted with CNA 6. CNA 6 stated she was assigned to Resident 1. CNA 6 stated she was not sure where Resident 1 was at this time. CNA 6 stated Resident 1 might be out on pass or at an appointment. CNA 6 stated the last time she saw Resident 1 was on the smoking patio during breakfast trays. On August 30, 2023, at 12:39 p.m., an interview was conducted with Licensed Vocational Nurse, (LVN 4). LVN 4 stated she had not been to an in-service regarding residents doing illegal drugs or finding illegal drugs in resident rooms. A review of Resident 1's IDT-Meeting dated August 11, 2023, at 3:51 p.m., indicated SSA was notified by the DON that he had called the police because resident was seen passing drugs of some sort to another resident. And (sic) was notified that he sells drugs out of the window of his room. Residents room is adjacent to the street and smoking patio. Officer notified resident that his belongings were to be searched and resident agreed .Resident was previously spoken to on August 2, 2023, about possession of contraband in his room. IDT entered the room with the officer while the officer searched resident's belongings and there was cracked filled pipes and also marijuana in his possession. Resident stated he did not know where that come (sic) from. The officer stated (sic) I was standing here when they searched your things and this was found in the black and grey bag that is in your possession Resident denied that it was his. Resident stated he was leaving then heading out of the building and left without signing AMA or obtaining order from MD . A review of Resident 2's IDT - Meeting dated August 2, 2023, at 1:53 p.m., indicated .she opened a pouch with a white substance, and liquid filled syringes . Resident 2's Drug Screen, Urine collected August 4, 2023, at 9 a.m., indicated positive results for amphetamine and Opiates. Resident 2's IDT-Meeting dated August 11, 2023, at 4:12 p.m., indicated .DON was notified that resident was under the influence of some substance .DON, ADM, MDS, SSD, with police went to residents' room where there was liquid filled needle with methamphetamine also marijuana . A review of Resident 3's IDT-Meeting dated August 2, 2023, at 1:35 p.m., indicated .DON was notified that resident was distributing drugs throughout the faculty (sic) .DON asked resident if he had drugs he then started pulling things out of his drawer an (sic) it as Marijuana (sic) also Methamphetamine (sic) filled needles. DON asked who's (sic), box was at the top of the closet he stated not [NAME] (sic) inside the box there were several needles filled with liquid Methamphetamine resident verbalized I don't know were (sic) that came from resident appeared to be high not acting himself . A review of Resident 3's CPAC - Nursing - SBAR, (Situation, Background, Assessment, Recommendation), Communication Form and progress note dated August 3, 2023, at 3:19 p.m., indicated .Suspected drug use due to substance found in room .At approximately 1500, IDT team began to search res room, (sic) Upon search, IDT team found powdered substance, liquid filled needles, powder meth, and PCP. Illegal substances and drug paraphernalia was (sic) confiscated. MD made aware . A review of Resident 3's Drug Screen Panel, Urine collected August 3, 2023, at 6 p.m., was positive for Amphetamines, Opiates, and Cannabinoids. A review of Resident 3's Drug Screen Panel, Urine collected August 25, 2023, at 4:20 a.m., was positive for Amphetamines, Opiates, and Cannabinoids. A review of Resident 3's Progress Notes dated August 27, 2023, at 6:20 p.m., indicated Resident appeared to be under the influence, speech was garbled, pale in color, noted to be laying in the bed half on the ground, unresponsive to verbal stimuli or touch . A review of Resident 4's IDT Meeting dated August 11, 2023, at 4:06 p.m., indicated .DON was notified there was drugs being distributed from resident room. IDT entered resident's room after police was (sic) called. Resident was found to have marijuana, also white powdered substance in a plastic bag, as well as crack pipes and marijuana filled vapes (sic) resident was advised of the facility policy and that he was out of compliance (sic) resident also verbalized he would like to go to a lower level of care (sic) SSD assured him that he would be places (sic) as soon as possible. Resident is alert and able to make needs known . Resident 4 had no orders for a drug screen and no documentation of supervision. A review of Resident 5's IDT Meeting dated August 11, 2023, at 4:14 p.m., indicated . 8/11/23 .DON was notified there was suspicion of drugs in residents (sic) room. IDT met with residents room it was found that resident was in possession of a sock full (sic) methadone ready to be distributed, also marijuana, and crack pipe with substance inside also liquor .Resident verbalized that it was wrong and that he would not do it again . A review of Resident 8's IDT - Meeting dated August 4, 2023, at 3:10 p.m., indicated IDT met with resident in regard to closing her door. Notified (sic) resident the door is to remain open due to recent noted substance use/ (sic) and having illegal substances while staying at facility. Resident (sic) verbalized understanding . A review of Resident 8's Drug Screen - Urine collected on August 8, 2023, at 9 p.m., was positive for amphetamines. A review of Resident 9's SBAR Communication Form and progress note dated August 2, 2023, at 3 p.m., indicated .IDT team began to search res. Room. Upon search, IDT team found a powder substance and liquid filled needles. Illegal substances and drug paraphernalia was confiscated. MD made aware . A review of Resident 9's Progress Notes dated August 13, 2023, at 5:54 p.m., indicated Resident noted to be possibly under the influence of a substance. Resident speaking erratically, pupils dilated, stating my insides itch really bad, I need a Benadryl to make my insides stop itching . A review of Resident 9's Progress Notes dated August 28, 2023, at 5:45 p.m., indicated Approx 1725 while on med pass, CN (charge nurse) received a page from IP to station one. On getting there the CN noted res on EMT gurney .Res noted with deviation from baseline, disoriented, and appears to be possibly under the influence of unknown substance . A review of Resident 9's Progress Notes dated August 28, 2023, at 11:40 p.m., indicated .received by RN .via (name of hospital), .was seen for AMS, (altered mental status), urine drug screen performed-positive for amphetamines and opiates . Resident 1, Resident 2, Resident 4, Resident 5, Resident 8, and Resident 9 had no documentation of supervision. A review of the facility's policy and procedure titled Safety and Supervision of Residents dated January, 2018, indicated .Our facility-oriented approach to safety addresses risks for groups of residents .Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes .The Interdisciplinary care team shall analyze information obtained from assessments, and observations to identify any specific .risks for individual residents .The care team shall target interventions for individual residents related to hazards in the environment, including adequate supervision . A review of the facility's policy and procedure titled Resident Drug & Alcohol Abuse undated, indicated .To Provide a safe and drug-free environment for residents while at the facility . The Facility has a zero tolerance policy for the use or possession of Illegal drugs (Including marijuana) or any type of drug apparatus In the Facility or on the grounds of the Facility. All illegal drugs and/or drug paraphernalia will be confiscated from the resident and/or their room .The only drugs permissible at the Facility and/or on Facility grounds are those for which there is an Attending Physician order .The facility has a zero tolerance policy for the use of alcohol in the Facility or on the ground of the Facility without a physician order .Any resident found In violation of the policy will be discharged to a more appropriate setting for care . a. Social Services Staff or designee may provide residents with this policy in the following circumstances: If the resident has a history of substance abuse .if the resident is at risk for post-acute withdrawal symptoms .If the resident is at risk for behavior disturbance .If the resident has a Substance Abuse Care Plan .If the resident has brought Illegal drugs or alcohol Into the Facility .If IDT feels it is appropriate to provide the resident with the policy . After the Social Worker or designee provides the resident with the policy, the resident will be asked to sign this document - Resident Drug & Alcohol Abuse Policy Acknowledgement, stating that they are aware of the Facility's zero tolerance policy on the use or possession of illegal drugs and alcohol abuse . On August 30, 2023, at 5:45 p.m. an immediate jeopardy (IJ - a situation in which immediate corrective action is necessary because the provider's noncompliance with one or more requirements has caused, or is likely to cause, serious injury, harm, impairment, or death to an individual receiving care in a facility), situation was identified and called in the presence of the Administrator and the Director of Nursing (DON 2) due to the facility's failure to address the individualized needs related to the substance use behavior, (Continually using drugs or alcohol even though it is causing or adding to physical or psychological problems), of seven residents, Residents 1, 2, 3, 4, 5, 8, and 9 who had history of substance use prior to admission and had been suspected of illegal drug use while at the facility. In addition, the facility failed to increase monitoring and supervision of the seven residents suspected of illegal drug use as well as the 136 residents. These failures had the potential to cause serious harm such as accidental death to the seven residents and could seriously affect the health and safety of the facility's 136 vulnerable residents not involved in illegal drug use. On September 1, 2023, at 1:05 p.m., the facility submitted an acceptable removal plan which indicated: 1. Residents 1. 2. 3. 4.5 and 7, 8, 9 and who have been affected by this deficient practice will be closely supervised by nursing staff. 2. Effective August 30, 2023, and ongoing Resident #3 went on a 1:1 on August 31, 2023. Resident #1 went on a 1:1 on August 31, 2023. Each will have a 1:1 until appropriate discharge takes place. 3. Effective August 31, 2023, and ongoing: a. Nursing staff RN's and LVN's will closely monitor every shift for those identified residents 1. 2. 3. 4., and 7, 8, 9, for suspected illegal drug use and under the Influence of drugs. RN's and LVN's will closely monitor for any unusual behavior, activity, signs, and symptoms of withdrawal, change in level of consciousness, LOC increased lethargy, slurred speech, and confusion and aggressiveness displayed. b. Licensed staff will immediately Notify MD and facility Administrator along with Sheriff's department for any residents that are suspected of doing drugs or under the Influence of illegal drugs. c. Nursing staff assigned to carts 1.2.3.4.5 will monitor residents if they are closely in contact with the above residents to ensure those residents are safe and are not participating in the use of illegal drugs. For residents 1, 2, 3, 4, 5, 7, 8, and 9 monitoring will be documented in the systems MAR. Monitoring for the above signs and symptoms will start immediately. 4. On August 31, 2023, at 7:15 a.m. and 3:45 p.m., and September 1, 2023, Administrator in serviced current working staff in the building. The following departments attended; Dietary, Housekeeping, Nursing, Maintenance, Department Heads, and Receptionist. In service consisted of the following information: Resident Supervision and what the responsibilities are when working during their daily shifts. They are to be alert and observe and monitor [NAME] any suspicious activity of residents 1. 2. 3. 4.5 and 7 ,8, 9 closely. Focus on any suspected drug use or suspicion of being under the influence of illegal drugs and notify Nursing and Administrator Immediately. 5. Facility Pharmacist will be in today August 31, 2023, to sit down and review with each resident identified 1, 2, 3, 4, 5, 7, 8, and 9. Pharmacist will review all current medications with each resident and discuss the negative interactions of those prescribed medications when mixed with illegal drugs occur. Documentation is in IDT notes. 6. All residents 1, 2, 3, 4, 5, 7, 8, and 9 have be seen by psychiatric services and orders in place in each resident chart to help with behavior management during their stay in the facility to help with safe facility discharge. 7. OOP (out on pass) orders will be on hold Effective August 31, 2023, and ongoing. 8. SSD will work with MD to initiate immediate safe and appropriate discharge plans for residents 1, 2, 3, 4, 5, 7, 8, and 9, effective August 31, 2023. 9. Visitors of the above residents will be closely supervised by shift RN and 1:1 throughout the evenings. Resident families will be asked to enter into a behavior agreement prior to visiting to help with above listed residents 1, 2, 3, 4, 5, 7, 8, and 9 behaviors. Resident visitors will be notified prior to visiting and subject to searches before any visits take place. Effective August 31, 2023, and ongoing. 10. Residents above that are involved in Illegal activity will be searched if they go out of the facility. Once they return. If any above stated resident refuses search, staff will immediately notify local [NAME] department for further assistance Effective August 31, 2023, and ongoing. 11. Residents MD will be informed of all incidents related to illegal drugs purchase/sale and resident suspected under the influence of illegal drugs. Effective August 31, 2023, and ongoing. 12. SSD will reach out to outside resources such as AA, Counseling and behavior health and have residents attend If accepted. Effective September 1, 2023, and ongoing. 13. RN will be responsible for rounding inside and outside of facility until Security guard is in place. Effective August 31, 2023, and ongoing. 14. Security guards will be employed by September 5, 2023, and in place from the hours of 5 p.m. to 5 a.m. Those security guards will be responsible for the exterior and interior visual inspections of the facility. Monitoring windows, doors, and visitors, and people coming onto the property. Contract secured effective August 31, 2023, security to start Effective September 5, 2023, and ongoing. 15. All admissions will be closely screened for appropriateness, Effective August 31, 2023, and ongoing. 16. CDPH will be notified of all incidents related to this deficient practice. Effective August 31, 2023, and ongoing. 17. Facility DON will conduct frequent rounding daily to Increase the monitoring of resident's safety Effective August 31, 2023, and ongoing. 18. Administrator will conduct frequent daily rounding to ensure resident safety. Effective August 31, 2023, and ongoing. 19. The administrator will meet with the security guard once employed, to review and discuss nightly reports. Effective September 1, 2023, and ongoing. 20. Administrator will ensure facility compliance and the monitoring of residents 1, 2, 3, 4, 5, 7, 8, and 9. Effective August 31, 2023, and ongoing. On September 1, 2023, at 1:14 p.m., a visit to the facility was conducted to ensure the corrective action plan was put into place. On September 1, 2023, at 5:30 p.m., the ADMIN, DON 2, and consultant were informed that the immediate jeopardy, (IJ), had been lifted after supervisor approval.

Based on observation, interview, and record review, the facility failed to implement infection control practice in preventing the transmission of COVID-19 ([MEDICAL CONDITION]- an illness caused by [MEDICAL CONDITION] that can be transmitted from person to person) infection when the facility staff required to wear a tight-fitting N95 respirator mask, were not fit-tested ( tests the seal between the respirator's facepiece and your face) in accordance to the Division of Occupational Safety and Health (CAL/OSHA- enforcing laws and regulations pertaining to workplace safety and health)requirements. This failure had the potential to result in serious harm due to an increase in COVID-19 transmission risk to staff and the vulnerable residents, which could lead to [MEDICAL CONDITION] and death. Findings: On December 30, 2020, at 9:45 a.m., upon entering the facility lobby, the staff inside the facility were observed wearing N95 respirator masks and face shields. On December 30, 2020, at 10:00 a.m., the Infection Preventionist (IP) and Administrator were interviewed. They stated all staff were required to wear N95 respirators and face shields when providing cares to residents because the facility had residents and staff who had tested positive for the COVID-19 infection, and residents with unknown and/or suspected COVID-19 status. A review of the untitled document provided by the facility dated December 30, 2020, indicated the facility had 17 staff members and 23 residents who tested positive for the COVID-19 infection and 126 residents with unknown and/or suspected COVID-19 status. The facility had a total of 149 residents. On December 30, 2020, at 10:55 a.m., Certified Nurse Assistant (CNA) 1 was observed in a resident's room providing care in the yellow zone (unit dedicated for the residents of unknown and/or suspected COVID-19 status due to exposure to a positive confirmed COVID-19 infected person) and was wearing an N95 respirator mask and face shield. In a concurrent interview, she stated she was not fit tested on the N95 that she used. On December 30, 2020, the following additional staff members were interviewed. These staff members wore N95 respirator masks and were assigned to provide direct care to the residents in the COVID-19 positive zone and yellow zone: - At 11:30 a.m., CNA 2 stated she was not fit tested on the N95 she used; - At 12:00 p.m., CNA 3 stated was not fit tested on the N95 she used; - At 12:15 p.m., CNA 4 stated he was not fit tested on the N95 he used; - At 12:50 p.m., Licensed Vocational Nurse (LVN) 1 stated she was not fit tested on the N95 she used; - At 1:05 p.m., LVN 2 stated she was not fit tested on the N95 she used; and - At 1:30 p.m., LVN 3 stated she was not fit tested on the N95 she used. On December 30, 2020, at 3:30 p.m., an interview was conducted with the IP. The IP stated the facility did not conduct an N95 fit testing on staff . The IP further stated the staff only did a seal check test ( action conducted by the respirator user to determine if the respirator is properly seated to the face) on the N95 respirator mask they used. In a concurrent interview, the Administrator stated the Medical Health Operational Area Coordinator (MHOAC) came to the facility on [DATE]. The MHOACH provided N95 Fit testing training on four designated staff members (the IP, Director of Staff Developer (DSD), DSD Assistant and Case Manager). The Administrator stated there were four staff members (DSD, IP, DSD Assistant, and Case Manager) trained by MHOACH on December 28, 2020 to conduct fit testing of respirators for the staff. However, the N95 fit testing for the staff had not started. On December 30, 2020, at 5:06 p.m., a follow-up interview was conducted with the Administrator. He stated the facility had the N95 fit test apparatus (equipment including a head gear and testing solution needed in order for the facility to be able to conduct the fit testing for staff) available since December 28, 2020. On December 30, 2020, at 5:40 p.m., an interview was conducted with the IP. She stated she was trained to conduct the N95 fit test to other staff members. She stated she was aware the N95 fit test apparatus was available but she did not conduct the fit testing on the other staff members after her training with MHOAC on December 28, 2020. On December 30, 2020, at 6:40 p.m., an interview with the Administrator was conducted. He stated he was not aware of the CAL/OSHA requirements to conduct the N95 fit testing before staff could work in a Covid-19 positive zone or yellow zone. He stated there were four designated staff members trained to conduct the N95 fit testing on December 28, 2020. However, the trained staff members did not start the N95 fit-testing due to the staff's busy assignments. A review of CDC (Center for Disease Control) guideline titled, Proper N95 Respirator Use for Respiratory Protection Preparedness, dated March 16, 2020, indicated, .The respirator must fit the user's face snugly (i.e., create a seal) to minimize the number of particles that bypass the filter through gaps between the user's skin and the respirator seal .OSHA requires healthcare workers who are expected to perform patient activities with those suspected or confirmed to be infected with COVID-19 to wear respiratory protection, such as an N95 respirator .staff that are required to use respiratory protection must undergo fit testing, medical clearance, and training . A review of CAL/OSHA requirement titled, Cal/OSHA Interim Guidance on COVID-19 for Health Care Facilities: Severe Respirator Supply Shortage, dated August 6, 2020, indicated, .Use Fit Testing Methods that Maximize Respirator Supplies and Fit Testing Efficiency. Initial respirator fit testing is required before an employee uses a respirator, or when an employee changes to a different model, make, or size of respirator. There are no changes to these requirements. Annual respirator fit testing is also required. To reduce usage of respirator and prioritize fit testing equipment and supplies for fit testing of new models, Cal/OSHA will allow a 90-day delay for meeting annual fit testing requirements provided there are no changes on employee's physical condition that could affect respirator fit. Such conditions include, but not limited to, facial scarring, dental changes, cosmetic surgery, or an obvious change in body weight .

Based on observation, interview, and record review, the facility failed, for eight of 40 residents (Residents 77, 89, 4, 129, 277, 155, 172, and 154), to ensure pharmacy services were provided in a timely manner when: 1. For Resident 77, the new physician's orders [REDACTED]. 2. For Resident 89, the intravenous (IV - into the veins) antibiotic ([MEDICATION NAME]) to treat the resident's urinary tract infection [MEDICAL CONDITION] was not readily available to administer; 3. For Resident 4, the IV antibiotic ([MEDICATION NAME]) to treat the resident's UTI was not readily available to administer; 4. For Resident 129, the routine medication - [MEDICATION NAME] (narcotic pain medication) was not readily available to administer for multiple scheduled doses; 5. For Resident 277, the routine medication - [MEDICATION NAME] (a narcotic pain medication used for migraine - intense headache and sensitivity to light) was not readily available to administer for multiple scheduled doses; 6. For Resident 155, the new physician's orders [REDACTED]. 7. For Resident 172, the routine medication - [MEDICATION NAME] (medication for anxiety) was not readily available to administer for multiple scheduled doses; and 8. For Resident 154, the routine medications - [MEDICATION NAME] (medication for [MEDICAL CONDITION] - pain from nerve damage) and [MEDICATION NAME] (medication for high cholesterol level) were not readily available to administer for multiple scheduled doses. These failures resulted in these residents not receiving medications as ordered by the physician to manage and treat medical conditions, and overall long-term health and well-being of the residents. On (MONTH) 12, 2019 at 2:37 p.m., the facility's Administrator and Director of Nursing (DON) 1 were verbally notified of the system failure which resulted in Immediate Jeopardy (IJ). This system failure resulted in a delay in receiving necessary medications to managed pain, to treat infections and to treat other medical conditions of the residents. The IJ was removed on (MONTH) 15, 2019 at 5:01 p.m., in the presence of the facility Administrator, after the facility's acceptable plan of action was reviewed and it was verified that the plan of action was implemented. Findings: 1. On (MONTH) 3, 2019, at 11:49 a.m., Resident 77 was observed sitting in her wheelchair, with facial grimacing, was moaning and massaging her left hand. Resident 77 stated her left hand was hurting. Resident 77 showed her left hand, and the area around the left thumb was swollen. Resident 77 stated it had been swollen and hurting for a week now. Resident 77 further stated she was in a lot of pain last night, she cried and she was not able to sleep because of too much pain. Resident 77 stated her nurse did not give her anything for pain last night and told her she was waiting for the pharmacy to deliver the pain medication ordered by the physician. On (MONTH) 5, 2019, at 11:06 a.m., a concurrent record review and interview was conducted with Licensed Vocational Nurse (LVN) 2. Resident 77 was admitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. Resident 77's physician's orders [REDACTED]. Resident 77's electronic Medication Record Administration (eMAR) for (MONTH) 2019, indicated the medication [MEDICATION NAME] was not administered on (MONTH) 2, 2019, at 5 p.m., and indicated 9 (facility chart codes 9 = other/see progress notes) as the reason. Resident 77's progress notes dated (MONTH) 2, 2019, at 7:31 p.m., indicated awaiting delivery for the medication [MEDICATION NAME]. LVN 2 stated she called the physician on (MONTH) 2, 2019, at 9 a.m. because Resident 77's left hand was still swollen and the resident still complained of pain. LVN 2 stated she received an order from the physician for Resident 77 to be started on [MEDICATION NAME]. LVN 2 stated the physician's orders [REDACTED]. LVN 2 stated the medication should have been delivered in the afternoon by the pharmacy since it was ordered on the morning of (MONTH) 2, 2019. LVN 2 stated she did not call the pharmacy to inquire for the time of delivery of the medication [MEDICATION NAME]. LVN 2 further stated the nurse from the evening shift should have called the pharmacy for follow up. On (MONTH) 5, 2019, at 2:22 p.m., Director of Nursing (DON) 2 was interviewed. DON 2 stated the pharmacy delivery of medication was daily, three times a day. DON 2 stated, for new medication orders especially for pain, the nurse should have called the pharmacy to inquire for the time of delivery, to ensure the medication would be available for administration. On (MONTH) 11, 2019, at 8:45 a.m., the pharmacy owner (PO) was interviewed. The PO stated for new physician's orders [REDACTED]. The PO stated if the medication was available in the automated drug dispensing system (ADDS - computer controlled storage, dispensing and tracking of medications), the licensed nurse could use the medication from it while waiting for pharmacy delivery. The PO verified the physician's orders [REDACTED]. The PO stated the [MEDICATION NAME] should have been delivered on (MONTH) 2, 2019, at 12 noon. The PO further stated he did not know why it was not delivered as scheduled. 2. On (MONTH) 5, 2019, at 2:46 p.m., Resident 89's record review was conducted with Director of Nursing (DON) 2. Resident 89 was readmitted to the facility on (MONTH) 28, 2019, with [DIAGNOSES REDACTED]. Resident 89's physician's orders [REDACTED]. Resident 89's electronic Medication Administration Record [REDACTED] On (MONTH) 11, 2019, at 8:45 a.m., the pharmacy owner (PO) was interviewed. The PO stated for new physician's orders [REDACTED]. The PO stated if the medication was available in the automated drug dispensing system (ADDS - computer controlled storage, dispensing and tracking of medications), the licensed nurse could use the medication from it while waiting for pharmacy delivery. The PO verified the IV antibiotic [MEDICATION NAME] was available from the ADDS. The PO verified Resident 89's physician's orders [REDACTED]. The PO verified the IV antibiotic [MEDICATION NAME] for Resident 89 was not available for administration except from the stock in the ADDS. The PO stated there was no record the IV antibiotic [MEDICATION NAME] was pulled in the ADDS for Resident 89 on (MONTH) 28, 2019. On (MONTH) 7, 2019, at 4:22 p.m., Registered Nurse (RN) 1 was interviewed. RN 1 verified she was the RN assigned to give IV antibiotics on (MONTH) 28, 2019, evening shift (3 p.m. to 11:30 p.m.) RN 1 verified Resident 89's eMAR for the month of (MONTH) 2019, did not have her signature on IV antibiotic [MEDICATION NAME] to indicate it was administered to the resident on (MONTH) 28, 2019, at 10 p.m. RN 1 verified there was no documented evidence the IV antibiotic [MEDICATION NAME] was given to Resident 89 on (MONTH) 28, 2019, at 10 p.m. as ordered. RN 1 stated she forgot to sign the eMAR but she administered the IV antibiotic [MEDICATION NAME] to Resident 89. RN 1 stated the IV antibiotic [MEDICATION NAME] she administered to the resident was from the discontinued medications stored in the medication room. RN 1 stated when an order of IV antibiotic for a resident was not available, the RNs in the facility would use, if it was available, discontinued IV antibiotic medications stored in the medication room. RN 1 stated she was aware when a medication was not available, the licensed nurse should call the pharmacy to inquire for the availability of the medication or the licensed nurse should get a dose from the ADDS when the medication was in stock and available for administration. RN 1 stated she did not call the pharmacy nor took a dose from the ADDS when Resident 89's IV antibiotic [MEDICATION NAME] was not available. RN 1 stated she used the IV [MEDICATION NAME] from discontinued medication and administered to Resident 89 on (MONTH) 28, 2019, at 10 p.m. 3. On (MONTH) 5, 2019, at 2:46 p.m., Resident 4's record review was conducted with Director of Nursing (DON) 2. Resident 4 was readmitted to the facility on (MONTH) 28, 2019, with [DIAGNOSES REDACTED]. Resident 4's physician's orders [REDACTED]. Resident 4's electronic Medication Administration Record [REDACTED] Resident 4's (eMAR) for the month of (MONTH) 2019, indicated the IV antibiotic [MEDICATION NAME] did not have a signature to indicate it was administered to the resident on (MONTH) 1, 2019, at 6 a.m. and 2 p.m. On (MONTH) 11, 2019, at 8:45 a.m., the pharmacy owner (PO) was interviewed. The PO verified Resident 89's IV antibiotic [MEDICATION NAME] 750 mg was delivered on (MONTH) 29, 2019, for five doses and on (MONTH) 2, 2019, for 10 doses. The PO stated there would be no IV antibiotic [MEDICATION NAME] 750 mg available after the 5 doses were used by (MONTH) 31, 2019, and before the 10 doses were delivered on (MONTH) 2, 2019, unless it was pulled out from the automated drug dispensing system (ADDS - computer controlled storage, dispensing and tracking of medications). The PO verified there was no record the IV antibiotic [MEDICATION NAME] was taken from the ADDS for Resident 4 on (MONTH) 30 and 31, 2019 and (MONTH) 1, 2019. On (MONTH) 12, 2019, at 8:40 a.m., a concurrent record review and interview was conducted with RN 2. RN 2 verified he was the RN assigned to give IV antibiotics on (MONTH) 30, 2019 and (MONTH) 1, 2019, night shift (11 p.m. to 7:30 a.m.). RN 2 verified he did not sign Resident 4's eMAR on (MONTH) 30, 2019, at 6 a.m., and (MONTH) 1, 2019, at 6 a.m. to indicate the IV antibiotic [MEDICATION NAME] was administered to the resident. RN 2 verified there was no documented evidence the IV antibiotic [MEDICATION NAME] 750 mg was given on those dates as ordered. RN 2 verified Resident 4's eMAR for (MONTH) 2019, indicated the IV antibiotic [MEDICATION NAME] 750 mg were signed to indicate it was administered to Resident 4 on (MONTH) 30, 2019, at 2 p.m. (as the first dose) through (MONTH) 31, 2019, at 10 p.m. (as the last dose from the five doses delivered by the pharmacy on (MONTH) 29, 2019). RN 2 stated he gave the IV antibiotic [MEDICATION NAME] 750 mg to Resident 4 on (MONTH) 30, 2019, at 6 a.m., and (MONTH) 1, 2019, at 6 a.m. RN 2 further stated he forgot to sign the eMAR to indicate it was administered to the resident. RN 2 stated he could not remember where he got the IV antibiotic [MEDICATION NAME] 750 mg on those dates. RN 2 stated he may have used the medication from the discontinued medications stored in the medication room or he may have borrowed from another resident that was on IV antibiotic [MEDICATION NAME]. However, he was unable to provide documented evidence of either. On (MONTH) 12, 2019, at 8:56 a.m., a concurrent record review and interview was conducted with RN 3. RN 3 verified she was the RN assigned to give IV antibiotics on (MONTH) 1, 2019, day shift (7 a.m. to 3:30 p.m.). RN 3 verified she did not sign Resident 4's eMAR on (MONTH) 1, 2019, at 2 p.m., to indicate the IV antibiotic [MEDICATION NAME] 750 mg was administered to Resident 4. RN 3 verified there was no documented evidence the IV antibiotic [MEDICATION NAME] 750 mg was given on (MONTH) 1, 2019, at 2 p.m. as ordered. RN 3 stated if she did not sign the eMAR it meant the medication was not available. RN 3 stated she should have called the pharmacy or checked the ADDS for the availability of the IV antibiotic [MEDICATION NAME] but she did not do it. 4. On (MONTH) 7, 2019, Resident 129's record was reviewed. Resident 129 was admitted to the facility on (MONTH) 20, 2014, with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The (MONTH) 2019 electronic Medication Administration Record [REDACTED].m, 6 a.m., 12 p.m., and 6 a.m. In addition, the eMAR indicated Resident 129 did not receive the [MEDICATION NAME] tablet for pain on the following dates: - (MONTH) 16, 2019, at 6 p.m.; - (MONTH) 17, 2019, at 12 a.m.; and - (MONTH) 21, 2019, at 12 a.m. and 6 a.m. The corresponding Medication Administration Notes for the dates Resident 129 did not receive her routine [MEDICATION NAME] medication for pain, indicated the licensed nurses were not able to give the medication because it was not available pending pharmacy delivery. On (MONTH) 7, 2019, at 10:26 a.m., Licensed Vocational Nurse (LVN) 3 was interviewed. LVN 3 stated he was not able to administer the [MEDICATION NAME] medication to Resident 129 on (MONTH) 21, 2019, at 12 a.m. and 6 a.m., because the medication was not available. LVN 3 further stated there was a delay in the delivery of the medication from the pharmacy. LVN 3 stated the late delivery of medications had been an ongoing problem. LVN 3 stated he had called the pharmacy frequently to remind them of his refill orders request and to deliver the medication on time. LVN 3 stated the usual cause of the late delivery of the medication from the pharmacy was the pharmacy had to wait for a physician's authorization for a refill of the medication. On (MONTH) 7, 2019, at 10:33 a.m., an observation with a concurrent interview was conducted on Resident 129. Resident 129 was alert and was up in her wheelchair inside her room. Resident 129 stated she took the routine [MEDICATION NAME] medication to help manage her chronic pai[DIAGNOSES REDACTED]. Resident 129 stated she remembered missing a couple of doses of her [MEDICATION NAME] medication in (MONTH) 2019. Resident 129 further stated the licensed nurses just kept telling her to wait at that time because it was going to be delivered soon. Resident 129 stated she waited but her [MEDICATION NAME] was not delivered on time. Resident 129 stated she felt her body tense up with pain when she did not get her [MEDICATION NAME] pain medication as scheduled. Resident 129 stated this was not the first time she had missed her medications because it was not available. Resident 129 stated, I really did not appreciate that. 5. On (MONTH) 7, 2019, at 9:30 a.m., Resident 277's record was reviewed. Resident 277 was admitted to the facility on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The (MONTH) 2019 electronic Medication Administration Record [REDACTED]. In aadition, the eMAR indicated Resident 277 did not receive the medication [MEDICATION NAME] on the following dates: - (MONTH) 5, 2019 at 6 a.m., 2 p.m., and 10 p.m.; - (MONTH) 6, 2019, at 6 a.m. and 10 p.m.; - (MONTH) 7, 2019, at 6 a.m. and 10 p.m.; and - (MONTH) 10, 2019, at 6 a.m., 2 p.m., and 10 p.m. The corresponding Medication Administration Notes for the dates Resident 277 did not receive her routine [MEDICATION NAME] for migraine, indicated the licensed nurses were not able to give the medication because it was not available pending pharmacy delivery. On (MONTH) 7, 2019, at 10:44 a.m., an observation with a concurrent interview was conducted on Resident 277. Resident 277 was in bed, alert, and conversant. Resident 277 stated the doctor prescribed the [MEDICATION NAME] specifically to treat her bad migraine problem. Resident 277 stated she remembered missing doses of her medication in (MONTH) 2019 because it was not available. She stated this was not the first time she had missed doses of her medications because of medication unavailability due to the delayed delivery from the pharmacy. Resident 277 stated the facility was aware of the issues with the late delivery of her medications because she had complained about it all the time. She stated she had been monitoring her medication supply because the licensed nurses let her medication run out before they called the pharmacy for a refill. On (MONTH) 7, 2019, at 11:04 a.m., Licensed Vocational Nurse (LVN) 4 was interviewed. LVN 4 stated she was not able to administer Resident 277's [MEDICATION NAME] on (MONTH) 5, 2019 at 2 p.m. and (MONTH) 10, 2019, at 2 p.m. LVN 4 further stated the [MEDICATION NAME] was not administered because it was not available pending pharmacy delivery. LVN 4 stated there had been issues with the pharmacy regarding the delayed delivery of medications, which resulted in the residents not getting their medications on time as ordered by the physician. LVN 4 stated the pharmacy usually delivered a certain amount of medications good for at least three days only and the licensed nurses had to request for a refill order again. LVN 4 stated she had asked the pharmacy why they only delivered a certain amount of medication that would only last a couple of days and she was told, That's all they had. On (MONTH) 11, 2019, at 8:20 a.m., the Pharmacy Owner (PO) was interviewed. The PO stated he was not aware of the issues regarding the residents not receiving their medications on time due to medication unavailability as a result of delayed delivery of medications from the pharmacy. The PO further stated he was not informed the pharmacy had been having issues with the delay to get a physician's authorization to refill narcotic medications. The PO stated non-narcotic medication should have been delivered within four hours. The PO stated the licensed nurses should have requested refill orders for narcotic medications that needed physician auhtorization for refills, three to five days before they ran out of the medication. 6. On (MONTH) 3, 2019, at 9:45 a.m., Resident 155 was observed lying in bed, alert, and responsive. Resident 155 complained of back pain due to his broken bed. At 12:22 p.m., he was observed sitting in the wheel chair in the back dining room waiting for his lunch. Resident 155 complained of intolerable pain. Resident 155 requested to be put back to his bed. At 12:47 p.m., Resident was observed in the room sitting on the wheelchair. Resident stated he still had pain in his lower back since last night, due to his bed being broken. Resident 155 stated the nurse, told me I need to wait until tomorrow to fix my bed. When I turn it feels like the pain is stabbing me. On (MONTH) 4, 2019, at 9:19 a.m., Resident 155 was observed lying in bed. Resident 155 had facial grimacing. and stated he had pain in his upper and lower back radiating to his hip. On (MONTH) 4, 2019, at 9:47 a.m., an interview was conducted with the Licensed Vocational Nurse (LVN) 5. LVN 5 stated the [MEDICATION NAME] was ordered on (MONTH) 3, 2019, at 2 p.m. LVN 5 stated the new order for [MEDICATION NAME] needed a physician's signature before the pharmacy could deliver the [MEDICATION NAME]. LVN 5 stated [MEDICATION NAME] was available in the automated drug dispensing system (ADDS - computer controlled storage, dispensing and tracking of medications), but required an access code to open the ADDS. LVN 5 further stated the pharmacist refused to give the access code until the physician's signature was obtained. On (MONTH) 4, 2019, Resident 155's records were reviewed. Resident 155 was admitted to the facility on (MONTH) 3, (YEAR). The History and Physical dated (MONTH) 12, (YEAR), indicated, that Resident 155, can make needs known but can not make medical decisions. Resident 155's physician's orders [REDACTED].[MEDICATION NAME] (HCL) tablet 50 milligram (MG) by mouth every six hours for pain management . Resident 155's electronic Medication Administration Record [REDACTED] On (MONTH) 4, 2019, at 12:45 p.m., a follow up interview and record review was conducted with LVN 5. LVN 5 stated Resident 155 was scheduled to receive the [MEDICATION NAME] every six hours routinely for pain management, to start on (MONTH) 3, 2019, at 6 p.m, but the medication was not available. LVN 5 further stated the [MEDICATION NAME] was not available because the pharmacy was waiting for the physician's signature prior to delivery of the medication On (MONTH) 7, 2019, at 11:30 a.m., an interview was conducted with the Pharmacy Owner (PO). The PO stated he was not aware of the late delivery of the medication to the facility. PO stated until the physician signed the medication order, pharmacy would not give the code of the ADDS to the licensed nurse. The PO stated the access code for the ADDS will be given to the licensed nurse when the physician sign the new medication order. The PO stated the Pharmacist should have called the physician to follow up for the physician's signature. The PO further stated if there was no response from the physician, the pharmacist should have called the facility for assistance. On (MONTH) 7, 2019, at 3 p.m., an interview was conducted with Director of Nursing (DON) 2. DON 2 stated Resident 155's pain medication should have been given in a timely manner as ordered by the physician. The undated facility's policy and procedure titled, MEDICATION ORDERING AND RECEIVING FROM PHARMACY, indicated, .New medications .If needed before the next regular delivery, phone the medication order to the pharmacy immediately upon receipt. Inform the pharmacy of the need for prompt delivery and request delivery within (4) hours .Timely delivery of new orders is required so that medication administration is not delayed . 7. On (MONTH) 7, 2019, Resident 172's record was reviewed. Resident 172 was readmitted to the facility on (MONTH) 2, (YEAR), with a [DIAGNOSES REDACTED]. Resident 172's physician order [REDACTED].[MEDICATION NAME] tablet 0.5 milligram (mg) via gastrostomy tube (GT- incision in the abdominal wall used to administer medication and nutrition) every six hours for anxiety . The (MONTH) 2019 electronic Medication Administration Record [REDACTED].m, 6 a.m., 12 p.m., and 6 p.m. In addition the eMAR indicated Resident 172 did not receive the [MEDICATION NAME] tablet for anxiety on the following dates: - (MONTH) 11, 2019, at 6 p.m.; - (MONTH) 12, 2019, at 12 a.m, 6 a.m., 12 p.m., and 6 p.m; - (MONTH) 13, 2019, at 12 a.m, 6 a.m., 12 p.m., and 6 p.m; - (MONTH) 14, 2019, at 12 a.m, 6 a.m., 12 p.m., and 6 p.m; - (MONTH) 15, 2019, at 12 a.m, 6 a.m., 12 p.m., and 6 p.m; - (MONTH) 16, 2019, at 12 a.m, 6 a.m., 12 p.m., and 6 p.m; - (MONTH) 17, 2019, at 12 a.m, 6 a.m., 12 p.m., and 6 p.m; - (MONTH) 18, 2019, at 12 a.m, and 6 a.m., - (MONTH) 19, 2019, at 12 a.m, 6 a.m., 12 p.m., and 6 p.m; - (MONTH) 20, 2019, at 12 a.m, 6 a.m., 12 p.m., and 6 p.m; - (MONTH) 21, 2019, at 12 a.m, 6 a.m., 12 p.m., and 6 p.m; and - (MONTH) 22, 2019, at 12 a.m, 6 a.m., 12 p.m., and 6 p.m; Resident 172's electronic Medication Administration Record [REDACTED]. On (MONTH) 7, 2019, at 10:46 a.m., Director of Nursing (DON) 2 was interviewed. DON 2 confirmed and acknowledged Resident 172 missed 43 doses of [MEDICATION NAME]. DIN 2 stated the [MEDICATION NAME] was not available because the pharmacy was waiting for the physician's authorization. DON 2 stated the Licensed Nurses (LN) did not follow up with the pharmacy for the status of the refill order request of [MEDICATION NAME]. DON 2 further stated the LN should have communicated with the pharmacy for the status of the request. DON 2 stated the LN should have notified the physician when the [MEDICATION NAME] was not available. On (MONTH) 7, 2019, at 11:30 a.m., an interview was conducted with the Pharmacy Owner (PO). The PO stated he was not aware of the late delivery of the medication to the facility. The PO stated non-narcotic medication should have been delivered within four hours. The PO stated the licensed nurses should have requested for refill orders, of narcotic medications that needed physician's authorization, three to five days before they ran out of the medication. 8a. On (MONTH) 5, 2019, Resident 154's record was reviewed. Resident 154 was admitted to the facility on (MONTH) 17, (YEAR), with [DIAGNOSES REDACTED]. Resident 154's electronic Medication Administration Record [REDACTED]. The physician's orders [REDACTED]. In addition the eMAR indicated the medication [MEDICATION NAME] was not administered to the resident on (MONTH) 6, 8, 12, 13, 18, 19 and 23, 2019 at 8 p.m. The corresponding progress notes by the licensed nurses on those dates, indicated the medication was not administered to Resident 154 due to not being available per pharmacy. On (MONTH) 11, 2019, at 8:21 a.m., the Pharmacy Owner (PO) was interviewed. The PO confirmed there was a request for the medication [MEDICATION NAME] refill received on (MONTH) 6, 2019 and it was delivered on (MONTH) 9, 2019, for 14 tablets. The PO stated the [MEDICATION NAME] should be available for administration after it was delivered on (MONTH) 9, 2019. 8b. On (MONTH) 5, 2019, Resident 154's electronic Medication Administration Record [REDACTED]. The physician's orders [REDACTED]. In addition, the eMAR indicated the medication [MEDICATION NAME] was not administered to Resident 154 on (MONTH) 18, 2019, at 5 p.m. The correspondending progress notes by the licensed nurse indicated the medication was not administered to Resident 154 due to not being available per pharmacy. On (MONTH) 11, 2019, at 8:21 a.m., the Pharmacy Owner (PO) was interviewed. The PO confirmed there was a delivery of medication Neurointin on (MONTH) 14, 2019, for 14 tablets. The PO stated [MEDICATION NAME] should be available for administration after it was delivered on (MONTH) 14, 2019. On (MONTH) 11, 2019, at 11:44 a.m., Director of Nursing (DON) 1 was interviewed. DON 1 stated licensed nurses should inform the charge nurse when medications were not available, they should call the pharmacy and notify the physician for missed medication doses. She further stated the residents were not getting their medications as ordered. The physician's orders [REDACTED]. The undated facility policy titled , Medication Ordering and Receiving from Pharmacy was reviewed. The policy indicated, .Medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt . if not automatically refilled by the pharmacy, repeat medications (refills) are .ordered as follows . Reorder medication (three to four) days in advance of need to assure an adequate supply is on hand. When reordering medication that requires special processing (such as Schedule II controlled substances .) .New medications, except for emergency or stat (need to give immediately) medications, are ordered as follows . If needed before the next regular delivery, phone the medication order to the pharmacy immediately upon receipt. Inform pharmacy of the need for prompt delivery and request delivery within (4) hours . Timely delivery of new orders is required so that medication administration is not delayed . The emergency kit is used when the resident needs a medication prior to pharmacy delivery .

Based on observation, interview, and record review, the facility failed to ensure eight of 40 residents reviewed (Residents 77, 89, 4, 129, 277, 155, 172, and 154) were free of significant medication error when: 1. Resident 77 did not receive her first dose of [MEDICATION NAME] (medication for pain) as ordered by the physician. This failure resulted in the resident experiencing increased pain. 2. Resident 89, did not receive her intravenous (IV - into the veins) antibiotics ([MEDICATION NAME] and Fluconazole) on multiple occasions for treatment of [REDACTED]. In addition, Resident 89 may have received discontinued IV antibiotic medication. This failure could jeopardize the resident's health and safety for not treating the UTI appropriately that could result into complications such as kidney damage. In addition, the resident could have received expired or inaccurate medication dosages from the possible use of discontinued medications. 3. Resident 4, did not receive his IV antibiotics ([MEDICATION NAME] and [MEDICATION NAME]) on multiple occasions for treatment of [REDACTED]. In addition, Resident 4 may have received discontinued IV antibiotic medication. This failure could jeopardize the resident's health and safety for not treating the UTI appropriately that could result into complications such as kidney damage. In addition, the resident could have received expired or inaccurate medication dosages from the possible use of discontinued medications. 4. Resident 129 did not receive her routine medication [MEDICATION NAME] (narcotic pain medication) on multiple occasions for the month of (MONTH) 2019. This failure resulted in the resident to experience increased pain. 5. Resident 277 did not receive her routine medication [MEDICATION NAME] (a narcotic pain medication used for migraine - intense headache and sensitivity to light) on multiple occasions for the month of (MONTH) 2019. This failure resulted in the potential for the resident to experience excessive migraine headaches. 6. Resident 155 did not receive three doses of the new physician's orders [REDACTED]. This failure resulted in the resident to experiencing increased pain. 7. Resident 172 did not receive her routine medication [MEDICATION NAME] (medication for anxiety) from (MONTH) 11 to 22, 2019. This failure put the resident at risk to experience increased anxiety. 8. Resident 172 did not receive her IV antibiotic [MEDICATION NAME] on (MONTH) 11, 2019, at 9 a.m., for treatment of [REDACTED]. This failure could jeopardize the resident's health and safety for not treating the pneumonia that could result into complications such as [MEDICAL CONDITION] and death. 9. Resident 154 did not receive his routine medication [MEDICATION NAME] (for treatment of [REDACTED].{[MEDICAL CONDITION] - lung disease that block the airflow and make it difficult to breathe}) on multiple occasions at night when the resident was asleep from (MONTH) (YEAR) to (MONTH) 2019. This failure could jeopardize the resident's health and safety for not managing and treating the [MEDICAL CONDITION] that could result into complications such as [MEDICAL CONDITION] and death. 10. Resident 154 did not receive his routine medications ([MEDICATION NAME] - medication for [MEDICAL CONDITION] {pain from nerve damage}; [MEDICATION NAME] - medication for high cholesterol level; [MEDICATION NAME] - treatment for [REDACTED]. This failure could jeopardize the resident's health and safety for not managing and treating the medical conditions, overall long-term health and well-being of the resident. On (MONTH) 12, 2019 at 2:37 p.m., the facility's Administrator and Director of Nursing (DON) 1 were verbally notified of the system failure which resulted in an Immediate Jeopardy (IJ). This system failure resulted in a delay in receiving necessary medications to manage pain, to treat infections and to treat other medical conditions of the residents. The IJ was removed on (MONTH) 15, 2019 at 5:01 p.m., in the presence of the facility Administrator, after the facility's acceptable plan of action was reviewed and it was verified that the plan of action was implemented. Findings: 1. On (MONTH) 3, 2019, at 11:49 a.m., Resident 77 was observed sitting in her wheelchair, with facial grimacing, was moaning and massaging her left hand. Resident 77 stated her left hand was hurting. Resident 77 showed her left hand, and the area on the left thumb was swollen. Resident 77 stated it had been swollen and hurting for a week now. Resident 77 stated she was in a lot of pain last night, she cried and could not sleep because of too much pain. She further stated her nurse did not give her anything for pain last night and told her she was waiting for the pharmacy to deliver the pain medication ordered by the physician. On (MONTH) 5, 2019, at 11:06 a.m., a concurrent record review and interview was conducted with Licensed Vocational Nurse (LVN) 2. Resident 77 was admitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. Resident 77's physician's orders [REDACTED]. A physician's orders [REDACTED]. Resident 77's electronic Medication Record Administration (eMAR) for (MONTH) 2019, indicated the medication [MEDICATION NAME] was not administered on (MONTH) 2, 2019, at 5 p.m., and indicated 9 (facility chart codes 9 = other/see progress notes) as a reason. In addition, the eMAR did not indicate Resident 77 was offered non-pharmacological interventions nor was given the Tylenol for pain on (MONTH) 2, 2019. Resident 77's progress notes dated (MONTH) 2, 2019, at 7:31 p.m., indicated awaiting delivery for the medication [MEDICATION NAME]. LVN 2 stated she called the physician on (MONTH) 2, 2019, at 9 a.m. because Resident 77's left hand was still swollen and the resident still complained of pain. LVN 2 stated she received an order from the physician for Resident 77 to be started on [MEDICATION NAME]. LVN 2 stated the physician's orders [REDACTED]. LVN 2 stated the medication should have been delivered in the afternoon by the pharmacy since it was ordered on the morning of (MONTH) 2, 2019. LVN 2 stated she did not call the pharmacy to inquire for the time of delivery of the medication. LVN 2 further stated the nurse from the evening shift should have called the pharmacy to follow up. LVN 2 further stated Resident 77 was in pain on (MONTH) 2, 2019. LVN 2 stated she should have offered non-pharmacological interventions or give the Tylenol to Resident 77 for pain management while waiting for the [MEDICATION NAME] to be delivered. On (MONTH) 5, 2019, at 2:22 p.m., Director of Nursing (DON) 2 was interviewed. DON 2 stated the pharmacy delivery of medications in the facility were daily, three times a day. DON 2 stated, for new medication orders especially for pain, the nurse should have called the pharmacy to inquire for the time of delivery, to ensure the medication would be available for administration. DON 2 stated Resident 77 should have offered non-pharmacological interventions or given the Tylenol for pain while waiting for the [MEDICATION NAME] to be delivered. The undated facility policy and procedure titled, MEDICATION ORDERING AND RECEIVING FROM PHARMACY, indicated, .New medications .If needed before the next regular delivery, phone the medication order to the pharmacy immediately upon receipt. Inform the pharmacy of the need for prompt delivery and request delivery within (4) hours .Timely delivery of new orders is required so that medication administration is not delayed . 2. On (MONTH) 5, 2019, at 2:46 p.m., Resident 89's record review was conducted with Director of Nursing (DON) 1. Resident 89 was readmitted to the facility on (MONTH) 28, 2019, with [DIAGNOSES REDACTED]. Resident 89's physician's orders [REDACTED]. - on (MONTH) 28, 2019, [MEDICATION NAME] 3.375 gram to be given IV every eight hours for UTI. - on (MONTH) 29, 2019, Fluconazole 200 milligram (mg) to be given IV once a day for UTI. Resident 89's electronic Medication Administration Record [REDACTED] Resident 89's eMAR for the month of (MONTH) 2019, indicated the following, for IV antibiotics: - [MEDICATION NAME] did not have a signature to indicate it was administered to the resident on (MONTH) 1, 2019 at 6 a.m. and 2 p.m.; - Fluconazole did not have a signature to indicate it was administered to the resident on (MONTH) 1, 2019 at 9 a.m. On (MONTH) 7, 2019, at 4:22 p.m., Registered Nurse (RN) 1 was interviewed. RN 1 verified she was the RN assigned to give IV antibiotics on (MONTH) 28, 2019, evening shift (3 p.m. to 11:30 p.m.) RN 1 verified Resident 89's eMAR for the month of (MONTH) 2019 did not have her signature on the IV antibiotic [MEDICATION NAME] to indicate it was administered to the resident on (MONTH) 28, 2019, at 10 p.m. RN 1 verified there was no documented evidence the IV antibiotic [MEDICATION NAME] was given to Resident 89 on (MONTH) 28, 2019, at 10 p.m. as ordered. RN 1 stated she forgot to sign the eMAR but she administered the IV antibiotic [MEDICATION NAME] to Resident 89. RN 1 stated Resident 89's IV antibiotic [MEDICATION NAME] was not available due to pharmacy delivery. RN 1 further stated the IV [MEDICATION NAME] she administered to Resident 89 was from the discontinued medications stored in the medication room. However, she was unable to provide documented evidence. RN 1 stated when an order of IV antibiotic for a resident was not available, the RNs in the facility would use, if it was available, discontiued IV antibiotic medications stored in the medication room. RN 1 stated she was aware when a medication was not available, the licensed nurse should call the pharmacy to inquire for the availability of the medication or the licensed nurse should get a dose from the automated drug dispensing system (ADDS - computer controlled storage, dispensing and tracking of medications) when the medicacation was in stock and available for administration. RN 1 stated she did not call the pharmacy nor took a dose from the ADDS when Resident 89's IV antibiotic [MEDICATION NAME] was not available. RN 1 stated she used the IV [MEDICATION NAME] antibiotic from discontinued medication to administer to Resident 89 on (MONTH) 28, 2019, at 10 p.m. On (MONTH) 12, 2019, at 8:40 a.m., RN 2 was interviewed. RN 2 verified he was the RN assigned to give IV antibiotics on (MONTH) 30, 2019 and (MONTH) 1, 2019 at night shift (11 p.m. to 7:30 a.m.) RN 2 verified Resident 89's eMAR did not have his signature on the IV antibiotic [MEDICATION NAME] to indicate it was administered to the resident on (MONTH) 30, 2019, at 6 a.m. and (MONTH) 1, 2019, at 6 a.m. RN 2 verified there was no documented evidence the IV antibiotic [MEDICATION NAME] was given to Resident 89 on (MONTH) 30, 2019, at 6 a.m. and (MONTH) 1, 2019, at 6 a.m. as ordered. RN 2 verified he made a late entry on (MONTH) 5, 2019, by signing the eMAR for (MONTH) 30, 2019, at 6 a.m. and (MONTH) 1, 2019, at 6 a.m. for the IV antibiotic he did not sign. RN 2 stated he should have signed the eMAR after each administration of the medication to the resident. RN 2 further stated he could not remember if the antibiotics were given or not to Resident 89 on the dates he did not sign. RN 2 stated he was told by the facility that he missed signing the eMAR so he made a late entry. RN 2 further stated he was not sure, for the late entry signature he made, if the antibiotic [MEDICATION NAME] was administered to Resident 89 or not. On (MONTH) 12, 2019, at 8:56 a.m., RN 3 was interviewed. RN 3 verified she was the RN assigned to give IV antibiotics on (MONTH) 1, 2019, day shift (7 a.m. to 3:30 p.m.) RN 3 verified Resident 89's eMAR for the month of (MONTH) 2019, had the following IV antibiotic order: - [MEDICATION NAME] did not have her signature to indicate it was administered to the resident on (MONTH) 1, 2019, at 2 p.m.; and - Fluconazole did not have her signature to indicate it was administered to the resident on (MONTH) 1, 2019, at 9 a.m. RN 3 verified there was no documented evidence the IV antibiotic [MEDICATION NAME] and Fluconazole were administered to Resident 89 on (MONTH) 1, 2019, at 9 a.m. and 2 p.m. as ordered. RN 3 verified she made a late entry on (MONTH) 6, 2019, by signing the eMAR on (MONTH) 1, 2019, at 9 a.m. and 2 p.m. for the IV antibiotics she did not sign. RN 3 stated she should have signed the eMAR after each administration of the medication to the resident. RN 3 further stated she could not remember if the antibiotics were given or not to Resident 89 on the dates she did not sign. RN 3 stated she received her eMAR audits from the medical records with the missing signature. RN 3 further stated she just wanted to fix her audits and made sure there was nothing missing on Resident 89's eMAR. 3. On (MONTH) 5, 2019, at 2:46 p.m., Resident 4's record review was conducted with Director of Nursing (DON) 2. Resident 4 was readmitted to the facility on (MONTH) 28, 2019, with [DIAGNOSES REDACTED]. Resident 4's physician's orders [REDACTED]. - on (MONTH) 29, 2019, Meropenem ([MEDICATION NAME]) one gram to be given IV every eight hours for UTI. - on (MONTH) 30, 2019, [MEDICATION NAME] 750 milligram (mg) to be given IV every eight hours for UTI. Resident 4's electronic Medication Administration Record [REDACTED] Resident 4's eMAR for the month of (MONTH) 2019, indicated the IV antibiotics [MEDICATION NAME] and [MEDICATION NAME] did not have a signature indicating it was administered to the resident on (MONTH) 1, 2019, at 6 a.m. and 2 p.m. On (MONTH) 12, 2019, at 8:40 a.m., a concurrent record review and interview was conducted with RN 2. RN 2 verified he was the RN assigned to give IV antibiotics on (MONTH) 30, 2019 and (MONTH) 1, 2019, night shift (11 p.m. to 7:30 a.m.). RN 2 verified he did not sign Resident 4's eMAR on (MONTH) 30, 2019, at 6 a.m., and (MONTH) 1, 2019, at 6 a.m. to indicate the IV antibiotics [MEDICATION NAME] and [MEDICATION NAME] were administered to the resident. RN 2 verified there was no documented evidence the IV antibiotics [MEDICATION NAME] and [MEDICATION NAME] were given on those dates as ordered. RN 2 verified he made a late entry on (MONTH) 5, 2019, by signing the eMAR on (MONTH) 30, 2019, at 6 a.m. and (MONTH) 1, 2019, at 6 a.m., for the IV antibiotics he did not sign RN 2 stated he should have signed the eMAR after each administration of the medication to the resident. RN 2 further stated he could not remember if the antibiotics were given or not to Resident 4 on the dates he did not sign. RN 2 stated he was told by the facility that he missed signing the eMAR so he made a late entry. RN 2 further stated he was not sure for the late entry signature he made if the IV antibiotics were administered to Resident 4 or not. RN 2 stated for Resident 4's IV antibiotic [MEDICATION NAME], he may have used the medication from the discontinued medication or he may have borrowed from another resident that was on IV antibiotic [MEDICATION NAME]. However, he was unable to provide documented evidence of either. On (MONTH) 12, 2019, at 8:56 a.m., a concurrent record review and interview was conducted with RN 3. RN 3 verified she was the RN assigned to give IV antibiotics on (MONTH) 1, 2019, day shift (7 a.m. to 3:30 p.m.). RN 3 verified she did not sign Resident 4's eMAR on (MONTH) 1, 2019, at 2 p.m., to indicate the IV antibiotic [MEDICATION NAME] and [MEDICATION NAME] were administered to the resident. RN 3 verified there was no documented evidence the IV antibiotic [MEDICATION NAME] and [MEDICATION NAME] were given on (MONTH) 1, 2019, at 2 p.m. as ordered. RN 3 verified she made a late entry on (MONTH) 6, 2019, by signing the eMAR for (MONTH) 1, 2019 at and 2 p.m. for the IV antibiotics she did not sign. RN 3 stated if she did not sign the eMAR it meant the medication was not available or she did not administer it. RN 3 further stated she could not remember if the antibiotics were given or not to Resident 4 on the dates she did not sign. RN 3 stated she received her eMAR audits from the medical records with the missing signature. RN 3 further stated she just wanted to fix her audits and made sure there was nothing missing on Resident 4's eMAR. The facility policy and procedure titled, Administering Medications, dated (MONTH) (YEAR), was reviewed. The policy indicated, .Medications shall be administered in a safe and timely manner, and as prescribed .The individual administering the medication must initial the resident's MAR indicated [REDACTED].Medications ordered for a particular resident may not be administered to another resident . The undated facility's policy and procedure titled, DISPOSAL OF MEDICATIONS AND MEDICATION-RELATED SUPPLIES, was reviewed. The policy indicated, .When medications are discontinued by a prescriber .the medications are marked as discontinued and destroyed .Medications are removed from the medication cart immediately upon receipt of an order to discontinue (to avoid inadvertent administration) . 4. On (MONTH) 7, 2019, Resident 129's record was reviewed. Resident 129 was admitted to the facility on (MONTH) 20, 2014, with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The (MONTH) 2019 electronic Medication Administration Record [REDACTED].m, 6 a.m., 12 p.m., and 6 a.m. In addition, the eMAR indicated Resident 129 did not receive the [MEDICATION NAME] tablet for pain on the following dates: - (MONTH) 16, 2019, at 6 p.m.; - (MONTH) 17, 2019, at 12 a.m.; and - (MONTH) 21, 2019, at 12 a.m. and 6 a.m. The corresponding Medication Administratuion Notes for the dates Resident 129 did not receive her routine [MEDICATION NAME] medication for pain, indicated the licensed nurses were not able to give the medication because it was not available pending pharmacy delivery. On (MONTH) 7, 2019, at 10:26 a.m., Licensed Vocational Nurse (LVN) 3 was interviewed. LVN 3 stated he was not able to administer the [MEDICATION NAME] medication to Resident 129 on (MONTH) 21, 2019, at 12 a.m. and 6 a.m., because the medication was not available. LVN 3 further stated there was a delay in the delivery of the medication from the pharmacy. On (MONTH) 7, 2019, at 10:33 a.m., an observation with a concurrent interview was conducted on Resident 129. Resident 129 was alert and was up in her wheelchair inside her room. Resident 129 stated she took the routine [MEDICATION NAME] medication to help manage her chronic pai[DIAGNOSES REDACTED]. Resident 129 stated she remembered missing a couple of doses of her [MEDICATION NAME] medication in (MONTH) 2019. Resident 129 further stated the licensed nurses just kept telling her to wait at that time because it was going to be delivered soon. Resident 129 stated she waited but her [MEDICATION NAME] was not delivered on time and she missed some doses scheduled. Resident 129 stated she felt her body tense up with pain when she did not get her [MEDICATION NAME] pain medication as scheduled. Resident 129 stated this was not the first time she had missed her medications because it was not available. Resident 129 stated, I really did not appreciate that. 5. On (MONTH) 7, 2019, at 9:30 a.m., Resident 277's record was reviewed. Resident 277 was admitted to the facility on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The (MONTH) 2019 electronic Medication Administration Record [REDACTED]. In addition, the eMAR indicated Resident 277 did not receive the medication [MEDICATION NAME] on the following dates: - (MONTH) 5, 2019 at 6 a.m., 2 p.m., and 10 p.m.; - (MONTH) 6, 2019, at 6 a.m. and 10 p.m.; - (MONTH) 7, 2019, at 6 a.m. and 10 p.m.; and - (MONTH) 10, 2019, at 6 a.m., 2 p.m., and 10 p.m. The corresponding Medication Administration Notes for these dates that Resident 277 did not receive her routine [MEDICATION NAME] medication for migraine, indicated the licensed nurses were not able to give the medication because it was not available pending pharmacy delivery. On (MONTH) 7, 2019, at 10:44 a.m., an observation with a concurrent interview was conducted on Resident 277. Resident 277 was in bed, alert, and conversant. Resident 277 stated the doctor prescribed her the [MEDICATION NAME] medication specifically to treat her bad migraine problem. Resident 277 stated she remembered missing doses of her [MEDICATION NAME] medication in (MONTH) 2019 because the medication was not available. Resident 277 stated this was not the first she had missed doses of her medication because of medication unavailability due to the delayed delivery of her medication from the pharmacy. Resident 277 stated she had been monitoring her medication supply because the licensed nurses let her medication run out before they call the pharmacy for a refill. Resident 277 stated the [MEDICATION NAME] was the only medication that helped her treat her bad migraine problem. On (MONTH) 7, 2019, at 11:04 a.m., Licensed Vocational Nurse (LVN) 4 was interviewed. LVN 4 stated she was not able to administer Resident 277's [MEDICATION NAME] medication on (MONTH) 5, 2019 at 2 p.m. and (MONTH) 10, 2019, at 2 p.m. LVN 4 further stated the [MEDICATION NAME] medication was not administered because it was not available pending pharmacy delivery. LVN 4 stated there had been issues with the pharmacy regarding the delayed delivery of medications, which resulted in the residents not getting their medications on time as ordered by the physician. The facility's policy and procedure titled, Administering Medications, dated (MONTH) (YEAR), was reviewed. The policy indicated, .Medications shall be administered in a safe and timely manner, and as prescribed . 6. On (MONTH) 3, 2019, at 9:45 a.m., Resident 155 was observed lying in bed, alert, and responsive. Resident 155 complained of back pain due to his broken bed. At 12:22 p.m., Resident 155 was observed sitting in the wheel chair in the back dining room waiting for his lunch. Resident complained of intolerable pain, and requested to be put back to bed. At 12:47 p.m., Resident 155 was observed in the room sitting on the wheelchair. Resident 155 stated he was still having pain in his lower back since last night, due to his bed being broken. Resident 155 stated, the nurse told me I need to wait until tomorrow to fix my bed. When I turn it feels like the pain is stabbing me. On (MONTH) 4, 2019, at 9:19 a.m., Resident 155 was observed lying in bed. Resident 155 had facial grimacing and stated he had pain in his upper and lower back radiating to his hip. On (MONTH) 4, 2019, at 9:47 a.m., an interview was conducted with the Licensed Vocational Nurse (LVN) 5. LVN 5 stated [MEDICATION NAME] was ordered on (MONTH) 3, 2019, at 2 pm. LVN 5 stated the new order for [MEDICATION NAME] needed a physician's signature before the pharmacy could deliver it. LVN 5 stated the [MEDICATION NAME] was available in the automated drug dispensing system (ADDS - computer controlled storage, dispensing and tracking of medications), but required an access code to open the ADDS. LVN 5 stated the pharmacist refused to give the access code until the physician's signature was obtained. On (MONTH) 4, 2019, Resident 155's record was reviewed. Resident 155 was admitted to the facility on (MONTH) 3, (YEAR). The History and Physical dated (MONTH) 12, (YEAR), indicated that Resident 155, can make needs known but can not make medical decisions. Resident 155's physician's orders [REDACTED].[MEDICATION NAME] (HCL) tablet 50 milligram (MG) by mouth every six hours for pain management . Resident 155's electronic Medication Administration Record [REDACTED] On (MONTH) 4, 2019, at 12:45 p.m., a follow up interview and record review was conducted with LVN 5. LVN 5 stated Resident 155 was scheduled to received the [MEDICATION NAME] every six hours routinely for pain management, to start on (MONTH) 3, 2019, at 6 p.m, but the medication was not available. LVN 5 further stated the [MEDICATION NAME] was not available because the pharmacy was waiting for the physiciana's signature prior to delivery of the medication On (MONTH) 7, 2019, at 11:30 a.m., an interview was conducted with the Pharmacy Owner (PO). The PO stated he was not aware of the late delivery of the medication to the facility. The PO stated until the physician signed the medication order, the pharmacy would not give the ADDS code to the licensed nurse. The PO stated the access code for the ADDS will be given to the licensed nurse when the physician sign the new medication order. The PO stated the Pharmacist should have called the physician to follow up on the physician's signature. The PO further stated if there was no response from the physician, the pharmacist should have called the facility for assistance. On (MONTH) 7, 2019, at 3 p.m., an interview was conducted with Director of Nursing (DON) 2. DON 2 stated Resident 155's pain medication should have been given in a timely manner as ordered by the physician. The undated facility's policy and procedure titled, MEDICATION ORDERING AND RECEIVING FROM PHARMACY, indicated, .New medications .If needed before the next regular delivery, phone the medication order to the pharmacy immediately upon receipt. Inform the pharmacy of the need for prompt delivery and request delivery within (4) hours .Timely delivery of new orders is required so that medication administration is not delayed . 7. On (MONTH) 7, 2019, Resident 172's record was reviewed. Resident 172 was readmitted to the facility on (MONTH) 2, (YEAR), with a [DIAGNOSES REDACTED]. Resident 172's physician order [REDACTED].[MEDICATION NAME] tablet 0.5 milligram (mg) via gastrostomy tube (GT- incision in the abdominal wall used to administer medication and nutrition) every six hours for anxiety . The (MONTH) 2019 electronic Medication Administration Record [REDACTED].m, 6 a.m., 12 p.m., and 6 p.m. In addition the eMAR indicated Resident 172 did not receive the [MEDICATION NAME] on the following dates: - (MONTH) 11, 2019, at 6 p.m.; - (MONTH) 12, 2019, at 12 a.m, 6 a.m., 12 p.m., and 6 p.m; - (MONTH) 13, 2019, at 12 a.m, 6 a.m., 12 p.m., and 6 p.m; - (MONTH) 14, 2019, at 12 a.m, 6 a.m., 12 p.m., and 6 p.m; - (MONTH) 15, 2019, at 12 a.m, 6 a.m., 12 p.m., and 6 p.m; - (MONTH) 16, 2019, at 12 a.m, 6 a.m., 12 p.m., and 6 p.m; - (MONTH) 17, 2019, at 12 a.m, 6 a.m., 12 p.m., and 6 p.m; - (MONTH) 18, 2019, at 12 a.m, and 6 a.m., - (MONTH) 19, 2019, at 12 a.m, 6 a.m., 12 p.m., and 6 p.m; - (MONTH) 20, 2019, at 12 a.m, 6 a.m., 12 p.m., and 6 p.m; - (MONTH) 21, 2019, at 12 a.m, 6 a.m., 12 p.m., and 6 p.m; and - (MONTH) 22, 2019, at 12 a.m, 6 a.m., 12 p.m., and 6 p.m; Resident 172's eMAR for the month of (MONTH) 11, 2019 to (MONTH) 22, 2019, the [MEDICATION NAME] 0.5 mg was not given to the resident for 12 days, a total of 43 doses. On (MONTH) 7, 2019, at 10:46 a.m., Director of Nursing (DON) 2 was interviewed. DON 2 confirmed and acknowledged Resident 172 missed 43 doses of [MEDICATION NAME] 0.5 mg. DON 2 stated the [MEDICATION NAME] was not available because the pharmacy was waiting for the physician's authorization. DON 2 stated the Licensed Nurses (LN) did not follow up with the pharmacy for the status of [MEDICATION NAME] refill. DON 2 further stated the LN should have communicated with the pharmacy for the status of the request. DON 2 stated the LN should have notified the physician when Resident 172's [MEDICATION NAME] was not available. On (MONTH) 7, 2019, at 11:30 a.m., an interview was conducted with the pharmacy Owner (PO). The PO stated he was not aware of the medications late delivery of the medication to the facility. The PO stated the LN should have requested refill orders, for medications that needed physician auhtorization, three to five days before they ran out of the medication. 8. On (MONTH) 7, 2019, Resident 172's record was reviewed. Resident 172 was readmitted to the facility on (MONTH) 2, (YEAR). Resident 172's History and Physical dated (MONTH) 3, (YEAR), indicated, does not have the capacity to understand and make decisions. Resident 172's physician's orders [REDACTED].[MEDICATION NAME] Solution (HCL) 750 milligram (mg) intravenously every twelve hours until (MONTH) 14, 2019, for pneumonia . The (MONTH) 2019 electronic Medication Administration Record [REDACTED] The corresponding nurses notes on the dates the medication was not administered to Resident 172 indicated, the IV [MEDICATION NAME] was not administered to the resident due to pending delivery from the pharmacy. There was no documented evidence Resident 172's physician was notified the IV [MEDICATION NAME] was not administered to the resident. On (MONTH) 7, 2019, at 8:50 a.m., an interview was conducted with the Registered Nurse (RN) 3. RN 3 stated she did not administer the IV [MEDICATION NAME] because it was not available. RN 3 further stated the pharmacy was unreliable. On (MONTH) 7, 2019, at 11:30 a.m., an interview was conducted with Pharmacy Owner (PO). The PO stated the [MEDICATION NAME] was delivered and signed received by the RN 2 on (MONTH) 11, 2019, at 5 a.m. On (MONTH) 7, 2019, at 11:50 a.m., a follow up interview was conducted with the RN 3. RN 3 stated she did not see the IV [MEDICATION NAME] inside the IV Medication Cart. RN 3 confirmed she did not administer the IV medication on (MONTH) 11, 2019, at 9 a.m. 9. On (MONTH) 5, 2019, Resident 154's record was reviewed. Resident 154 was admitted to the facility on (MONTH) 17, (YEAR), with [DIAGNOSES REDACTED]. Resident 154's electronic Medication Administration Record [REDACTED]. The physician's orders [REDACTED]. Further review of the eMAR indicated Resident 154 did not rec (TRUNCATED)

Based on interview, and record review, the facility's Quality Assessment and Assurance (QAA) committee failed to identify, develop, and implement an appropriate plan of action to correct quality deficiencies related to Pharmaceutical Services when: 1. The facility failed to identify quality concerns regarding the residents' medication availability for administration (Cross Reference F755); and 2. The facility failed to identify quality concerns regarding licensed nurses care practices that meets expected professional standards, when multiple licensed nurses failed to follow the facility's policy and procedure for medication administration (Cross Reference F684 and F760). These failures placed the residents at risk for delay in receiving necessary medications to manage pain, to treat infections and to treat other medical conditions. The above failures had resulted in an Immediate Jeopardy and Substandard Quality of Care. Findings: On (MONTH) 7, (YEAR), the following records were reviewed: - Resident 77's electronic Medication Administration Record [REDACTED] - Resident 89's eMAR for the month of (MONTH) 2019 and (MONTH) 2019, indicated the resident did not receive her intravenous (IV - into the veins) antibiotics ([MEDICATION NAME] and Fluconazole) on multiple occasions for treatment of [REDACTED]. - Resident 4's eMAR for the month of (MONTH) 2019 and (MONTH) 2019, indicated the resident did not receive his IV antibiotics ([MEDICATION NAME] and [MEDICATION NAME]) on multiple occasions for treatment of [REDACTED].>- Resident 129's eMAR for the month of (MONTH) 2019, indicated the resident did not receive her routine medication [MEDICATION NAME] (narcotic pain medication) on multiple occasions; - Resident 277's eMAR for the month of (MONTH) 2019, indicated the resident did not receive her routine medication [MEDICATION NAME] (a narcotic pain medication used for migraine - intense headache and sensitivity to light) on multiple occasions; - Resident 155's eMAR for the month of (MONTH) 2019, indicated the resident did not receive three doses of a new physician's orders [REDACTED]. - Resident 172's eMAR for the month of (MONTH) 2019, indicated the resident did not receive her routine medication [MEDICATION NAME] (medication for anxiety) from (MONTH) 11 to 22, 2019 In addition, Resident 172 did not receive her intravenous (IV) antibiotics ([MEDICATION NAME]) for treatment of [REDACTED]. - Resident 154's eMAR indicated the resident did not receive his routine medication [MEDICATION NAME] (for treatment of [REDACTED].{[MEDICAL CONDITION] - lung disease that block the airflow and make it difficult to breathe}) on multiple occasions at night when the resident was asleep from (MONTH) (YEAR) to (MONTH) 2019. In addition, Resident 154 did not receive his routine medications ([MEDICATION NAME] - medication for [MEDICAL CONDITION] {pain from nerve damage}; [MEDICATION NAME] - treatment for [REDACTED]. On (MONTH) 7, 2019, at 10:29 a.m., the Administrator was interviewed. The Administrator stated one of the QAA projects for improvement was the medication administration review. The Administrator further stated it was the Assistant Director of Nursing (ADON) who was assigned to do it. The Administrator stated he was not familiar on the details of the medication administration review because he had no clinical background. The Administrator further stated he relied on the reports being given to him from the nursing staff team. The Administrator stated the report he received from the ADON had no issues or concerns on residents' medication being available for administration. The Administrator stated there were some concerns on the delay with the pharmacy obtaining authorization from the physician and it was addressed on the QAA meeting with the pharmacy consultant last (MONTH) (YEAR). On (MONTH) 7, 2019, at 11:03 a.m., the Pharmacy Consultant (PC) was interviewed. The PC stated she was made aware of the issue for delayed authorization of the physician for narcotic medication orders and refills on the last QAA meeting in (MONTH) (YEAR). The PC stated she remembered having a talk with one of the physician regarding timely authorization of the narcotic medications but did not followed up if the issue still continued to exist. The PC stated she did not ask for the Medical Director's (MD) assistance because the facility had a new MD on (MONTH) (YEAR). On (MONTH) 7, 2019, at 10:45 a.m., the ADON was interviewed. The ADON stated the facility conducted a medication reconciliation for each resident that started in (MONTH) (YEAR). She stated she assigned licensed nurses a weekly schedule list of residents medication reconciliation to check. The ADON stated the licensed nurses would do a triple check of the resident's medication from the physician order, to the medication supply available, to the resident's electronic Medication Administration Record [REDACTED] The ADON stated for physician order [REDACTED]. The ADON stated she received the medication reconciliation report from the nurses on the weekly basis. The ADON stated there was no issue on medication availability and she made sure medications were delivered on time to be administered to the residents. The ADON stated she relied on the medication reconciliation report being given to her by the staff to know if there was an issue or concern with medication availability. The Medical Record Director (MRD) was responsible in the audits of the residents' electronic Medication Administration Record [REDACTED] The ADON stated she did not have a system to count how many resident's medication reconciliations report she receive on a weekly basis, nor to know if all residents were being checked for weekly medication reconciliation. The ADON further stated she did not have a list of what were the issues and concerns the licensed nurses were having on the residents' medication availablity from the medication reconciliation report. On (MONTH) 11, 2019, at 3:15 p.m., the Medical Record Director (MRD) was interviewed. The MRD stated medical records conduct a weekly audit of all the residents eMAR. The MRD stated a copy of the weekly eMAR audit report were given to the Administrator and the Director of Nursing (DON). The MRD stated if there were missing signature in the eMAR from the audit, a copy would be given directly to the licensed nurses. The MRD stated the licensed nurses have 30 days to correct the eMAR audit and return the audit report to her. The MRD stated she had multiple eMAR audits with missing signatures but she did not have a system on tracking the total number of eMAR audits with missing signature of licensed nurses she had weekly. The MRD further stated she based the amount on the thickness of audit report copy she have to give to the licensed nurses weekly. On (MONTH) 11, 2019, at 8:20 a.m., the Pharmacy Owner (PO) was interviewed. The PO stated there were several pharmacy deliveries made on the facility every day. The PO stated for STAT medication it would be delivered within one hour and for other new medication order it would be delivered within 4 hours. The PO stated he was not aware of the issues regarding the residents not receiving their medications on time due to medication unavailability as a result of delayed delivery of medications form the pharmacy. The PO further stated he was not informed the pharmacy had been having issues with the delay to get a physician's authorization to refill narcotic medications. The facility policy and procedure titled, Quality Assessment and Assurance (QAA), dated (MONTH) (YEAR), was reviewed. The policy indicated, .The QA&A Committee oversees and identifies all efforts that improve the quality of care in the facility by monitoring performance measure, directing improvement actions, and evaluating the effectiveness of quality management activities .

Based on observation, interview, and record review, the facility failed to ensure 12 of 40 residents reviewed (Residents 77, 89, 4, 47, 129, 277, 43, 155, 172, 157, 83, and 154) received treatment and care in accordance with professional standards of practice and the comprehensive care plan when: 1. Resident 77 did not receive her first dose of [MEDICATION NAME] (medication for pain) as ordered by the physician. In addition, Resident 77's left hand swelling and pain was not addressed and reported to the physician in a timely manner. This failure resulted in the resident experiencing increased pain. 2. Resident 89, did not receive her intravenous (IV - into the veins) antibiotics ([MEDICATION NAME] and Fluconazole) on multiple occasions for treatment of [REDACTED]. In addition, Resident 89 may have received discontinued IV antibiotic medication. This failure could jeopardize the resident's health and safety for not treating the UTI appropriately that could result into complications such as kidney damage. In addition, the resident could have received expired or inaccurate medication dosages from the possible use of discontinued medications. 3a. Resident 4, did not receive his IV antibiotics ([MEDICATION NAME] and [MEDICATION NAME]) on multiple occasions for treatment of [REDACTED]. In addition, Resident 4 may have received discontinued IV antibiotic medication. This failure could jeopardize the resident's health and safety for not treating the UTI appropriately that could result into complications such as kidney damage. In addition, the resident could have received expired or inaccurate medication dosages from the possible use of discontinued medications. 3b. Resident 4's right hand [MEDICAL CONDITION] (swelling caused by fluid in the body tissue) was not addressed and reported to the physician since it was identified on (MONTH) 29, 2019. This failure may result in further potential problems and complications in the resident's medical condition. 3c. Resident 4's bilateral hand and knee splints were not provided since the Physical Therapy (PT - healthcare specialty that evaluate and treat individuals with limitation in functional mobility) evaluation on (MONTH) 7, (YEAR). This failure may result in further potential decline in the resident's range of motion. 4. Resident 47's bilateral foot drop (difficulty in lifting the front part of the foot) splints were not provided since (MONTH) 31, (YEAR). This failure may result in further potential decline in the resident's range of motion. 5. Resident 129 did not receive her routine medication [MEDICATION NAME] (narcotic pain medication) on multiple occasions for the month of (MONTH) 2019. This failure resulted in the resident experiencing increased pain. 6. Resident 277 did not receive her routine medication [MEDICATION NAME] (a narcotic pain medication used for migraine - intense headache and sensitivity to light) on multiple occasions for the month of (MONTH) 2019. This failure resulted in the potential for the resident to experience excessive migraine headaches. 7. Resident 43's open wound on the left side of the abdomen was not addressed and reported to the physician since it was identified on (MONTH) 3, 2019. This failure may result in further potential problems and complications in the resident's medical condition. 8. Resident 155 did not receive three doses of a new physician's orders [REDACTED]. This failure resulted in the resident experiencing increased pain. 9. Resident 172 did not receive her routine medication [MEDICATION NAME] (medication for anxiety) from (MONTH) 11 to 22, 2019. This failure put the resident at risk to experience increased anxiety. 10. Resident 172 did not receive her IV antibiotic [MEDICATION NAME] for treatment of [REDACTED]. This failure could jeopardize the resident's health and safety for not treating the pneumonia that could result into complications such as [MEDICAL CONDITION] and death. 11. Resident 157's peripherally inserted central catheter (PICC - a kind of intravenous access) was not monitored and provided PICC line care since it was used on (MONTH) 27, (YEAR). This failure may result in further potential problems and complications in the resident's medical condition such as infection. 12. Resident 83's cloudy urine with sedimentation (particles in the fluids) from the Foley Catheter ( FC - a flexible tube that passes through the urethra and into the bladder to drain urine) was not addressed and reported to the physician. This failure may result in further potential problems and complications in the resident's medical condition such as urinary infection. 13. Resident 154 did not receive his routine medication [MEDICATION NAME] (medication for [MEDICAL CONDITION] {[MEDICAL CONDITION] - lung disease that block the airflow and make it difficult to breathe}) on multiple occasions at night when the resident was asleep from (MONTH) (YEAR) to (MONTH) 2019. This failure could jeopardize the resident's health and safety for not managing and treating the [MEDICAL CONDITION] that could result into complications like [MEDICAL CONDITION] and death. 14. Resident 154 did not receive his routine medications ([MEDICATION NAME] - medication for [MEDICAL CONDITION] {pain from nerve damage}; [MEDICATION NAME] - medication for high cholesterol level; [MEDICATION NAME] - medication for [MEDICAL CONDITION] {mental disorder}; and [MEDICATION NAME] - medication for acid reflux) on multiple occasions for the month of (MONTH) 2019. This failure could jeopardize the resident's health and safety for not managing and treating the medical conditions, overall long-term health and well-being of the resident. Findings: 1. On (MONTH) 3, 2019, at 11:49 a.m., Resident 77 was observed sitting in her wheelchair, with facial grimacing, was moaning and massaging her left hand. Resident 77 stated her left hand was hurting. She showed her left hand, and the area around the left thumb was swollen. Resident 77 stated it had been swollen and hurting for a week now. She further stated she was in a lot of pain last night, she cried and she was not able to sleep because of too much pain. Resident 77 stated her nurse did not give her anything for pain last night and told her she was waiting for the pharmacy to deliver the pain medication ordered by the physician. On (MONTH) 5, 2019, at 11:06 a.m., a concurrent record review and interview was conducted with Licensed Vocational Nurse (LVN) 2. Resident 77 was admitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. Resident 77's physician's orders [REDACTED]. A physician's orders [REDACTED]. Resident 77's electronic Medication Record Administration (eMAR) for (MONTH) 2019, indicated the medication [MEDICATION NAME] was not administered on (MONTH) 2, 2019, at 5 p.m., and indicated 9 (facility chart codes 9 = other/see progress notes) as a reason. In addition, the eMAR did not indicate Resident 77 was offered non-pharmacological interventions nor was given the Tylenol for pain on (MONTH) 2, 2019. Resident 77's progress notes dated (MONTH) 2, 2019, at 7:31 p.m., indicated awaiting delivery for the medication [MEDICATION NAME]. LVN 2 stated when she was the charge nurse for Resident 77 last week ([DATE] to (MONTH) 2, 2019) the resident had complained of swelling and pain on her left hand. LVN 2 verified there was no documented evidence Resident 77's left hand swelling and pain were addressed nor the physician notified on the week the resident complained. LVN 2 verified there was no documented evidence a care plan was developed addressing Resident 77's left hand swelling and pain. LVN 2 stated when she came back from two days off from work (February 2, 2019) Resident 77's left hand was still swollen and the resident still complained of pain. LVN 2 further stated she called and notified the physician and received an order for [REDACTED]. She stated she did not know why it was not addressed last week when Resident 77 started to have swelling and pain on the left hand. LVN 2 stated the [MEDICATION NAME] should have been delivered in the afternoon by the pharmacy since it was ordered on the morning of (MONTH) 2, 2019. LVN 2 stated she did not call the pharmacy to inquire for the time of delivery of the medication. LVN 2 further stated the nurse from the evening shift should have called the pharmacy to follow up. LVN 2 confirmed Resident 77 was in pain on (MONTH) 2, 2019. LVN 2 stated she should have offered non-pharmacological interventions or gave the Tylenol to Resident 77 for pain management while waiting for the [MEDICATION NAME] to be delivered. On (MONTH) 5, 2019, at 2:22 p.m., Director of Nursing (DON) 2 was interviewed. DON 2 stated the pharmacy delivery of medications in the facility were daily, three times a day. DON 2 stated if there was a change of condition in the resident, the licensed nurse should have done an assessment, notified the physician, and developed a care plan. DON 2 stated, for new medication orders especially for pain, the nurse should have called the pharmacy, to inquire for the time of delivery, to ensure the medication would be available for administration. DON 2 stated Resident 77 should have been offered non-pharmacological interventions or given the Tylenol for pain while waiting for the [MEDICATION NAME] to be delivered. The undated facility policy and procedure titled, MEDICATION ORDERING AND RECEIVING FROM PHARMACY, was reviewed. The policy indicated, .New medications .If needed before the next regular delivery, phone the medication order to the pharmacy immediately upon receipt. Inform the pharmacy of the need for prompt delivery and request delivery within (4) hours .Timely delivery of new orders is required so that medication administration is not delayed . The facility policy and procedure titled, Changes in Resident Condition, dated (MONTH) 2005 was reviewed. The policy indicated, .a significant change in the resident's physical, mental or psychosocial status; The SBAR (Situation, Background, Assessment, Recommendation) in EHR (electronic health record); a communication note utilized to assess and document changes in condition .provide assessment information to physician . Changes in condition are communicated from shift to shift through the 24 hour report management system . Changes in the resident status that affect the problem(s)/goal(s) or approach(es) on his/her care plan are documented as revisions and communicated to the interdisciplinary caregivers . 2. On (MONTH) 5, 2019, at 2:46 p.m., Resident 89's record review was conducted with Director of Nursing (DON) 2. Resident 89 was readmitted to the facility on (MONTH) 28, 2019, with [DIAGNOSES REDACTED]. Resident 89's physician's orders [REDACTED]. - on (MONTH) 28, 2019, [MEDICATION NAME] 3.375 gram to be given IV every eight hours for UTI. - on (MONTH) 29, 2019, Fluconazole 200 milligram (mg) to be given IV once a day for UTI. Resident 89's electronic Medication Administration Record [REDACTED] - IV antibiotic [MEDICATION NAME] did not have a signature to indicate it was administered to the resident on (MONTH) 28, 2019, at 10 p.m. and (MONTH) 30, 2019, at 6 a.m. Resident 89's eMAR for the month of (MONTH) 2019, indicated: - IV antibiotic [MEDICATION NAME] did not have a signature indicating it was administered to the resident on (MONTH) 1, 2019, at 6 a.m. and 2 p.m.; and - IV antibiotic Fluconazole did not have a signature indicating it was administered to the resident on (MONTH) 1, 2019 at 9 a.m. On (MONTH) 7, 2019, at 4:22 p.m., Registered Nurse (RN) 1 was interviewed. RN 1 verified she was the RN assigned to give IV antibiotics on (MONTH) 28, 2019, evening shift (3 p.m. to 11:30 p.m.) RN 1 verified Resident 89's eMAR for the month of (MONTH) 2019, did not have her signature on IV antibiotic [MEDICATION NAME] as indication it was administered to the resident on (MONTH) 28, 2019, at 10 p.m. RN 1 verified there was no documented evidence the IV antibiotic [MEDICATION NAME] was given to Resident 89 on (MONTH) 28, 2019, at 10 p.m. as ordered. RN 1 stated she forgot to signed the eMAR but she administered the IV antibiotic [MEDICATION NAME] to Resident 89. RN 1 stated Resident 89's IV antibiotic [MEDICATION NAME] was not available due to pharmacy delivery. She further stated the IV [MEDICATION NAME] she administered to the resident was from the discontinued medications stored in the medication room. RN 1 stated when an order of IV antibiotic for a resident was not available, the RNs in the facility would use, if it was available, discontinued IV antibiotic medications stored in the medication room. RN 1 further stated she was aware when a medication was not available, the licensed nurse should call the pharmacy to inquire for the availability of the medication or the licensed nurse should get a dose from the automated drug dispensing system (ADDS - computer controlled storage, dispensing and tracking of medications) when the medication was in stock and available for administration. RN 1 stated she did not call the pharmacy nor took a dose from the ADDS when Resident 89's IV antibiotic [MEDICATION NAME] was not available. RN 1 stated she used the IV [MEDICATION NAME] antibiotic from discontinued medication to administered to Resident 89 on (MONTH) 28, 2019, at 10 p.m. However, she was unable to provide documented evidence. On (MONTH) 12, 2019, at 8:40 a.m., RN 2 was interviewed. RN 2 verified he was the RN assigned to give IV antibiotics on (MONTH) 30, 2019 and (MONTH) 1, 2019, night shift (11 p.m. to 7:30 a.m.) RN 2 verified Resident 89's eMAR did not have his signature on IV antibiotic [MEDICATION NAME] to indicate it was administered to the resident on (MONTH) 30, 2019, at 6 a.m. and (MONTH) 1, 2019, at 6 a.m. RN 2 verified there was no documented evidence the IV antibiotic [MEDICATION NAME] was given to Resident 89 on (MONTH) 30, 2019, at 6 a.m. and (MONTH) 1, 2019, at 6 a.m. as ordered. RN 2 verified he made a late entry on (MONTH) 5, 2019, by signing the eMAR for (MONTH) 30, 2019, at 6 a.m. and (MONTH) 1, 2019, at 6 a.m., for IV antibiotic he did not sign as administered to the resident. RN 2 stated he should have signed the eMAR after each administration of the medication to the resident. RN 2 further stated he did not remember if the antibiotic was given or not to Resident 89 on the dates he did not sign. RN 2 stated he was told by the facility that he missed signing the eMAR so he made a late entry. RN 2 further stated he was not sure for the late entry signature he made if the IV antibiotic [MEDICATION NAME] was administered to the resident or not. On (MONTH) 12, 2019, at 8:56 a.m., RN 3 was interviewed. RN 3 verified she was the RN assigned to give IV antibiotics on (MONTH) 1, 2019, day shift (7 a.m. to 3:30 p.m.) RN 3 verified Resident 89's eMAR for the month of (MONTH) 2019, had the following IV antibiotics order: - [MEDICATION NAME] did not have her signature to indicate it was administered to the resident on (MONTH) 1, 2019, at 2 p.m.; and - Fluconazole did not have her signature to indicate it was administered to the resident on (MONTH) 1, 2019, at 9 a.m. RN 3 verified there was no documented evidence the IV antibiotic [MEDICATION NAME] and Fluconazole were administered to Resident 89 on (MONTH) 1, 2019, at 9 a.m. and 2 p.m. RN 3 verified she made a late entry on (MONTH) 6, 2019, by signing the eMAR for (MONTH) 1, 2019 at 9 a.m. and 2 p.m. for the IV antibiotics she did not sign as administered to the resident. RN 3 stated she should have signed the eMAR after each administration of the medication to the resident. RN 3 further stated she was not sure for the late entry signature she made if the IV antibiotics were administered to the resident or not. RN 3 stated she received her eMAR audits from the medical records with the missing signature. RN 3 further stated she just wanted to fix her audits and made sure there was nothing missing on Resident 89's eMAR. 3a. On (MONTH) 5, 2019, at 2:46 p.m., Resident 4's record review was conducted with Director of Nursing (DON) 2. Resident 4 was readmitted to the facility on (MONTH) 28, 2019, with [DIAGNOSES REDACTED]. Resident 4's physician's orders [REDACTED]. - on (MONTH) 29, 2019, Meropenem ([MEDICATION NAME]) one gram to be given IV every eight hours for UTI. - on (MONTH) 30, 2019, [MEDICATION NAME] 750 milligram (mg) to be given IV every eight hours for UTI. Resident 4's electronic Medication Administration Record [REDACTED] Resident 4's eMAR for the month of (MONTH) 2019, indicated the IV antibiotics [MEDICATION NAME] and [MEDICATION NAME] did not have a signature to indicate it was administered to the resident on (MONTH) 1, 2019, at 6 a.m. and 2 p.m. On (MONTH) 12, 2019, at 8:40 a.m., a concurrent record review and interview was conducted with RN 2. RN 2 verified he was the RN assigned to give IV antibiotics on (MONTH) 30, 2019 and (MONTH) 1, 2019, night shift (11 p.m. to 7:30 a.m.). RN 2 verified he did not sign Resident 4's eMAR on (MONTH) 30, 2019, at 6 a.m., and (MONTH) 1, 2019, at 6 a.m. to indicate the IV antibiotics [MEDICATION NAME] and [MEDICATION NAME] were administered to the resident. RN 2 verified there was no documented evidence the IV antibiotics [MEDICATION NAME] and [MEDICATION NAME] were given on those dates. RN 2 verified he made a late entry on (MONTH) 5, 2019, by signing the eMAR for (MONTH) 30, 2019, at 6 a.m. and (MONTH) 1, 2019, at 6 a.m. for IV antibiotics he did not sign as administered to the resident. RN 2 stated he should have signed the eMAR after each administration of the medication to the resident. RN 2 further stated he did not remember if the IV antibiotics were given or not to Resident 4 on the dates he did not sign. RN 2 stated he was told by the facility that he missed signing the eMAR so he made a late entry. RN 2 further stated he was not sure for the late entry signature he made if the IV antibiotics were administered to Resident 4 or not. RN 2 stated for Resident 4's IV antibiotic [MEDICATION NAME], he may have used the medication from the discontinued medication or he may have borrowed from another resident that was on IV antibiotic [MEDICATION NAME]. However, he was unable to provide documented evidence of either. On (MONTH) 12, 2019, at 8:56 a.m., a concurrent record review and interview was conducted with RN 3. RN 3 verified she was the RN assigned to give IV antibiotics on (MONTH) 1, 2019, day shift (7 a.m. to 3:30 p.m.). RN 3 verified she did not sign Resident 4's eMAR on (MONTH) 1, 2019, at 2 p.m., to indicate the IV antibiotic [MEDICATION NAME] and [MEDICATION NAME] were administered to the resident. RN 3 verified there was no documented evidence the IV antibiotic [MEDICATION NAME] and [MEDICATION NAME] were given on (MONTH) 1, 2019, at 2 p.m. RN 3 verified she made a late entry on (MONTH) 6, 2019, by signing the eMAR for (MONTH) 1, 2019 at and 2 p.m. for IV antibiotics she did not sign as administered to the resident. RN 3 stated if she did not sign the eMAR it means the medication was not available or she did not administered it. RN 3 further stated she could not remember if the IV antibiotics were administered or not to Resident 4 on the dates she did not sign. RN 3 stated she received her eMAR audits from the medical records with the missing signature. RN 3 further stated she just wanted to fix her audits and made sure there was nothing missing on Resident 4's eMAR. The facility policy and procedure titled, Administering Medications, dated (MONTH) (YEAR), was reviewed. The policy indicated, .Medications shall be administered in a safe and timely manner, and as prescribed .The individual administering the medication must initial the resident's MAR indicated [REDACTED].Medications ordered for a particular resident may not be administered to another resident . The undated facility policy and procedure titled, DISPOSAL OF MEDICATIONS AND MEDICATION-RELATED SUPPLIES, was reviewed. The policy indicated, .When medications are discontinued by a prescriber .the medications are marked as discontinued and destroyed .Medications are removed from the medication cart immediately upon receipt of an order to discontinue (to avoid inadvertent administration) . The facility's policy and procedure titled, Documentation of Principle, dated (MONTH) 2014, was reviewed. The policy indicated, .Complete Entries - Entries must be Accurate; Timely - recorded within the required time period; Objective - record facts and what it is, do not assume . 3b. On (MONTH) 3, 2019, at 12:18 p.m., a concurrent observation was conducted with Licensed Vocational Nurse (LVN) 1. Resident 4 was observed lying down in bed, turned on his left side with both upper extremities were contracted (a muscle that shortened or tightened) and unable to move. Resident 4's right arm was straightened out with wrist contracture, the right hand was swollen, and not elevated on a pillow. Both hands had no splint or hand towel roll applied. On (MONTH) 11, 2019, at 2:56 p.m., a concurrent record review and interview was conducted with the Assistant Director of Nursing (ADON). Resident 4 was readmitted to the facility on (MONTH) 28, 2019, with [DIAGNOSES REDACTED]. Resident 4's nursing admission assessment dated (MONTH) 28, 2019, indicated the resident had [MEDICAL CONDITION] of the right hand. There was no documented evidence the physician was notified of Resident 4's right hand [MEDICAL CONDITION] and a care plan was not developed since identified on (MONTH) 28, 2019. The ADON stated Resident 4's right hand [MEDICAL CONDITION] should have been addressed. The ADON further stated the licensed nurse should have notified the physician and should have developed a care plan. The facility policy and procedure titled, Changes in Resident Condition, dated (MONTH) 2005 was reviewed. The policy indicated, .a significant change in the resident's physical, mental or psychosocial status; The SBAR (Situation, Background, Assessment, Recommendation) in EHR (electronic health record); a communication note utilized to assess and document changes in condition .provide assessment information to physician . Changes in condition are communicated from shift to shift through the 24 hour report management system . Changes in the resident status that affect the problem(s)/goal(s) or approach(es) on his/her care plan are documented as revisions and communicated to the interdisciplinary caregivers . 3c. On (MONTH) 3, 2019, at 12:18 p.m., a concurrent observation was conducted with Licensed Vocational Nurse (LVN) 1. Resident 4 was observed lying down in bed, turned on his left side with both upper extremities contracted (a muscle that shortened or tightened) and unable to move. Resident 4's right arm was straightened out with wrist contracture, the right hand was swollen, and not elevated on a pillow. Both hands had no splint or hand towel roll applied. On (MONTH) 11, 2019, at 11:11 a.m., a concurrent record review and interview was conducted with the Rehabilitation Director (RD). Resident 4 was admitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. Resident 4's, OT (Occupational Therapy) Evaluation & Plan of Treatment, dated (MONTH) 7, 2019, indicated, .Long-Term Goals .Patient will increase tolerance in wearing right hand resting splint to 4 hours to prevent decline and for contracture mgmt. (management) . Resident 4's, PT Evaluation & Plan of Treatment, dated (MONTH) 7, 2019, indicated, .Long-Term Goals .Patient will safely wear a knee extension splint on right knee and left knee for up to 6 hours . There was no documented evidence the splints for the right hand and bilateral knees were used and applied to Resident 4 since the PT and OT evaluation on (MONTH) 7, (YEAR). The RD stated, the ordering of the splints for Resident's 4 right hand and bilateral knees were not followed up when the Resident 4 was transferred out to the hospital in (MONTH) (YEAR). The RD stated it should have been ordered and made sure it was available for Resident 4 to use when the resident came back to the facility. 4. On (MONTH) 4, 2019, Resident 47 was observed lying in bed. Both lower extremities were noted with foot drop, and did not have a splint or brace applied on the resident's legs and feet. On (MONTH) 11, 2019, at 1:15 p.m., a concurrent record review and interview was conducted with the Rehabilitation Director (RD). Resident 47 was admitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. Resident 47's, PT Evaluation & Plan of Treatment, dated (MONTH) 16, (YEAR), indicated, .Long-Term Goals .Patient will safely wear a foot drop splint on the right foot and left foot for up to 6 hours . There was no documented evidence the foot drop splints were used and applied to Resident 47's feet since the resident was discharged from the PT services on (MONTH) 31, (YEAR). On (MONTH) 11, 2019, at 4 p.m., the Registered Physical Therapist (RPT) was interviewed. The RPT stated after the resident's discharge from PT services, a recommendation of what the resident would need for range of motion should be provided. The RPT stated Resident 47 needed the splints for her feet to prevent further decline or worsening of the foot drop. The RPT stated she forgot to include on her recommendation the need for ordering of the foot drop splints after discharging Resident 47 from PT services on (MONTH) 31, (YEAR). 5. On (MONTH) 7, 2019, Resident 129's record was reviewed. Resident 129 was admitted to the facility on (MONTH) 20, 2014, with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The (MONTH) 2019 electronic Medication Administration Record [REDACTED].m, 6 a.m., 12 p.m., and 6 a.m. In addition, the eMAR indicated Resident 129 did not receive the [MEDICATION NAME] tablet for pain on the following dates: - (MONTH) 16, 2019, at 6 p.m.; - (MONTH) 17, 2019, at 12 a.m.; and - (MONTH) 21, 2019, at 12 a.m. and 6 a.m. The corresponding Medication Administratuion Note for the dates Resident 129 did not receive her routine [MEDICATION NAME] medication for pain, indicated the licensed nurses were not able to give the medication because it was not available pending pharmacy delivery. On (MONTH) 7, 2019, at 10:26 a.m., Licensed Vocational Nurse (LVN) 3 was interviewed. LVN 3 stated he was not able to administer the [MEDICATION NAME] medication to Resident 129 on (MONTH) 21, 2019, at 12 a.m. and 6 a.m., because the medication was not available. LVN 3 further stated there was a delay in the delivery of the medication from the pharmacy. On (MONTH) 7, 2019, at 10:33 a.m., an observation with a concurrent interview was conducted on Resident 129. Resident 129 was alert and was up in her wheelchair inside her room. Resident 129 stated she took the routine [MEDICATION NAME] medication to help manage her chronic pai[DIAGNOSES REDACTED]. Resident 129 stated she remembered missing a couple of doses of her [MEDICATION NAME] medication in (MONTH) 2019. Resident 129 further stated the licensed nurses just kept telling her to wait at that time because it was going to be delivered soon. Resident 129 stated she waited but her [MEDICATION NAME] was not delivered on time and she missed some doses scheduled. Resident 129 stated she felt her body tense up with pain when she did not get her [MEDICATION NAME] pain medication as scheduled. Resident 129 stated this was not the first time she had missed her medications because it was not available. Resident 129 stated, I really did not appreciate that. 6. On (MONTH) 7, 2019, at 9:30 a.m., Resident 277's record was reviewed. Resident 277 was admitted to the facility on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The (MONTH) 2019 electronic Medication Administration Record [REDACTED]. In addition, the eMAR indicated Resident 277 did not receive the medication [MEDICATION NAME] on the following dates: - (MONTH) 5, 2019 at 6 a.m., 2 p.m., and 10 p.m.; - (MONTH) 6, 2019, at 6 a.m. and 10 p.m.; - (MONTH) 7, 2019, at 6 a.m. and 10 p.m.; and - (MONTH) 10, 2019, at 6 a.m., 2 p.m., and 10 p.m. The corresponding Medication Administration Note for the dates Resident 277 did not receive her routine [MEDICATION NAME] medication for migraine, indicated the licensed nurses were not able to give the medication because it was not available pending pharmacy delivery. On (MONTH) 7, 2019, at 10:44 a.m., an observation with a concurrent interview was conducted on Resident 277. Resident 277 was in bed, alert, and conversant. Resident 277 stated the doctor prescribed her the [MEDICATION NAME] medication specifically to treat her bad migraine problem. Resident 277 stated she remembered missing doses of her [MEDICATION NAME] medication in (MONTH) 2019 because the medication was not available. Resident 277 stated this was not the first she had missed doses of her medication because of medication unavailability due to the delayed delivery of her medication from the pharmacy. Resident 277 stated she had been monitoring her medication supply because the licensed nurses let her medication ran out before they call the pharmacy for a refill. Resident 277 stated the [MEDICATION NAME] was the only medication that helped her treat her bad migraine problem. On (MONTH) 7, 2019, at 11:04 a.m., Licensed Vocational Nurse (LVN) 4 was interviewed. LVN 4 stated she was not able to administer Resident 277's [MEDICATION NAME] medication on (MONTH) 5, 2019 at 2 p.m. and (MONTH) 10, 2019, at 2 p.m. LVN 4 further stated the [MEDICATION NAME] medication was not administered because it was not available pending pharmacy delivery. LVN 4 stated there had been issues with the pharmacy regarding the delayed delivery of medications, which resulted in the residents not getting their medications on time as ordered by the physician. The facility's policy and procedure titled, Administering Medications, dated (MONTH) (YEAR), was reviewed. The policy indicated, .Medications shall be administered in a safe and timely manner, and as prescribed . 7. On (MONTH) 3, 2019, at 9:44 a.m., an observation with an interview was conducted with Certified Nursing Assistant (CNA) 2 on Resident 43. Resident 43 was in bed, alert, and gave the permission to inspect her abdomen for a skin problem. CNA 2 lifted Resident 43's gown to expose her abdomen. On the left side of her abdomen near the stoma (surgically created opening between the intestine and the abdominal wall) site, was an open wound. The open wound had a moist red wound base and was approximately 2.5 by 2 cm (centimeter) in size. The wound edge was dry and slightly reddened. A type of a

Based on observation, interview, and record review, the facility failed to ensure the facility policy and procedure for medication administration was implemented and residents received their medications as ordered by the physician and without significant medication errors. During a review of the medication administration process, the following was identified: 1. The Medication Administration Records (MAR) were not verified prior to nurses administering medications; 2. Medication bubble packs were not popped in order by date or verified against the MAR prior to medication administration; 3. Medications discontinued by the physician were not removed from the medication cart. As a result, these discontinued medications continued to be administered by nursing; 4. Medication administered by nursing was not routinely documented as given on the electronic Medication Administration Record [REDACTED] 5. There was no auditing process in place to identify medication errors. These system failures resulted in Residents' 102, 26, 55, 70, 12, 75, 20, 46, 34, 117, 68, 23, and 108 experiencing significant medication errors. These facility failures had the increased potential to cause exacerbation (worsening of medical symptoms) of the residents' medical problems, resulting in an increased potential for harm, injury, or death. Due to multiple resident's not receiving their medications as ordered by the physician, the administrator was verbally notified of an Immediate Jeopardy situation on February 21, 2017, at 4:45 p.m The Immediate Jeopardy was removed in the presence of the Administrator on February 22, 2017, at 2 p.m., after the facility provided an acceptable and immediate action plan implementing measures to ensure facility residents received their medications as ordered by the physician to the California Department of Public Health. Findings: On February 16, 2017, a facility policy and procedure titled, Medication Administration was reviewed. The policy indicated: Purpose: 1. To assure that residents receive their medication as ordered by the physician. Procedure: .1. Check the medication administration sheet . .3. Identify the resident . .5. Administer the medication . .6. Chart the medication given In an interview with the DON (Director of Nursing) on February 15, 2017, at 10:00 a.m., he confirmed medications were not given and further stated the physician was not notified of the missed medications. On February 15, 2017, at 4:40 p.m., in an interview conducted with the facility administrator, he stated all ordered medications should be given as ordered. He further stated, when any medications were missed, the staff should contact the physician and make the physician aware of the missed medications. 1 a. A record review was conducted for Resident 102. The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 102's MAR indicated [REDACTED]. The MAR indicated [REDACTED] -[MEDICATION NAME] 10 milligrams (mg) For Dementia; -Asorbic Acid 500 mg Supplement; -Aspirin 81 mg For Stroke; -[MEDICATION NAME] ER 30 mg For [MEDICAL CONDITION]; -[MEDICATION NAME] 10 mg For muscle spasms; -[MEDICATION NAME] 0.5 mg For pain management; -Keflex 500 mg For [MEDICATION NAME]; -Multivitamins Supplement; -[MEDICATION NAME] 600 mg For high cholesterol; -[MEDICATION NAME] 25 mg For high blood pressure. b.) The record was reviewed for Resident 26. Resident 26 was admitted on [DATE], for [MEDICAL CONDITION] (progressive disease of the lungs causing shortness of breath), High blood pressure, Parkinson Disease (disorder of the nervous system affecting movement), [MEDICAL CONDITION] (mental illness causing an altered perception of reality), and Bi-Polar (severe mood swings). Resident 26's MAR indicated [REDACTED]. The MAR indicated [REDACTED] -Aspirin 81 milligrams (mg) for stroke; -Atorvastatin 10 mg For high cholesterol; -[MEDICATION NAME] 0.5 mg For [MEDICAL CONDITION]; -[MEDICATION NAME] 125 mg For [MEDICAL CONDITION] Disorder; -[MEDICATION NAME] sodium 250 mg For bowel management; -[MEDICATION NAME] 18 mcg For [MEDICAL CONDITION]; -[MEDICATION NAME] ,[DATE] mcg/dose for shortness of breath; -Calcium [MEDICATION NAME] 600 mg Supplement; -[MEDICATION NAME] 5 mg for high blood pressure; -[MEDICATION NAME] 25 mg for high blood pressure; -[MEDICATION NAME] 10 mg For Dementia; and -[MEDICATION NAME] 1.5 mg For [MEDICAL CONDITION]. c.) The record was reviewed for Resident 55. Resident 55 was admitted on [DATE], for Diabetes (high blood sugar), Dementia (disease causing memory loss), and [MEDICAL CONDITION] (severe [MEDICAL CONDITION]). Resident 55's MAR indicated [REDACTED]. The MAR indicated [REDACTED] -Multivitamins daily. Supplement; -[MEDICATION NAME] 10 mg for Dementia; -[MEDICATION NAME] 100 mg for Constipation; and -[MEDICATION NAME] 500 mg for [MEDICAL CONDITION]. d.) The record was reviewed for Resident 70. Resident 70 was admitted on [DATE], for Hypertension (high blood pressure), Stroke (sudden interruption in the blood flow of the brain), Diabetes (high blood sugar), and Dementia (disease causing memory loss). Resident 70's MAR indicated [REDACTED]. The MAR indicated [REDACTED] -[MEDICATION NAME] 5 milligrams (mg) for Dementia; -Aspirin 81 mg for Stroke; -[MEDICATION NAME] 10 mg for high blood pressure; -[MEDICATION NAME] 60 units for high blood sugar; -[MEDICATION NAME] 3 mg for sleep regulation; -[MEDICATION NAME] 250 mg supplement; -[MEDICATION NAME] 1000 mg for high blood sugar; -Humalog 5 units for high blood sugar; and -[MEDICATION NAME] 50 mg for high blood pressure. e.) The record was reviewed for Resident 12. Resident 12 was admitted on [DATE], for Stroke (sudden interruption in the blood flow to the brain), Osteo-Arthritis (inflammation of the joints), Hypertension (high blood pressure), Dementia (progressive memory loss), and [MEDICAL CONDITION] Fibrillation (irregular heart rhythm). Resident 12's MAR indicated [REDACTED]. The MAR indicated [REDACTED] -Aspirin 81 milligrams (mg) for [MEDICAL CONDITION] Fib; -Atorvastatin 40 mg for high cholesterol; -[MEDICATION NAME] 60 mg for depression; -[MEDICATION NAME] 20 mg for acid reflux; -[MEDICATION NAME] 30 ml for bowel management; -Multivitamins daily Supplement; -Potassium 10 milli-equivalent (meq) Supplement; -[MEDICATION NAME] 25 mg for fluid removal; -Vitamin C 500 mg Supplement; -[MEDICATION NAME] 25 mg for blood pressure; -[MEDICATION NAME] 50 mg for blood pressure; -Eliquis 5 mg to prevent blood clots; -[MEDICATION NAME] 40 mg for fluid removal; -[MEDICATION NAME] 150 mg for nerve pain; -[MEDICATION NAME] ,[DATE] mg for pain. 2.) On February 15, 2017, Resident 75's record was reviewed. The resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 75's MAR (Medication Administration Record) was conducted. The medication [MEDICATION NAME] (medication used to treat hypertension) 12.5 milligrams did not have documentation to indicated if it was administered or held on February 6, 7, 8, and 11, at 9 a.m. On February 15, 2017, at 2:40 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 8. LVN 8 reviewed the bubble pack (card containing the prescribed medication) and the MAR. LVN 8 stated, We are to follow the dates on the card but this resident did have extra cards so there is no way to know for sure if he received the meds. 3.) On February 15, 2017, at 5:29 p.m., an investigation was conducted regarding missed medications for Resident 20, and the physician not being notified when the medications were missed. On February 15, 2017, Resident 20's record was reviewed. Resident 20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On February 16, 2017, at 2:43 p.m., Licensed Vocational Nurse 8 (LVN 8) was interviewed. LVN 8 stated the staff nurses are to follow the dates on the medication administration card (when popping medications from the card), and document on the Controlled Drug Record. After reviewing the medication administration card and Controlled Drug Record, she was unable to verify if Resident 20's following medications were given: - [MEDICATION NAME] Tablet 10 MG (milligrams) Give 1 tablet by mouth in the morning related to ESSENTIAL (PRIMARY) HYPERTENSION Hold if SBP (systolic blood pressure - upper numerical value when blood is pumped out of the heart to the body) < (less than) 100 or HR (heart rate) < 60 on February 5, 2017, at 9 a.m. -[MEDICATION NAME] Tablet 0.5 MG ([MEDICATION NAME]) Give 1 tablet by mouth two times a day related to ANXIETY DISORDER, UNSPECIFIED m/b (manifested by) constant verbalization of anxiety/becoming easily agitated such as not being able to relax/inability to focus on February 5, 2017, February 7, 2017, February 8, 2017, and February 11, 2017, at 9 a.m. 4 a. On February 15, 2017, Resident 46's record was reviewed. Resident 46 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. -[MEDICATION NAME] tablet 10 milligram (mg) Give one tablet by mouth one time a day related to Essential (primary) hypertension; -Aspirin Tablet 81 mg Give one tablet by mouth one time a day related for Heart Health; -[MEDICATION NAME] (HCL) Tablet 1000 mg Give one tablet by mouth one time a day related to Type 2 Diabetes Mellitus; and -NAME] tablet Delayed 40 mg Give one tablet by mouth one time a day related to Gastro-[MEDICAL CONDITION] reflux disease (GERD) . A review of Resident 46's Medication Administration Record [REDACTED] The physician's orders [REDACTED]. -Vitamin C Tablet ([MEDICATION NAME] Acid) Give 250 MG by mouth every day evening shift for wound healing; and -[MEDICATION NAME] R Solution (Insulin Regular Human) inject as per sliding scale .subcutaneous before meals and bedtime for blood sugar management. A review of Resident 46's Medication Administration Record [REDACTED]. In addition, the MAR indicated [REDACTED]. On February 15, 2017, at 6:20 p.m., an interview was conducted with the Director of Nurses (DON). The DON acknowledged the medication were not administered for Resident 46 as ordered by the physician, and the physician was not notified of the missed medications. b. On February 15, 2017, Resident 34's record was reviewed. Resident 34 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. -[MEDICATION NAME] Tablet 40 milligram (mg) Give one tablet by mouth in the morning for [MEDICAL CONDITION]; -[MEDICATION NAME] Tablet 2.5 mg one tablet by mouth in the morning for Hypertension; and -Carvedilol Tablet 6.25 mg Give one tablet by mouth two times a day for hypertension. A review of Resident 34's Medication Administration Record [REDACTED]. A concurrent interview was conducted with Registered Nurse (RN) 1, who acknowledged the medications were not administered as ordered by the physician. c. On February 15, 2017, Resident 117's record was reviewed. Resident 117 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. -[MEDICATION NAME] Tablet 10 mg (milligram) Give one tablet by mouth in the morning related to essential (primary) hypertension; -[MEDICATION NAME] Tablet 5 mg .give 1 tablet by mouth in the morning for depression; -[MEDICATION NAME] tablet 0.5 mg give 1 tablet via [DEVICE] two times a day for [MEDICAL CONDITION] (not given 9 a.m.); and -Singular tablet 10 mg give 1 tablet via [DEVICE] in the morning for pneumonia. A review of Resident 117's Medication Administration Record [REDACTED]. A concurrent interview was conducted with Registered Nurse (RN) 1, who acknowledged the medications were not given as ordered by the physician. 5 a. On February 15, 2017, at 8:30 a.m., during the medication pass with Licensed Vocational Nurse (LVN) 6. LVN 6 was observed administering [MEDICATION NAME] (anti-depression medication) 200 mg (milligrams) to Resident 68. Resident 68's record was reviewed on February 15, 2017. The physician orders [REDACTED]. During interview with LVN 6 on February 15, 2017, at 2:30 p.m., LVN 6 stated,I assumed the resident was still taking [MEDICATION NAME] since the resident was taking it for so long. Additionally, Resident 68's physician orders [REDACTED].>-Pantoprazole (medication to treat gastroesopheal reflux) Sodium Tablet Delayed Release 40 mg Give 1 tablet by mouth in the morning; -[MEDICATION NAME] (medication for muscle spasm) Tablet 10 mg Give 1 tablet by mouth three times a day; -Multi-Vitamin/ Minerals Tablet Give 1 tablet by mouth in the morning; and -Vitamin B Complex Tablet Give 1 tablet by mouth in the morning. On February 15, 2017, at 2:30 p.m., LVN 6 was interviewed. LVN 6 stated she did not administer the four medications ordered for Resident 68 during the medication pass observation. b. On February 15, 2017, at 8:45 a.m., during the medication pass observation, LVN 6 was observed administering [MEDICATION NAME] (behavior medication) 0.25 mg to Resident 23. Resident 23's record was reviewed on February 15, 2017. The physician order [REDACTED]. On February 15, 2017, at 2:30 p.m., LVN 6 was interviewed. LVN 6 stated she administered [MEDICATION NAME] 0.25 mg to Resident 23 since the medication cards were still in the medication drawer and she did not know the medication was discontinued. During a concurrent interview with the Director of Nursing (DON), DON stated the licensed nurse who discontinued the medication order should have pulled out the medication card from the medication cart. DON further stated the medication nurse should compare the medication card with the medication order during the medication pass. c. On February 15, 2017, at 8:45 a.m., Resident 23's medication pass was observed. During the medication pass, Resident 23 did not receive a multivitamin with minerals. During a review and verification of Resident 23's current medications, Resident 23's physician orders [REDACTED].>-Multi-Vitamin/Minerals Tablet Give 1 tablet by mouth in the morning. On February 15, 2017, at 2:30 p.m., LVN 6 was interviewed and acknowledged she did not administer the multiple vitamin with minerals for Resident 23. e. The facility's medication storage was inspected with Licensed Vocational Nurse (LVN) 3 on February 15, 2017, at 9:10 a.m. [MEDICATION NAME] 1% drops expiration date of February 5, 2017, was observed available for use. During a concurrent interview conducted with LVN 3, she stated the medication should not have been available for use because it was expired. f. On February 21, 2017, at 2 p.m. an interview was conducted with the facility Administrator. During the interview, he stated medical records did audits weekly on the eMAR to ensure medications were documented when they were given. In addition, he stated nursing completed audits to pull discontinued medications out of the medication carts, but those audits were not documented. A copy of the eMAR audits was requested. On February 21, 2017, at 5 p.m., the Administrator stated the facility could not find any audits of the eMAR completed for the last few months. He stated he did not know what happened to the audits.

Based on observation, interview, and record review, the facility failed to ensure two of three unsampled residents received their medications as ordered by the physician during the medication pass observation. (Resident 68 and Resident 23). This facility failure increased the potential for serious harm to residents who received discontinued medications and residents with missed medications that were not administered as ordered by the physician, In addition, this facility failure increased the potential for residents to experience medical complications [REDACTED]. During the facility medication pass reconciliation on February 15, 2016, the following was identified: 1. Resident 68 received a discontinued medication ([MEDICATION NAME]); 2. Resident 23 received discontinued medication ([MEDICATION NAME]); and 3. Resident 68 and 23 had medications ordered that were not administered. As a result the facility had a medication error rate of 20%. Due to the facility's significant medication error rate of 20%, the Administrator was verbally notified of an Immediate Jeopardy situation on February 16, 2017, at 12:45 p.m. The Immediate Jeopardy was removed in the presence of the Administrator on February 22, 2017, at 2:10 p.m., after the facility provided an acceptable and immediate action plan implementing measures to ensure medications would be administered without error to the California Department of Public Health. Findings: 1. On February 15, 2017, at 8:30 a.m., during the medication pass observation with Licensed Vocational Nurse (LVN) 6, LVN 6 was observed administering [MEDICATION NAME] (medication for depression) 200 mg (milligrams) to Resident 68. Resident 68's record was reviewed on February 15, 2017. The physician orders [REDACTED]. During an interview with LVN 6 on February 15, 2017, at 2:30 p.m., LVN 6 stated,I assumed the resident was still taking [MEDICATION NAME] since the resident was taking it for so long. 2. On February 15, 2017, at 8:45 a.m., during the medication pass observation, LVN 6 was observed administering [MEDICATION NAME] (behavior medication) 0.25 mg (milligrams) to Resident 23. Resident 23's record was reviewed on February 15, 2017. The physician order [REDACTED]. On February 15, 2017, at 2:30 p.m., LVN 6 was interviewed. LVN 6 stated she administered the Resident 23's [MEDICATION NAME] 0.25 mg because the medication cards were still in the medication drawer. During a concurrent interview with the Director of Nursing (DON), he stated the licensed nurse who discontinued the medication order should pull the medication card from the medication cart. The DON further stated, during the medication pass, the medication nurse should compare the medication card with the medication order. 3 a. On February 15, 2017, beginning at 8:30 a.m., during medication pass observations, LVN 6 was observed administering medications for Resident 68. On February 15, 2017, a record review to reconcile the medications administered during the medication pass observation was conducted for Resident 68. Resident 68's active physician orders [REDACTED].>1. Pantoprazole (medication to treat [MEDICAL CONDITION] reflux) Sodium Tablet Delayed Release 40 mg Give 1 tablet by mouth in the morning .; 2. [MEDICATION NAME] (medication for muscle spasm) Tablet 10 MG Give 1 tablet by mouth three times a day .; 3. Multi-Vitamin/ Minerals Tablet Give 1 tablet by mouth in the morning .; and 4. Vitamin B Complex Tablet Give 1 tablet by mouth in the morning . These four medications were not among the medications administered during the medication pass observation. On February 15, 2017, at 2:30 p.m., LVN 6 was interviewed. LVN 6 stated she did not administer the four medications as ordered for Resident 68. 3 b. On February 15, 2017, beginning at 8:30 a.m., during medication pass observations, LVN 6 was observed administering medications for Resident 23. On February 15, 2017, a record review to reconcile the medications administered during the medication pass observation was conducted for Resident 23. Resident 23's active physician orders [REDACTED].>Multi-Vitamin/Minerals Tablet Give 1 tablet by mouth in the morning . LVN 6 acknowledged she did not administer the Multiple-Vitamin/Minerals for Resident 23. The facility policy and procedure titled, Medication Administration, was reviewed and indicated: . Medications are administered in accordance with written orders of the attending physician. .Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength, and route.

Based on observation, interview and record review, the facility failed to ensure the following: Each resident was treated as individual with dignity and respect and was not be subjected to verbal or physical abuse of any kind. Each resident had the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Resident 1 was treated with dignity and respect while getting assistance from staff to use the restroom on September 18, 2013. Resident 1 was free from physical abuse, while getting assistance from staff on September 18, 2913. Findings: A record review was conducted on Resident 1 on September 24, 2013. The record indicated Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. An interview was conducted with Resident 1's daughter on September 24, 2013, at 12:45 p.m. The daughter stated "Mom has a significant bruise on the left wrist. The daughter further stated... " Mom said that she had to go to the bathroom she had her arm up and the girl (Certified Nursing Assistant-CNA 1) grabbed her left arm and pulled her towards the bathroom." The daughter stated, " She (Patient 1) said, it hurt her and would not have complained but the roommate said she needed to complain." The daughter communicated that her mother was primarily at the facility for respite care, and remains on hospice at a nearby board and care. An interview was conducted with Resident 1's roommate, Resident 2 (Name Withheld) on September 24, 2013, at 10:50 a.m. Resident 2 stated, " (Resident 1) was being assisted out of the bathroom and the CNA 1(Name Withheld) grabbed (Resident 1's) arm in a downward motion to the bed. " Resident 2 added that Resident 1 continued to say, "You ' re hurting me." "There were two bruises later on." Patient 2 further stated, " All day (Patient 1) kept saying, " She hurt me." Resident 2 stated, "I don't want to see anyone else hurt...everyone else (here) treats me good except her (CNA 1)." An interview was conducted with Resident 1's caretaker at the board and care on September 27, 2013, at 4:45 p.m. The caretaker stated, " She (Resident 1) told me that when she was at that facility ... the nurse jerked her out of bed by her arms." The caretaker added that this was one of the first things Resident 1 told her when she arrived at the board and care. A record review was conducted of Resident 1 ' s Minimum Data Set (MDS-a comprehensive assessment of a resident) dated July 27, 2013, page 8, indicated, Resident 1 did not have any long term or short term memory problems. The form further indicated under " Cognitive Skills for Daily Decision Making, " Resident 1 was independent with making decisions regarding tasks of daily life. At the board and care facility, an observation and interview was conducted with Resident 1 on September 27, 2013, at 4:30 p.m. Resident 1 stated, "One particular person pulled me out of bed by my arm...I told the nurse who did it " Oh...you hurt my arm." Resident 1 presented her left arm to the surveyor. Resident 1 was alert and able to make her needs known. At this same time, an observation was conducted of Resident 1's left forearm (lower arm). Resident 1 had two bruises present on the outer aspect of the lower arm. The distal bruise (farther away from the heart) on the left forearm measured one inch long by one inch wide. The proximal bruise (closest to the heart) measured one and one half inch long by one half inch wide. This observation was conducted 9 days after the incident. A record review was conducted on Resident 1 on September 24, 2013. Resident 1's care plan dated September 13, 2013 did not have any entry relating to the alleged incident that was reported by Resident 1's roommate on Friday, September 20, 2013. A record review of the Administrator's written statement to the Department, dated September 24, 2013, indicated, Resident 2 reported CNA 1 "was frustrated and pulling on (Resident 1's) arm, hurting her and yelling her to stop getting up and down." The report further stated..."our investigation found that (CNA 1) was inappropriate in her care and service to (Resident 1). She did cause pain to the resident by pulling on her arm, resulting in bruising." During an interview on December 10, 2013, at 1 p.m., the administrative staff stated the following: 1. Resident 1 has a daughter (another) who resides in the facility and was observed by staff pulling on Resident 1 ' s arm ...the DON stated she (the relative) would attempt to get her out of bed or lead her to different areas of the facility. 2. There was a discrepancy with the answers from those interviewed as to whether Resident 1 was pulled up from the bed or pulled down from the bed. Resident 1 was not a reliable source. 3. Resident 1 had multiple skin issues on admission, had two falls and was on medication that had the potential for this resident to bruise easily with her stay at the facility which may have contributed to the bruises on the left forearm. There was no mention of this information (resident to resident contact) by the facility staff members during the Health Facilities Evaluator Nurse (HFEN) investigation, prior to the December 10, 2013, interview and record review. There was no documentation in the medical record or a care plan that reflected this occurrence. There was documentation regarding skin tears and bruising with the admission skin assessment. There was not an updated skin assessment clarifying the new bruises to the left lower forearm. Resident 1 ' s record had a physician's orders [REDACTED]. There was no documented evidence that the nurses re-evaluated Resident 1 ' s skin status in their notation with the new bruises or document on the care plan about the new bruises. A review of the undated facility policy and procedure titled, "Prohibition of Abuse, Neglect, Mistreatment and Misappropriation of Resident Property," indicated, under policy statement, "Resident must not be subjected to abuse by anyone, including but not limited to; community staff other residents, consultants, or volunteers, staff of other agencies serving the residents, family members, visitors, legal guardians, friends or individuals." The policy further indicated, under Executive Director/designee, " 5. The Executive Director/designee identifies events such as suspicious bruising or residents, occurrences, patterns, and trends that may constitute abuse: and to determine the direction of the investigation. " The facility failed to ensure Resident 1 was by treated with dignity and respect on September 18, 2013, when CNA 1 pulled on Resident 1's arm causing pain and bruising to the left lower forearm. The facility failed to ensure Resident 1 was free from physical abuse on September 18, 2013, when CNA 1 pulled Resident 1's arm; causing pain and bruising to the left lower forearm. The above violation had a direct or immediate relationship to the health, safety, and security of patients.