Every finding on record at Santa Cruz Post Acute

Based on interview and record review, the facility failed to meet professional standards of practice when Licensed Vocational Nurse A (LVN A) and LVN B did not follow their policy and procedures for administering medication when they did not document their initials and make entries in the Electronic Medication Administration Record (eMAR) after giving medications for 1 of 2 residents (Resident 1). This failure has the potential not to track when the medications were last given that may lead to double dosing or missed medications that may compromise Resident 1's health and safety. Findings:Review of Resident 1's medical record indicated he was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), glaucoma (an eye disease that can cause blindness) depression, (persistent feeling of sadness and loss of interest) legal blindness (visual impairment), cervical radiculopathy (nerve compression in the neck) and hypertension (high blood pressure).Review of Resident 1's physicians' orders for April 1, 2026 to May 6, 2026 indicated, Tresiba (insulin injection medication for diabetes) 100 units per milliliter (U/ml, units of measurement) inject 35 units subcutaneously (fatty tissue layer between skin and muscle) one time a day at 1 p.m., Dorzolamide Hydrochloride (HCl) (eye drops) 2-0.5 percent, instill one drop in both eyes at 9 a.m. and 1 p.m., Brimonidine Tartrate (eye drops) 0.2 percent, instill one drop in both eyes at 9 a.m., 12 noon and 5 p.m., Gabapentin capsule (medication used for numbness and tingling of legs) 100 milligrams (mg, unit of measurement) give two capsules orally at 9 a.m., 12 noon and 5 p.m., Ibuprofen tablet (medication use for pain and inflammation) 400 mg give one tablet orally at 9 a.m., 1 p.m., and 9 p.m., Aspirin chewable (blood thinner medication) 81 mg give one tablet orally at 9 a.m., Meloxicam (pain medication) 7.5 mg give one tablet orally at 9 a.m., Multivitamin/Minerals (supplement) to give one tablet orally at 9 a.m., Omeprazole (medication used acid reflux) 20 mg give one tablet orally at 9 a.m., Sertraline HCl ( antidepressant) 150 mg give one capsule orally at 9 a.m., Atropine Sulfate 1% (eye drops) instill one drop in right eye at 9 a.m. and 5 p.m., Glucophage (medication used for DM) 1000 mg give one tablet orally at 9 a.m. and 5 p.m.Review of Resident 1's printed eMAR for April 1, 2026 to May 10, 2026 indicated, on 4/2/26 there were no licensed nurse initials and entries for the following medications: Tresiba 35 units injection at 1 p.m., Dorzolamide HCl eye drops at 1p.m., Brimonidine Tartrate eye drops at 12 noon, Gabapentin 100 mg, 2 capsules at 12 noon, and Ibuprofen 400 mg tablet at 1p.mDuring an interview and record review of the April 2, 2026 eMAR with the LVN B on 5/11/26 at 1:58 p.m., she confirmed that she was assigned to Resident 1 on 4/2/26 in the morning shift. LVN B stated she forgot to put her initials and entries in eMAR for the above medications after she gave them to Resident 1. LVN B acknowledged she should have put her initials and entries immediately after the above medications were given to Resident 1 on 4/2/26 morning shift scheduled times as per their facility's policy and procedures.Review of Resident 1's printed eMAR for May 2026 on 5/11/26 indicated, on 5/6/26 there were no licensed nurse initials and entries for the following medications: Tresiba 35 units injection at 1 p.m., Dorzolamide HCl eye drops at 9 a.m. and 1p.m., Brimonidine Tartrate eye drops at 9 a.m. and 12 noon, Gabapentin 100 mg, 2 capsules at 9 a.m. and 12 noon, Ibuprofen 400 mg tablet at 9 a.m. and 1p.m., Aspirin chewable 81 mg tablet at 9 a.m., Meloxicam 7.5 mg one tablet at 9 a.m., Multivitamin/Minerals one tablet at 9 a.m., Omeprazole 20 mg tablet at 9 a.m., Sertraline HCI 150 mg one capsule at 9 a.m., Atropine Sulfate 1 percent one drop in right eye at 9 a.m., and Glucophage 1000 mg one tablet at 9 a.m.During an interview and record review of the May 6, 2026 eMAR with the LVN A on 5/11/26 at 1:48 p.m., she confirmed that she was assigned to Resident 1 on 5/6/26 in the morning shift. LVN A stated she forgot to put her initials and entries in eMAR for the above medications after she gave them to Resident 1. LVN A acknowledged she should have put her initials and entries immediately after the above medications were given on 5/6/26 morning shift scheduled times as per their facility's medication administration practices and procedures.During an interview with the Director of Nursing (DON) on 5/11/26 at 1:30 p.m., she acknowledged that LVNs A and B should have documented their initials and entries immediately in the eMAR after they gave the above medications to Resident 1 on 4/2/26 and 5/6/26 morning shifts scheduled times as per facility's procedures and practices.Review of the revised facility's policy and procedures dated 4/2019 titled, Administering Medications indicated, the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. If the drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication will initial and circle the MAR space provided for that drug and dose. For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR maybe flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication.

Based on observation, interview, and record review, the facility failed serve food that accommodated allergies, intolerances, and preferences for one of three residents (Resident 1). This failure had the potential to affect the resident's health and well-being.Findings: Review of Resident 1's clinical record indicated the resident was admitted with diagnoses including osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D) and chronic obstructive pulmonary disorder (COPD, a chronic lung disease causing difficulty in breathing).Review of Resident 1's Dietary Interview/Pre-Screen, dated 11/28/25 indicated the resident had food intolerances for bell pepper.Review of the facility's Fall/Winter Week 2 Menu, indicated Sweet and Sour Pork, steamed rice, and Asian vegetable blend was served for dinner on Friday.Review of Resident 1's tray card indicated she had an allergy to bell peppers.Review of Resident 1's SBAR Summary for Providers, dated 12/5/25 indicated the resident's nurse was informed by the certified nursing assistant that Resident 1's heart was beating fast. The SBAR indicated Resident 1's blood pressure was 150/100 and her heart rate was 136. It indicated Resident 1 was sent to the hospital.Review of Resident 1's Interdisciplinary Team progress note, dated 12/8/25 indicated, on 12/5/25 Resident 1 mixed [NAME] sweet and sour sauce to the rice. The note indicated the sauce contained dried red and green bell peppers. The note indicated Resident 1 claimed that she started to feel her mouth get numb and feel upset stomach. The note also indicated that no clinical findings of an acute allergic response was identified during the hospital emergency room evaluation. During an interview on 3/11/26 at 3 p.m., the registered dietician (RD) confirmed Resident 1 had an intolerance to bell peppers. The RD stated the sauce/condiment packet contained bell peppers.During an interview on 3/11/26 at 3:08 p.m., certified nursing assistant A stated Resident 1 was allergic to something that she got on her tray.During an observation on 3/11/26 at 3:44 p.m., the [NAME] sweet and sour sauce had ingredients listed. It indicated it contained dried red and green bell peppers.During an interview on 3/11/26 at 3:52 p.m., the dietary director (DD) confirmed per the facility's Fall/Winter Week 2 Menu, on 12/5/25 residents were served Sweet and Sour Pork, steamed rice, and Asian vegetable blend for dinner.During an interview on 3/12/26 at 11:02 a.m., the DD confirmed the [NAME] sauce was served on the tray for the sweet and sour pork meal.Review of the facility's policy, Food Allergies and Intolerances, dated 8/2017 indicated, Residents with food allergies and/or intolerances are identified upon admission and offered food substitutions of similar appeal and nutritional value. Steps are taken to prevent resident exposure to the allergen(s).

Based on interview and record review, the facility failed to provide the necessary treatment and services in accordance with professional standards of practice for one of three sampled residents (Resident 1)'s when:1. The Licensed Nurses (LN) did not consistently provide the treatment per physician's order to Resident 1's open wound on bilateral heels during the process of reclassification from a blister (is a painful skin condition where fluid fills a space between layers of skin) to deep tissue injury (DTI, is a type of subcutaneous tissue damage that results from an externally applied mechanical load (pressure)) then a diabetic ulcer (is an open sore or wound on the foot of a person with diabetes (high blood sugar)).2. Licensed nurses did not obtain a wound treatment order to provide pressure ulcer care in timely manner for Resident 1 on 7/20/25, 7/21/25, 7/23/25 and 7/24/25 upon identification of a stage two (St. 2) pressure ulcer on his sacrum area when he returned from the hospital on 7/19/25.3. The facility did not develop a care plan to address Resident 1's PU on his sacrum (a bony structure that is located at the base of the spine)These failures could delay Resident 1's diabetic foot ulcer and pressure ulcers' healing and treatment.1. During a review of Resident 1's clinical record indicated he was admitted on [DATE] and readmitted to the facility on [DATE] with several emergency department (ED, a 24/7 facility that provides rapid diagnosis, urgent care, and inpatient admission for stabilizing seriously ill) visits on 2/15/25, 2/22/25 and 2/23/25 associated with his change of condition. During an interview on 2/2/26, at 11:10 a.m. and 12:20 p.m., with the director of nursing director (DON), the DON stated Resident 1 had blisters on his bilateral heel upon admission, and after the wound treatment his left heel was healed by 3/10/25. The right heel remained not healed requiring wound treatment. The DON further stated, in the year 2025, the facility had employed several registry nurses, and this could have resulted in some missing wound treatment. A review of Resident 1's treatment administration record (TAR) from the month of 2/2025 through 8/2025, the TAR indicated Resident 1's wound treatment order had changed several times from 2/2025 to 8/2025, and found missing wound treatment as follows: A wound order dated 2/1/25 to 2/21/25 for Abrasion to Right Lateral Malleolus - Cleanse with NS (normal saline, is a crystalloid fluid), pat dry, apply Medi honey (is a medical-grade, antibacterial Leptospermum honey used to treat acute and chronic wounds, including burns, diabetic foot ulcers), cover with dry dressing every dayshift in 2/2025's TAR had missing entries for wound care on 2/10/25 and 2/19/25. A wound order dated 2/19/25 to 3/11/25 for Blister to Left Lateral Heel - Cleanse with NS, pat dry, apply Betadine, cover with dry dressing every dayshift in 2/2025 and 3/2025's TAR had missing entries for wound care on 2/23/25 and 3/10/25. A wound order dated 2/19/25 to 3/26/25 for Blister to Right Lateral Heel - Cleanse with NS, pat dry, apply betadine, wrap with Kerlix every dayshift in 2/2025 and 3/2025's TAR had missing entries for wound care on 2/23/25, 2/24/25, 3/15/25 and 3/26/25. A wound order dated 3/27/25to 4/2/25 for Blister to Right Lateral Heel - Cleanse with NS, pat dry, apply triple antibiotic ointment to wound bed, cover with dry dressing every dayshift in 3/2025's TAR had missing entries for wound care on 3/29/25. A wound order dated 4/3/25 to 4/4/25 for Blister to Right Lateral Heel - Cleanse with NS, pat dry, apply Medi honey to wound bed, cover with dry dressing every dayshift in 4/2025's TAR had missing signatures for wound care on 4/4/25. A wound order dated 4/5/25 to 4/17/25 for DTI to right Lateral Heel - Cleanse with NS, pat dry, apply TAO to wound bed, cover with dry dressing every dayshift in 4/2025's TAR had missing entries for wound care on 4/12/25 and 4/13/25. A wound order dated 5/8/25 to 5/13/25 for Diabetic Ulcer to Right Lateral Heel - Cleanse with NS, pat dry, apply Medi Honey, cover with ABD (abdominal) pad, cover with dry dressing every dayshift in 5/2025's TAR had missing entries for wound care on 5/10/25 and 5/11/25. A wound order dated 5/14/25 for Mupirocin External Ointment 2 % (Mupirocin, is used to treat secondarily infected traumatic skin lesions due to specific bacteria) Apply to Right Lateral Heel topically every dayshift every other day for Wound Care for 30 Days in 5/2025 and 6/2025's TAR had missing entries for wound care on 5/24/25, 5/28/25 and 6/13/25. A wound order dated 6/21/25 to 6/24/25 for Diabetic Ulcer to Right Lateral Heel - Cleanse with NS, pat dry, apply Mupirocin ointment to wound bed, Apply Santyl to Wound bed, cover with dry dressing every dayshift every other day had missing entries for wound care on 6/21/25. A wound order dated 6/25/25 to 7/17/25 for Diabetic Ulcer to Right Lateral Heel - Cleanse with NS, pat dry, apply barrier cream, apply clotrimazole cream, cover with calcium alginate AG, cover with dry dressing, wrap with Kerlix, secure with tape every dayshift in 6/2025's TAR had missing entries for wound care on 6/26/25. During an interview on 2/24/26, at around 10:10 a.m., with the DON, she confirmed missing wound treatment as listed above. On 2/10/25, 2/19/25, 2/23/25, 3/10/25, 2/23/25, 2/24/25, 3/15/25, 3/29/25, 3/25, 4/4/25, 4/12/25, 4/13/25, 4/12/25, 4/13/25, 5/10/25, 5/11/25, 5/24/25, 5/28/25, 6/13/25, 6/21/25 and 6/26/26/25, Resident 1's TAR was not signed by the licensed nurses. The DON admitted , if there was no signature, the treatment was not done. 2. During a review of Resident 1's TAR in 7/2025, it indicated a wound treatment order for stage 2 pressure ulcer (is damage to the skin and underlying tissue caused by prolonged pressure) to sacrum, cleanse with NS or soap and water, pat dry, apply barrier cream, cover with foam dressing every dayshift. Start date on 7/26/25. During a review of Resident 1's weekly wound assessment, it indicated his sacrum wound was assessed on 7/22/25 and 7/25/25 during a wound dressing change to cleanse with NS, apply barrier cream and cover with foam dressing.During a telephone interview on 2/10/26, at 2:35 p.m., with the DON, she confirmed the St.2 pressure ulcer was found upon his return from the hospital on 7/19/25 and the staff missed to obtain a wound treatment order; hence, the wound treatment were not done on the following days: 7/20/25, 7/21/25, 7/23/25 and 7/24/25. The DON further stated that Resident 1 had a hospitalization from 7/9/25 through 7/19/25, and the St.2 pressure ulcer was acquired during his hospital stay.During a review of the facility's undated policy and procedure (P&P) titled, Wound Care, the P&P indicated, Verify that there is a physician's order for this procedure.Apply treatments as indicated.3. During a review of Resident 1's care plans, there was care plan developed to address the resident's St.2 pressure ulcer on his sacrum.During an interview on 2/2/26 at 11:10 a.m. and 2/24/26 at 10:10 a.m., with the DON, the DON reviewed Resident 1's clinical record and could not find a care plan in place to address his pressure ulcer on his scrum. During a review of the facility's policy and procedure (P&P) titled, Prevention/Management of Pressure Ulcers/Injuries, revised 2/2023, the P&P indicated, Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. During a review of the facility's policy and procedure (P&P) titled, Care Plan, Comprehensive Person-Centered, dated 3/2022, the P&P indicated, A comprehensive, Person-Centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services to prevent urinary tract infections (UTIs) for one of three sampled residents (Resident 1) with foley catheter when: 1. Staff failed to follow a prescribed order dated 12/22/25 to collect a urine sample for culture and sensitivity (C&S, is a two-part diagnostic test used to detect urinary tract infections (UTIs) and determine the best antibiotic treatment) in timely manner.The nurses failure to collect urine culture sample had delayed the provision of appropriate treatment contributing to worsening in his condition resulting to transfer to acute hospital on 2/28/25 .2. Resident 1's indwelling foley catheter ( a device that drains urine (pee) from your urinary bladder into a collection bag outside of your body when you can't pee on your own) urine bag was found on the floor. This failure had the potential for Resident 1 to develop CAUTI (catheter associated urinary tract infection). 1. Review of Resident 1's admission record indicated he was initially admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses including retention of urine , other mechanical complication of indwelling urethral catheter and type two diabetes mellitus (is a chronic condition where your body cannot properly use or make enough insulin, leading to too much sugar (glucose) building up in your blood) with foot ulcer (is a serious complication affecting up to 34% of patients, often caused by neuropathy (loss of feeling), poor circulation, and infection risk). Review of Resident 1's minimum data set (MDS, is a federally mandated, standardized clinical assessment tool used to evaluate the physical, psychological, and psychosocial functioning of all residents), dated 11/25/25, it indicated his brief interview for mental status (BIMS, an assessment to screen for cognitive impairment in residents) score was 15 ( score of 13 to 15 means cognitively Intact). He had an indwelling foley catheter. Review of Resident 1's physician's orders, dated 12/22/25 at 8:11a.m., it indicated, collect urine for C&S (culture and sensitivity) every shift for burning with urination. During a review of Resident 1's nurse's note, dated 12/23/25, it indicated, Spoke with resident and family regarding pain in bladder area. His urine is dark yellow; no sediment observed. Resident has PRN Norco (pain medication) which is effective for pain. Resident calls his daughter when in pain and daughter calls the facility , when resident has discomfort . Family is asking to send to the hospital for evaluation several times a week for bladder discomfort. Resident educated to ask nurses on duty for pain medications. Resident and daughter expressed that staff does not care. Resident has a follow up appointment with urologist (specialist doctor for problems with urinary system) on 1/22/26. unable to schedule anything sooner. During a concurrent interview and record review on 2/23/26, at 10:50 a.m., with the director of nursing (DON), the DON confirmed Resident 1's urine sample for urine culture was collected on 12/28/25 at 3:10 a.m. The DON stated the urine sample was collected prior to his transfer to the hospital. The DON further stated Resident 1 was found with UTI in the hospital. Resident 1's hospital record indicated a urinalysis (UA, a urinalysis is a diagnostic test that examines a urine sample for UTIs or kidney disease) reports dated 12/28/25 indicating the urine sample was collected at 8:45 a.m. with positive results. During an interview on 2/23/26, at 1:35 p.m., with the DON, she stated the nurse who received the urine culture order on 12/22/25 no longer works in the facility. The DON stated nurses should have followed the physician's order to collect urine sample for culture. During an interview on 2/23/26, at 2:50 p.m., with registered nurse A (RN A), RN A stated after receiving the physician's order for urine culture order, the nurse had to put the order in electronic health records to be carried out during the shift, and if unable to collect urine sample then this should have been endorsed to next shift for follow up. During a telephone interview on 3/2/26, at 8:38 a.m., with the case manager (CM), the CM stated, Resident 1's urine culture test should have been done sooner or earlier to determine the best antibiotic treatment to prevent Resident 1's ED visit on 12/28/25. According to Resident 1's emergency department (ED, a specialized, 24/7 hospital facility designed to provide immediate, unscheduled care for acute, life-threatening, or severe health conditions) notes on12/28/25, his labs (laboratory) showed evidence of UTI. The notes indicated, daughter at bedside expresses concerns that patient has been complaining of abdominal pain for the last one to two weeks and she feels that the staff in the nursing facility has been ignoring his complaints. Resident 1 received intravenous (IV, is a quick way to get fluids, medicine, or blood directly into a person's vein through a small tube) antibiotics (medications to treat infection) and the foley catheter was changed. The computed tomography (CT, a medical imaging scan) revealed that Resident had cystitis (inflammation typically caused by bacterial infections (E. coli), resulting in painful, frequent, and urgent urination). During a review of Resident 1's SBAR (situation, background, assessment, recommendation, is a communication tool in nursing), dated 12/28/25, it indicated, Went to patients room to administer medication and noticed he was in a lot of pain. He said he had pain at his catheter site, and it feels like chilies (chills or shivering) when he urinates he wanted to go to the hospital. Administered routine pain medicine and his pain level went down to a 5/10 but he said he still wanted to go. During an interview on 2/23/26, at 1:35 p.m. with the DON, she stated the nurse who received the urine culture order on 12/22/25 was no longer working in the facility. DON confirmed Resident 1's urine culture order should be followed on 12/22/25 to collect urine culture, the urine specimen was delayed for follow-up. No endorsement or communication in place for the urine culture would need to be collected. During an interview on 2/23/26, at 2:50 p.m., with the registered nurse A (RN A), RN A stated after receiving the urine culture order would need to put in their system of electronic health records for carrying out during the shift, if not able to then would need to endorse to the nurse in next shift for collecting urine specimen. During a telephone interview on 3/2/26, at 8:38 a.m., with case manager (CM), CM stated that Resident 1's urine culture test should have been done sooner or earlier to determine the best antibiotic treatment for Resident 1 to prevent 12/28/25's ED visit.Review of the facility's policy and procedure (P&P) titled, Lab and Diagnostic Test Results-Clinical Protocol, dated 11/2018, it indicated , The staff will process test requisitions and arrange for tests. A nurse will identify the urgency of communicating with the attending physician based on physician request, the seriousness of any abnormality, and the individual's current condition. Before contacting the physician, the person who is to communicate.be prepared to discuss the following (to the extent that such information is available) including why the lab and diagnostic tests were obtained ( for example, as a routine screen or follow-up; to assess a condition change or recent onset of sign and symptoms, or to monitor a serum medication level. 2. During an observation on 2/23/26, at 12:55 p.m., Resident 1's urine collection bag connected to his urinary catheter was placed on the floor. Certified nursing assistant B (CNA B) who was present inside Resident 1's room validated the observation. CNA B stated the urine bag should not be placed on the floor. It should be secured on the bed rail above the floor and below the bladder of Resident 1 to prevent infections.During a review of the facility's policy and procedure (P&P) titled, Catheter Care , Urinary, dated 8/2022, it indicated, . Be sure the catheter tubing and drainage bag are kept off the floor. Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder.

Based on the interview and record review, the facility failed to follow Resident 1's physician order for collecting stool culture for one of three sampled residents (Resident 1) when Resident 1 had several days of diarrhea (loose stools). This failure had the potential to affect Resident 1's health and condition.During a review of Resident 1's medical record it indicated he was admitted to the facility on [DATE].During a review of Resident 1's nursing progress notes, dated 3/11/25 at 3:23 p.m., it indicated, Patient has been having diarrhea on and off since he has been here.During a review of Resident 1's physician order, dated 2/13/25, it indicated, Collect stool to r/o (rule out) C-diff (Clostridioides difficile, is a bacterium that causes severe, watery diarrhea and intestinal inflammation (colitis)) and norovirus (is a very contagious virus that causes vomiting and diarrhea).During a review of Resident 1's nursing progress notes, dated 3/12/25 at 1:25 p.m., it indicated, Resident 1 is due for a stool culture and c-diff sample to be sent to lab; however, he did not have a bm (BM, bowel movement) on PM shift (3 p.m. to 11 p.m.) and will need to collect sample on next shift. No further documentations regarding the stool culture would need to follow up. Review of this resident's Documentation Survey Report V2 for bowel continence record in 3/2025, it indicated Resident 1 had BM in AM (7 a.m. to 3 p.m.) and PM shift on 3/13/25 and also, he had a BM the next day on 3/14/25. During an interview on 1/30/26, at 3:30 p.m. and 2/10/26, at 2:45 p.m., with the director of nursing (DON), the DON confirmed nursing staff did not carry out the physician's order for stool culture. There was no documented evidence that the physician canceled or discontinued collection of stools for culture. During a review of the facility's undated policy and procedure (P&P) tilted, Lab and Diagnostic Test Results -Clinical Protocol, The staff will process test requisitions and arrange for tests. A nurse will identify the urgency of communicating with the Attending Physician. Physicians or nurses who have concerns about how test results have been handled or reported should communicate such concerns to the DON and/or Medical Director. Such concerns or disagreements should not prevent timely, clinically appropriate management of a current result or clinical situation.

Based on interview and record review, the facility failed to provide services that met professional standards of quality when pre-operative instructions were not followed prior to a scheduled procedure for one of three residents (Resident 1). This failure resulted in Resident 1's procedure cancellation and had the potential to result in health complications.Findings: Review of Resident 1's Office Visit Progress Notes, dated 8/11/25 indicated Patient 1 was scheduled for right ureteroscopy (procedure used to treat kidney stones) with possible laser endopyelotomy (procedure that opens up a blockage in the kidney) with ureteral stent placement (a procedure that places a flexible tube into the ureter [tube that drains urine from the kidney to the bladder] to allow urine to drain. The notes also indicated, Stop Eliquis [apixaban, anticoagulant that thins blood to treat and prevent blood clots] 3 days before surgery. Review of Resident 1's Physician Orders indicated she had an order dated 3/28/25 for apixaban 5 milligrams (mg, unit of measurement) one tablet by mouth two times a days for blood clot prevention. The orders also indicated she had an order dated 9/1/25 Resident 1 has surgical procedure on 9/2/25 pick up time is 5:15 have resident ready. Review of the Resident Calendar, dated 9/9/25 indicated Resident 1 had an appointments on 9/2/25 with instructions to arrive at 6 a.m. for a 7:30 a.m. surgery with urology and 9/8/25 with instructions to arrive at 6 a.m. for ureteroscopy surgery at 7:30 a.m. with pick up at 5:15 a.m. Review of Resident 1's September 2025 Medication Administration Record (record of medications given) indicated apixaban was not given on 9/1/25 and 9/2/25. It further indicated apixaban was given to Resident 1 twice a day from 9/3/25 to 9/8/25. During an interview on 9/9/25 at 2:22 p.m., the director of nursing (DON) stated on 9/2/25, transportation did not arrive to take Resident 1 to her appointment, so it was missed. She stated Resident 1's appointment was rescheduled for 9/8/25. She stated there was some miscommunication when it was rescheduled and there was no order to discontinue Eliquis prior to the 9/8/25 appointment. The DON stated it should have been communicated to the nurses. She stated Resident 1 was transported to her 9/8/25 appointment but her procedure was cancelled because Eliquis was given. The DON stated usually resident's scheduled appointments are reviewed during the morning meeting with department heads, but Resident 1's 9/8/25 was not. The DON stated there was no process to review Monday appointments that are added to the calendar on a Friday afternoon. She stated she did not know about the appointment until 9/8/25. During an interview on 9/9/25 at 2:30 p.m., the receptionist stated Resident 1's family member informed her about the Resident 1's rescheduled appointment. She stated she scheduled transportation and added Resident 1's 9/8/25 appointment to the Resident Calendar. Review of the facility's undated policy, Surgery-Related (Pre- and Postoperative) Management, indicated, As needed, the physician will evaluate a resident who is scheduled to undergo surgery and the assessment will focus on pertinent items including . identifying significant medication-related risks (for example, stopping anticoagulation .

Based on interview and record review, the facility failed to ensure resident safety to prevent accidents resulting in a fall for one of three residents (Resident 1) when the facility van's wheelchair securement system (a safety device installed in accessible vehicles used to keep a wheelchair in place during transport and also secure the wheelchair user with safety straps) used to transport Resident 1 did not meet Code of Federal regulations, Title 49, Part 38 (49 CFR S 38.23(d)(7), Americans with Disabilities Act [ADA] Accessibility Specifications for Transportation Vehicles), and the facility used three staff members (maintenance supervisor [MS], central supply staff [CSS], and the maintenance assistant [MA]) that were not qualified and/or were not trained to transport residents using the facility van: -The facility van lacked the required seat belt or safety belt, specifically the shoulder harness (strap that goes diagonally over the shoulder, across the chest, down to the lap) to secure a wheelchair user; - The maintenance supervisor (MS), central supply staff (CSS), and the maintenance assistant (MA) transported residents in the facility van without a certified nursing assistant certification, a requirement for a van driver; - The MA did not complete the Facility Vehicle Driver Training Program and did not conduct and complete a Pre-Trip Inspection Report prior to transporting Resident 1 using the facility van. The failures of transporting residents in the facility van without necessary safety belts resulted in Resident 1's fall in the facility van on [DATE], sustaining a skin tear and head injury, and had the potential to result in other residents' falls and injuries.Findings: Review of Resident 1's face sheet (a summary document containing a resident's personal and demographic information, including contact details and medical history), dated [DATE] indicated she was admitted to the facility with diagnoses including dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney or kidneys have failed) and difficulty in walking. Review of Resident 1's physician order indicated an order, dated [DATE], Dialysis schedule on Saturday [DATE] at [dialysis facility] in Watsonville. [The facility] will provide W/C [wheelchair] transport to dialysis with pick up at 10:30 AM. Review of Resident 1's Change of Condition progress note, dated [DATE] indicated, Per in house transport driver, resident fell during transportation going to dialysis . Resident noted with 3 cm [centimeter, unit of measurement] x 2cm x 0.5cm Right shin skin tear. Review of Resident 1's IDT note, dated [DATE], indicated, On [DATE], [Resident 1] returned to facility following scheduled dialysis appointment. Per in-house transport driver, resident experienced a fall incident [in the facility van] during transportation to dialysis, reportedly due to a seat malfunction within the transport vehicle. Incident occurred prior to arrival at dialysis facility. Upon return to facility, resident was assessed immediately by licensed nurse (LN) . MD ordered to send resident out to ER for further evaluation . Driver stated that the resident fell from the transport chair due to an apparent seat malfunction. Resident verbalized she was 'okay' at the time of the incident and expressed that she was comfortable proceeding with dialysis . Review of Resident 1's Emergency Department (ED) Physician Notes, dated [DATE] indicated, [Resident 1] is an [AGE] year old F [female] who had a mechanical fall while being transported to dialysis. She sustained a small skin tear to one of her lower extremities and struck her head . Physical Examination . Head: Moderate tenderness to palpation [examination of the body by using touch] in the left forehead area . she does note moderate to severe pain in the area Neck: Patient is complaining of diffuse neck pain and on physical exam had midline neck pain so could not be clinically cleared and was placed in a soft collar . The ED Physician Notes also indicated Resident 1's diagnosis was a closed head injury [traumatic brain injury caused by a blow to the head with no break in the skull]. Review of Resident 1's Discharge Instructions Document, dated [DATE] indicated, You were seen in the emergency department after a head injury . It is possible that you have a concussion . There is no imaging . that makes this diagnosis. The diagnosis is based on symptoms. Typical symptoms include headache, dizziness, and/or nausea/vomiting . Review of Resident 1's Nurse's Note, dated [DATE] indicated Resident 1 complained of headache, was given Tylenol (pain medication) 325 milligrams (mg, unit of measurement) two tablets. Review of Resident 1's Medication Administration Record for [DATE] indicated Resident 1 received Acetaminophen 325 mg two tablets as needed for mild/generalized body pain on [DATE] at 5:07 p.m., [DATE] at 8:52 a.m., and [DATE] at 9:36 a.m. During an interview on [DATE] at 2:43 p.m., the administrator (ADM) stated another driver, not the regular facility van driver, drove Resident 1 to the dialysis center on [DATE]. The ADM stated the facility had two staff members that could drive the facility van. During an interview on [DATE] at 2:14 p.m., the director of nursing (DON) stated the drivers just drive and do not have experience in patient care or assessment. She stated if the driver did not know what to do at that time, the driver should have called 911. The DON also stated that after a resident falls, another option for the driver would be to call the facility or speak to a nurse. During an interview on [DATE] at 12:26 p.m., licensed vocational nurse A (LVN A) stated he did not remember the name of the staff member driving the van. LVN A stated the staff member driving the van informed him that on their way to dialysis on [DATE], Resident 1 fell onto the floor of the van and hit her head. LVN A stated the staff member driving the van informed LVN A that he asked Resident 1 if she was okay, Resident 1 replied that she was fine, and they continued to the Resident 1's dialysis facility. LVN A stated when Resident 1 got back to the facility after having dialysis, she had a skin tear on her knee and was given pain medication. He stated because Resident 1 had a head injury, she was sent to a hospital emergency department. LVN A stated the staff member driving the van was not a healthcare provider and was not qualified to make the determination whether the resident was okay to go to dialysis. He stated the staff member driving the van should have at least informed the dialysis facility about Resident 1's fall on [DATE]. During an interview and concurrent document review on [DATE] at 1:54 p.m., the maintenance aide (MA) stated he was asked to transport Resident 1 in the facility van. Review of MA's text message from the marketing director (MD) dated [DATE] at 1:04 p.m. indicated, Please take [Resident 1] tomorrow Saturday to dialysis. Drop off and pick up . [The ADM] told me to let you [the MA] know. The MA stated he was not comfortable driving the resident because he had no experience transporting residents before and he was not trained to drive. The MA stated he felt forced to do it because he was told transporting residents would be added to his job description. He stated he was told if he did not drive Resident 1, they would find someone else to do his job. The MA stated on [DATE] he did his best to strap Resident 1 down with the straps they had in the van. He stated when he was driving on the highway, he looked back and saw Resident 1's wheelchair doing a wheelie on its back wheels. The MA stated he realized he did not have her strapped down the correct way. The MA stated when he stopped the van along the way to the dialysis facility, Resident 1 came out of the wheelchair, fell forward, and bumped her head against the fire extinguisher. The MA stated he panicked and asked if she was okay, but there was a language barrier because he did not speak the language Resident 1 spoke. He stated he only secured the back wheels and did not have Resident 1 strapped with a lap belt (belt stretched across the passenger's lap and secure them in their seat). He further stated after dropping off Resident 1 at dialysis, he called the facility to inform the nurse about Resident 1's fall. The MA stated the nurse told him he would assess Resident 1 when she gets back to the facility from dialysis. The MA stated after Resident 1's fall, the facility had shoulder straps on the side of the van installed. He said prior to Resident 1's fall, the van did not have the strap that goes up and across a resident's chest. During an interview on [DATE] at 10:40 a.m., the MA stated he did not perform an inspection or complete a form prior to transporting Resident 1 on [DATE]. The MA also stated after Resident 1's fall, he completed the driver training and was trained by the former director of staff development (FDSD). He stated he did not complete any other driver training from another staff member or DSD prior to driving the van on [DATE]. During an interview on [DATE] at 2:35 p.m. the ADM stated he could not find the Pre-Inspection Report for Resident 1's trip to dialysis on [DATE]. During an interview and concurrent record review on [DATE] at 1:14 p.m. with the contracted installer (CI) from a mobility equipment service company, the CI stated he installed equipment for the facility's van on [DATE]. Review of the facility's invoice, dated [DATE] indicated three items were installed, including a three-point kit belt system (seat belt that secures a person with straps across the chest and across the lap at three anchor points, one above the shoulder and two at the hips). He stated prior to installing the three-point harness, the facility van's securement system did not meet the regulations. The CI stated the van only had a lap belt and did not have a shoulder belt. He stated vans require that the person using the wheelchair is secured with a lap belt and an over-the-shoulder belt. He also stated that just having a lap belt is not as safe as having a lap belt and shoulder belt. During an interview and concurrent record review on [DATE] at 3:21 p.m. the former director of staff development (FDSD) stated she had experience driving a van for another facility. The FDSD stated all drivers should be trained prior to driving residents in the facility van. She stated the driver needs to inspect the van and complete a form each time the van is used. The FDSD stated the resident's wheelchair needs to be secured at four points. She stated the resident also needs to be secured by straps over the shoulder and lap, like a seat belt. The FDSD reviewed the Facility Vehicle Driver Training Program forms for MS, CSS, and MA. She confirmed the Facility Vehicle Driver Training Program forms for MS and CSS were undated. The FDSD stated she trained the MS and CSS, but she did not remember the date. She stated she conducted a driver training and all three staff (MS, CSS, and MA) were present on that day. The FDSD confirmed Facility Vehicle Driver Training Program form for MA was dated [DATE]. She stated that she did not train the MA prior to that date. During an interview on [DATE] at 9:45 am, the Payroll/Human Resources staff (PHRS) stated the Van Driver job description indicated the staff should be certified nursing assistants (CNA). The PHR confirmed MS, CS, and MA were not CNAs. She also stated the MA's termination date was [DATE]. During an interview on [DATE] at 1:24 p.m. the charge nurse (CN) from Resident 1's dialysis facility (CN) stated dialysis staff was not informed of Resident 1's fall prior to dialysis on [DATE]. The CN stated if dialysis staff was informed of a fall they would assess them and monitor for orientation, pupil dilation, etc. She also stated dialysis staff would have assessed Resident 1 to determine if they should call 911 for further evaluation. The CN stated if Resident 1 fell and hit her head, she would have sent her to the hospital via 911 right away. During an interview on [DATE] at 4:02 p.m., the CN stated she reviewed Resident 1's dialysis flowsheet and progress notes and confirmed there was no documentation that indicated dialysis staff was informed regarding Resident 1's fall prior to dialysis on [DATE]. Review of the facility's Job Description for Van Driver, dated 8/2018 indicated an essential duty was to ensure the safe transportation of residents to scheduled medical appointments or other approved activities, resident outing, etc. The van driver job description also indicated, Must have successfully completed CNA training and maintain all CE [continuing education] to maintain certification. Review of the facility's Vehicle Safety Manual, revised [DATE] contained the following documents: Facility Vehicle Driver New Hire Checklist, Facility Vehicle Driver Training Program, and Pre-Trip Inspection Report. Review of the Facility Vehicle Driver New Hire Checklist (undated) indicated the following are required for facility vehicle drivers and must be completed BEFORE driving facility vehicle: Must be a Certified Nursing Assistant; must be CPR Certified; required Facility Vehicle Training Program must be completed. Review of the Facility Vehicle Driver Training Program (undated) indicated, In order to become a certified facility vehicle driver you must complete the Facility Vehicle Driver Training Program which includes the following: .- Vehicle Occupant Protection and Wheelchair Securement- Facility Driver Safety Policy .- Accident Procedures- Vehicle Maintenance Procedures and Pre-Trip Inspection Report- First Aid/Personal Protective Equipment for Facility Vehicle. Review of the facility's Pre-Trip Inspection Report indicated, This report is to be completed before each usage of facility vehicle and signed below after vehicle is returned to facility. Review of the AMF [NAME] America Protektor Installation Manual (wheelchair securement system), dated 10/2022 indicated, All persons who will install, use and/or maintain this product must read, understand and follow all warnings and instructions provided in this manual . However nothing in this manual, and none of the safety devices installed on the product, substitute for proper training, careful operation and common sense. The manual indicated a common wheelchair securement and occupant restraint system contains the following and are to be used as a complete system: retractor tie downs (securement strap that automatically tighten to secure the wheelchair in place), occupant lap belt, occupant shoulder belt, user instructions. Review of the AMF [NAME] America User Manual, dated 3/2025 indicated specific items should be inspected carefully on a daily basis, including the functionality of the restraint system and floor and sidewall anchorages (fixed points installed directly on the floor or interior walls of the vehicle. The manual also indicated the wheelchair has rear securement points (where straps to secure the wheelchair should be attached) and front securement points. It indicated, Once you have four straps attached, release the brakes on the wheelchair and check for movement. Once secured the wheelchair should not move more than two (2) inches front-to-back or side-to-side. Reapply the brakes. The manual indicated, This product is not designed for use with only a pelvic securement [lap belt]. Always used only a lap/shoulder belt combination. The manual also indicated, WARNING Failure to follow all the warnings and instructions in this manual can result in product malfunction and loss of control of the vehicle - potentially causing an accident, severe personal injury or death to the vehicle occupants, other motorists or pedestrians. According to the Code of Federal Regulations, Title 49, Subtitle A, Part 38 (Americans with Disabilities Act [ADA] Accessibility Specifications for Transportation Vehicles), Subpart B - Buses, Vans and Systems, 49 CFR S 38.23(d)(7) indicated, Seat belt and shoulder harness. For each wheelchair or mobility aid securement device provided, a passenger seat belt and shoulder harness, complying with all applicable provisions of part 571 of this title [Federal Motor Vehicle Safety Standards], shall also be provided for use by wheelchair or mobility aid users. Such seat belts and shoulder harnesses shall not be used in lieu of a device which secures the wheelchair or mobility aid itself.

The facility failed to ensure the safety of one of three sampled residents (Resident 1) during in-bed care (a wide range of activities to ensure the health, comfort, and hygiene of someone who is bedridden), when:1. The facility failed to maintain Resident 1's safety during in-bed care.2. The facility failed to accurately complete Resident 1's fall risk assessment; and3. The facility failed to implement Resident 1's ADL (activities of daily living like bed bath, shower, transfer, positioning, etc.) care plan intervention to Ensure proper position.These failures resulted in Resident 1 sustaining comminuted fractures (a broken bone where the bone is shattered into more than two pieces) to the right tibia and fibula (the two bones in the right lower leg), requiring hospital transfer on August 17, 2025.A review of Resident1's face sheet (a one-page summary document that provides a quick overview of essential information about a person, most commonly used in healthcare settings to present a patient's demographic, medical history, and insurance details) indicated he was admitted to the facility on [DATE], with diagnoses including unspecified dementia (the loss of cognitive functioning that interferes with daily life and activities) and dysphagia following cerebral infarction (difficulty swallowing commonly associated with neurological impairment), Traumatic subdural hemorrhage (a collection of blood that accumulates between the brain and the outermost layer of the brain's protective membranes)with loss of consciousness of unspecified duration, other seizures (abnormal electrical activity in your brain).A review of Resident 1's Minimum Data Set (MDS, an assessment tool), GG section (Functional abilities) indicated Resident 1 was dependent (helper does all of the effort, Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helper is required for the resident to complete the activity) on staff for self-care (the ability to care for oneself including bathing, dressing, using the toilet, or eating ), and mobility (the ability to move or be moved including toilet transfers, sitting to lying, lying to sitting on side of bed, and rolling left and right).A Review of Resident 1's MDS dated [DATE], indicated brief interview for mental status (BIMS, cognition level) score was 00 (severe cognitive impairment, as the 0-7 points range is used for this category). A further Review of Resident 1's MDS, GG section dated 7/18/2025, indicated Resident 1 had impairments on one upper extremity (the shoulder, elbow, wrist, and hand) and both lower extremities (hip, knee, ankle, and foot ).1. A review of Resident 1's Interdisciplinary Team (IDT) Notes dated August 19, 2025, indicated that on August 14, 2025, at approximately 2:20 p.m., Resident 1 fell from bed during routine in-bed care performed by a CNA (certified nursing assistant).A review of Resident1's X-ray result dated August 17, 2025, revealed comminuted distal tibia and fibula fractures [a serious injury where the lower ends of both the shinbone (tibia) and calf bone (fibula) are broken into multiple pieces] with displacement and soft tissue swelling. During an interview with the Director of Nursing (DON) on October 3, 2025, at 1:10 p.m., the DON stated that certified nursing assistant (CNA) B rolled Resident 1 to the side of the bed while providing in-bed care. During this process, Resident 1 fell from the bed onto the floor mat on 8/14/2025. Resident 1's X-ray result dated August 17, 2025, revealed comminuted distal tibia and fibula fractures, and Resident 1 was transferred to the hospital for treatment the same day. The DON further stated that the CNA should have kept Resident 1 safe during care.During a phone interview with the Assistant Director of Nursing (ADON) on October 13, 2025, at 11:50 a.m., the ADON confirmed that the Minimum Data Set (MDS) Section GG, dated July 18, 2025, indicated Resident 1 was dependent and required the helper do all the effort or the assistance of two or more helpers for toilet transfers, sitting to lying, lying to sitting on side of bed, and rolling left and right. The ADON further confirmed that only one CNA was providing care to Resident 1 at the time of the fall incident on 8/14/2025, and that Resident 1 needed two-person assistance when rolling him to his left and right sides during care to prevent falls.During a phone interview with the MDS Coordinator (MDSC) on October 16, 2025, at 3:10 p.m., The MDSC confirmed that Minimum Data Set (MDS) Section GG, dated July 18, 2025, indicated Resident 1 was dependent and she further stated that Resident 1 had impairment on one of his upper extremity and both lower extremities, he need another helper to ensure safety when rolling left and right. A review of the facility's policy and procedure (P&P), Revision Date March 2018, titled Falls and Fall Risk, Managing indicated: .Several possible interventions may be identified considering resident fall risks, and staff may prioritize certain interventions based on the circumstances .2. A review of Resident 1's SBAR (an acronym for Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication) Communication Form and Progress Note dated March 23, 2025, indicated an unwitnessed fall when a nurse was doing rounds and found Resident 1 was sitting on the floor next to his bed.A review of Resident 1's Fall Risk assessment dated [DATE], indicated a score of 14 (scores of 16-42 indicate high fall risk). The assessment documented no falls within the last 90 days; however, the March 23,2025 fall incident occurred within that period of 90 days.During a phone interview with the Assistant Director of Nursing (ADON) on October 13, 2025, at 11:44 a.m., the ADON confirmed the fall risk assessment done on April 21, 2025, was inaccurate because it should have reflected one fall within the last 90 days.A review of the facility's policy and procedure (P&P), revision date March 2018, titled Fall Risk Assessment indicated: .the nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. The nursing staff will ask the resident and/or his/her family about any history of the resident falling.3. A review of Resident 1's care plan, initiated on November 23, 2023, indicated that Resident 1 was at risk for falls related to confusion, gait and balance problems, incontinence, crawling to the floor, refusal to use the call light, difficulty walking, muscle wasting and atrophy, seizures, and abnormal gait. The care plan interventions included: Ensure that the resident is properly positioned in bed.During a phone interview with the ADON on October 15, 2025, at a.m., the ADON confirmed that the care plan interventions indicated, Ensure that the resident is properly positioned on bed. The ADON stated that the staff should have implemented the intervention to ensure that Resident was positioned properly on the bed to prevent fall when turned to his side. A review of the facility's policy and procedure (P&P), revision date March 2022, titled Care Plans, Comprehensive Person-Centered indicated: . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .

Based on interview and record review, the facility failed to obtain informed consent for psychotropic medications from the responsible party (RP, a person empowered to make decisions for the resident) for one of three residents (Resident 1). This failure had the potential to result in the resident's RP not being fully informed regarding care and treatment in order to make health care decisions for the resident. Findings: Review of Resident 1's clinical record indicated he was admitted to the facility with diagnoses including toxic encephalopathy (neurologic disorder caused by exposure to toxic substances) and dementia (a progressive state of decline in mental abilities). Review of Resident 1's admission Record, printed 4/29/25 indicated the resident's contacts included a case worker and conservator, who was Resident 1's RP. Review of Resident 1's Informed Consent - Psychoactive Medication, dated 1/27/25 indicated the resident's psychoactive medications were escitalopram (an antidepressant medication used to treat depression or anxiety) and Seroquel (an antipsychotic medication used to treat mental health disorders). The informed consent indicated, Verbal consent obtained from [name of case worker] - case worker. During an interview on 5/19/25 at 2:18 p.m., the social services director (SSD) stated Resident 1's conservator is the resident's responsible party and is the main person who makes decisions for Resident 1. The SSD stated the case worker was not able to make any medical decisions for Resident 1. During an interview on 5/19/25 at 10:48 am, the case worker stated he definitely did not have the responsibility to make decisions for Resident 1. Review of the facility's 2001 policy, Psychotropic Medication Use, indicated, Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal: . The resident's/representative's right to accept or decline the treatment.

Based on observation, interview, and record review, the facility failed to ensure 13 out of 40 sampled residents (Residents 10, 19, 38, 39, 47, 53, 60, 67, 72, 93, 104, 111, and 121) were free from unnecessary medications when there was inadequate monitoring and systemic failure in the management of antihypertensive (medication to manage high blood pressure) and antiarrhythmic (medication to manage arrhythmia [abnormal or irregular heartbeats]) medications, and lack of monitoring for signs and symptoms related to the use of anticoagulants (medication to prevent blood clots). They are as follows: 1. During a medication pass observation, Licensed Vocational Nurse C (LVN C) failed to measure Resident 47's blood pressure (BP) before administering an antihypertensive medication, losartan 50 milligrams (mg, unit of measurement), to Resident 47. 2a. For Resident 104: - Nursing staff did not carry out the physician's order for daily BP monitoring. - He had a routine order for metoprolol (medication to lower BP and heart rate [HR]) with the direction to hold the medication if SBP less than (<)100 milliliters of mercury (mmHg, unit of measurement) and HR <60 beats per minute (bpm) order but the staff did not check the BP and HR daily before its administration. (Normal HR: 60 - 100 bpm) - He received daily amiodarone (a potent antiarrhythmic agent - medication to treat/prevent irregular or abnormal heart rhythms) without consistent and daily BP and HR monitoring, and without a comprehensive care plan. - He received four routine antihypertensive medications without daily BP monitoring: Metoprolol, Entresto (a combination medication for hypertension and heart failure [a condition when the heart cannot pump enough blood to meet the body's needs]), furosemide (a diuretic, or water pill, to remove excess salt and water, and thereby lowering BP), and spironolactone (a diuretic to manage hypertension). The nursing staff did not code the Medication Administration Record (MAR, official document where staff record medication administration and related monitoring) correctly to require the input of the required BP and HR before administration of these medications. The record review indicated there was a period where BP and HR were not checked for as long as 14 days, as follows: - Resident 104's BP was not checked for 14 days from 1/11/25 to 1/26/25; for 3 days from 1/26/25 to 1/30/25; for 7 days from 2/1/25 to 2/8/25; for 2 days from 2/9/25 to 2/12/25; for 5 days from 2/13/25 to 2/18/25; and for 6 days from 2/19/25 to 2/26/25. - Resident 104's HR measurement was not obtained for 14 days from 1/11/25 to 1/26/25; for 4 days from 1/26/25 to 1/30/25; for 11 days from 2/1/25 to 2/13/25, and for 8 days from 2/19/25 to 2/27/25. 2b. For six residents (Residents 10, 38, 54, 111, 121, and 287) receiving digoxin (an antiarrhythmic agent to treat heart failure and AF) - Resident 38 received digoxin 6 times when HR was outside of the prescribed parameter in January and February 2025 - Resident 111 had no HR obtained on 2/26/24, but digoxin was given - Resident 111 received digoxin daily since admission in June 2024 without monitoring for digoxin blood level (to monitor if the medication is within therapeutic range and to avoid toxicity) - Resident 10 had a physician's order to obtain digoxin level every 3 months since 4/1/24. There was no digoxin level done in July 2024, October 2024, and January 2025. - Six out of six residents did not have comprehensive care plan developed related to digoxin use (see F 656). 2c. The facility's consultant pharmacist (CP) failed to identify and report to the facility irregularities related to the above findings for above residents (Residents 10, 38, 54, 104, 111, 121, and 287) (See F 756) 2d. For eight residents (Residents 19, 38, 60, 67, 72, 93, 104, and 121) receiving amiodarone: - Eight out of eight residents had no documentation of BBW monitoring related to amiodarone - Eight out of eight residents had no documentation of BP and HR checks prior to administration of amiodarone until 2/28/2025 (day of survey); - Resident 72 received amiodarone on 2/28/2025 at 9:00 a.m. with BP of 95/87 when it was supposed to be held and the physician to be notified. - Seven out of eight residents did not have comprehensive care plan developed related to amiodarone use (see F 656). 2e. The competency checks for five licensed nurses (LNs) revealed one out of five LNs did not have nursing care competency and medication administration training (see F 726). The facility's noncompliance related to lack of monitoring of BP and HR prior to antihypertensive and antiarrhythmic medication administration and as ordered; hold parameters not being followed; lack of laboratory monitoring for digoxin level; lack of BBW monitoring for amiodarone; lack of hold parameters for these medications; inaccurate coding of the MAR; lack of comprehensive care planning; and lack of CP's recommendations or identification of irregularities related to these deficient practices had the potential for the residents to suffer adverse effects from severe hypotension or low BP (such as dizziness or lightheadedness, weakness, fatigue, confusion, blurred vision, nausea and vomiting) and worsening arrhythmias (such as chest pain, fainting, rapid or pounding heartbeats, sweating, collapse, and sudden cardiac arrest [heart stop beating suddenly]). Resident 104 had low BP readings on 1/7/25, 1/30/25, 2/1/25, 2/8/25, 2/13/25, and 2/19/25. Due to these systemic failures (as stated above) with the potential to affect all residents receiving antihypertensive and antiarrhythmic medications, the facility needed to take immediate action to correct the noncompliance. On 2/28/25 at 5:45 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified and declared, in the presence of the facility's Administrator, the Director of Nursing (DON), and the Regional Director of Clinical Services (RDCS) related to lack of BP and HR monitoring prior to antihypertensive and antiarrhythmic medication administration and as ordered; lack of laboratory monitoring for digoxin; lack of BP, HR, and BBW monitoring for amiodarone; lack of hold parameters for these medications; lack of comprehensive care planning; and lack of CP's recommendations or identification of irregularities related to these medication use. On 3/3/25, at 1:48 p.m., the IJ was removed after the Administrator submitted an acceptable IJ Removal Plan ([IJRP], a plan with interventions to immediately correct the deficient practices, and after the survey team verified and confirmed the corrective actions while onsite. The acceptable IJRP included the following corrective actions: A. The facility identified residents whose BP and HR need to be monitored. All 59 residents with antihypertensive and antiarrhythmic medications have their updated orders for BP and/or HR check prior to administration, hold parameters, BBW monitoring, digoxin level (when applicable), and developed comprehensive care plan. B. The DON or RDCS in-serviced/trained 7 out of 8 clinical leadership members, and 34 out of 38 licensed nurses (LNs) on ensuring that residents with anti-hypertensive and antiarrhythmic medications have orders for BP and/or HR check prior to administration, hold parameters, BBW monitoring order, digoxin level (when applicable) is carried out, and care plan is developed for use of those medications. LNs who are on vacation or leave and any new registry licensed nurses will be provided in-service/competency training before they work on the floor. C. The CP was provided an in-service by his supervisor on reviewing and identifying medication irregularities during monthly medication regimen review on 3/1/2025. The CP performed an audit of all residents on anti-hypertensive and antiarrhythmic medications for any inconsistencies on BP and/or HR checks prior to medication administration and on applicable lab test recommendations for those medications. This audit was completed by 3/2/2025. D. The interdisciplinary team (IDT, team composed of members from different departments involved in a resident's care) will continue to conduct a daily review of new admissions orders and any new orders for anti-hypertensive and antiarrhythmic medications and verify that those required components are present and being followed. E. The clinical leadership team started with random observation of several LNs during medication pass on 3/1/2025 to ensure that BP and/or HR are checked prior to giving medication(s) and hold parameters are followed. F. The Medical Director ([NAME]) has been actively consulted and involved by the clinical leadership team on ensuring that all residents receiving medications have appropriate vital signs (measure of basic functions: body temperature, HR, respiratory rate, BP) monitoring and checks, have hold parameters, and applicable lab orders for use of medications. G. The Medical Records Director (MRD) or designee will continue to perform compliance audits to ensure that residents with anti-hypertensive and antiarrhythmic medications have orders for BP and/or HR check prior to administration, hold parameters, black box monitoring, digoxin level (when applicable), and care plan. H. Corrective Action Plan will be reviewed at QAPI [Quality Assessment and Performance Improvement] Committee Meeting for 6 months using pertinent compliance audit information and resolutions from March 2025 through the end of August 2025 or until the desired outcome of 100% compliance is achieved and sustained for at least six consecutive months. 3. Resident 47 received daily losartan with a hold parameter without the nursing staff monitoring the BP prior to its administration. 4. Resident 104 received amiodarone on 2/28/2025 at 9:00 a.m. with BP of 98/66 when it was supposed to be held and the physician to be notified, after the concerns had been raised with facility leadership staff. 5. Resident 39 received Xarelto (an anticoagulant to prevent blood clots) without evidence of staff monitoring for signs and symptoms related to its use. 6. For Resident 53, the nursing staff did not consistently monitor the signs and symptoms related to the use of Eliquis (an anticoagulant). The failures had the potential for residents to suffer adverse effects of the medications including undetected severe hypotension, worsening of arrythmias, and anticoagulant-related symptoms such as bleeding, bruising, discolored urine, black, tarry stools, lethargy, sudden changes in mental status or vital signs, shortness of breath, or nosebleeds, and untimely interventions for the residents. Findings: The BP is measured in millimeters of mercury (mmHg, unit of measurement) and in two numbers. The upper number is the systolic BP, or SBP, indicating the pressure in the arteries when the heart beats and pumps blood through the body; the lower number is the diastolic BP, or DBP, is the pressure in the arteries when the heart rests between beats. According to the American Heart Association, normal BP is less than 120/80 mmHg; and low BP is a reading lower than 90/60 mmHg (www.heart.org; accessed 3/6/25) 1. During a medication pass observation on 2/24/25 at 9:33 a.m., LVN C was observed preparing and administering 8 medications, including a tablet of losartan 50 mg, to Resident 47. During the concurrent interview and record review on 2/24/25 at 9:52 a.m., when asked about Resident 47's BP for the administration of losartan, LVN C stated a certified nursing assistant (CNA) had already taken it earlier that day. She reviewed Resident 47's BP in the clinical record which indicated the latest BP was obtained the day prior, on 2/23/25 at 16:08 (4:08 p.m.). LVN C stated she did not check the resident's BP earlier that morning. On 2/24/25 at 9:54 a.m., she was observed returning to Resident 47's bedside and obtained her BP. It was 156/70 mmHg. After returning to the medication cart, LVN C stated, It was a mistake and she should have checked the BP before giving the losartan. A review of Resident 47's clinical record indicated a physician's order, dated 5/21/24, for losartan 50 mg, give 1 tablet one time a day for hypertension hold for systolic [BP] <110 [mmHg]. 2a. A review of Resident 104's admission record indicated he was admitted to the facility with diagnoses including pleural effusion (condition where excess fluid accumulates in the pleural space, the thin cavity between the lungs and the chest wall), heart failure, pulmonary edema (condition where excess fluid accumulates in the lungs, causing difficulty breathing), and unspecified peripheral vascular disease (slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel). A review of the cardiologist's (physician specialized in heart medical conditions) After Visit Summary, dated 9/9/24, indicated the resident was assessed with bruit (abnormal sound in an artery caused by turbulent blood flow). A review of Resident 104's Minimum Data Set (MDS, a care area assessment and screening tool), dated 12/17/24, indicated he had a BIMS (Brief Interview for Mental Status, a test given by medical professionals that helps determine a patient's cognitive understanding, scored from 1 to 15) score of 11, which indicated his cognitive condition was moderately impaired. On 2/27/25, a review of Resident 104's physician's orders, and January and February 2025 Medication Administration Records (MARs), indicated the following orders and administration times: A. Four routine antihypertensive medications: - Valsartan (treat high blood pressure and heart failure) 40 mg 1 tablet twice daily for hypertension, dated 4/12/24. On 1/30/25, valsartan was discontinued and switched to Entresto (combination of valsartan and sacubitril, another antihypertensive medication) 24-26 mg twice daily. One 2/4/25, Entresto was reduced to one time a day for hypertension. Part of its order indicated to Check BP without specified frequency. Each of these medications was scheduled to be administered daily at 10 a.m. - Furosemide 20 mg, give 1.5 tablets (30 mg) one time a day for edema (swelling caused by a buildup of fluid in body tissues) and hypertension, dated 8/23/24. It was scheduled to be administered daily at 9 a.m. - Spironolactone 25 mg, give 1 tablet one time day for fluid retention, dated 12/26/24. It was scheduled to be administered daily at 9 a.m. - Metoprolol extended release (ER) 25 mg one time a day for hypertension, hold for systolic BP < [less than] 100 [mmHg], [HR] <60 [bpm], dated 4/12/24. It was scheduled to be administered daily at 10 a.m. (Normal HR is between 60 - 100 bpm). B. Amiodarone 200 mg, 1 tablet by mouth one time a day for arrhythmia, dated 4/12/24. It was scheduled to be administered daily at 10 a.m. C. Check BP Q [every] day one time a day 'call clinic if SBP is less than 100 [mmHg] consistently, dated 1/30/25. It was scheduled daily at 9 a.m. A review of the Package Insert (PI, document included in the package of a medication that provides information about that drug and its use) for amiodarone, revised 10/2018, indicated it an antiarrhythmic medication to treat ventricular arrhythmias (life-threatening heart rhythm disturbance where the ventricles [lower chambers of the heart] quiver instead of contracting normally) and atrial fibrillation (an irregular heart rhythm that begins in your heart's upper chambers [atria]). The PI also indicated to monitor the patient's cardiac [heart] rhythm and blood pressure, and, if bradycardia [low HR] ensues, a B-adrenergic agonist [a type of medication to increase HR] or a pacemaker may be used . The review of the PI for amiodarone also indicates it has a Black Box Warning (BBW, strongest warning put in the labeling of a prescription drug by the Food and Drug Administration [FDA] to indicate the drug carries a significant risk of serious or life-threatening adverse effects) indicating it has potential to cause life-threatening liver toxicity, pulmonary [lung] toxicity, and worsening arrhythmia. (https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm, accessed 2/28/25) A review of Resident 104's January and February 2025 MARs indicated the nursing staff placed their initials and a check mark on in the entry for the Check BP one time a day with no corresponding BP readings. There were no corresponding BP readings for the administration of furosemide, valsartan or Entresto, and spironolactone. Similarly, there was no documentation of corresponding BP and HR for the administration of metoprolol despite the physician's order to hold for SBP <100 mmHg and HR <60 bpm. Furthermore, there was no hold parameters for or corresponding measurement of BP and HR for the use of amiodarone. Further review of Resident 104's BP and HR summary indicated: - Resident 104's BP was not checked for 14 days from 1/11/25 to 1/26/25; for 3 days from 1/26/25 to 1/30/25; for 7 days from 2/1/25 to 2/8/25; for 2 days from 2/9/25 to 2/12/25; for 5 days from 2/13/25 to 2/18/25; and for 6 days from 2/19/25 to 2/26/25. - Resident 104's HR measurement was not obtained for 14 days from 1/11/25 to 1/26/25; for 4 days from 1/26/25 to 1/30/25; for 11 days from 2/1/25 to 2/13/25, and for 8 days from 2/19/25 to 2/27/25. A review of Resident 104's clinical record also indicated there was no comprehensive care plan that included the diagnosis, goals/outcomes, monitoring parameters and interventions for Resident 104's arrhythmia or the monitoring of the BBW related to amiodarone use. During a concurrent interview and record review with the Director of Nursing (DON), the Infection Control Preventionist (IP), and Nurse Supervisor D (NS D) on 2/27/25 at 1:45 p.m., they reviewed Resident 104's clinical record and acknowledged the resident's BP and HR were not checked on a daily basis as per physician's order, and before administration of metoprolol; no BP checks done before the administration of Entresto, spironolactone, and furosemide; no hold parameters and no BP and HR check for amiodarone; and no comprehensive care plan for Residentn104's arrhythmia and amiodarone use. The IP and NS D stated the BP and HR should be checked at least daily, and the care plan should have been developed. The staff present also verified there were gaps of multiple days (as stated above) where BP and HR were not checked daily and acknowledged the potential for resident to suffer from undetected severe hypotension and arrhythmias (such as too slow HR) During an interview with Resident 104 on 2/27/25 at 2:09 p.m., when asked how often the staff obtained his HR, he stated, Here and there. About the BP measurement, Resident 104 stated, They get it when they come in, sometimes 2 to 3 times per day. It depends. During a telephone interview with the CP on 2/27/25 at 3:30 p.m., he stated residents receiving amiodarone should receive routine HR monitoring, and Resident 104 receiving four antihypertensive medications had a risk of hypotension. When asked whether he had identified and made a recommendation for the nursing staff to include HR and BP monitoring for the use of his antihypertensive and antiarrhythmic medications for Resident 104, the CP stated he did not. During an interview with the DON on 2/27/25 at 4:33 p.m., she stated, The blood pressure and pulse were not consistently done . The MAR was not coded right so it's not on the MAR. She explained the MAR should be coded to require an input of the BP and/or HR with BP and cardiac (heart) medications. When asked whether the BP and HR measurements were documented somewhere else, the DON stated no and that she checked the CNA's logs, and it's not there. On 2/28/25 at 9:26 a.m. in the presence of the Assistant Director of Staff Development (ADSD), a review of Resident 104's February 2025 MAR was conducted with LVN G. She confirmed she administered the metoprolol with the prescribed hold parameters, and documented she checked the BP on 2/5 and 2/6/25; however, there was no BP and HR measurement in the clinical record for both days. Both LVN G and the ADSD stated the nursing staff check BP and HR before giving BP and cardiac medications. The ADSD also reviewed the clinical record and stated, I am not sure what to say. During a concurrent interview and record review with LVN H on 2/28/25 at 9:42 a.m., she reviewed Resident 104's February 2025 MAR and confirmed she documented the administration of metoprolol with ordered hold parameters, and did the daily BP on 2/25/26; however, there were no BP and HR measurement on 2/25/26 in Resident 104's clinical record. She stated, If the MAR doesn't say then I don't put in there unless I put in the progress notes. When asked to look up the progress notes, LVN H stated, I know I did not. During a concurrent interview and record review with LVN I on 2/28/25 at 9:55 a.m., a review of Resident 104's February 2025 MAR with LVN I indicated she documented she administered the metoprolol and did the daily BP check on 2/10, 2/11, 2/15, and 2/21/25 during which there were no documentation of daily BP and HR measurement. She stated, I checked them but not entered into the system because it didn't have entry to enter, but I always check them. In a concurrent interview and record review with Registered Nurse (RN) J on 2/28/25 at 10:11 a.m., a review of Resident 104's February 2025 MAR with RN J indicated she administered the BP medications, including the metoprolol; and the daily BP check, on 2/3, 2/4, 2/14, 2/22, 2/23, and 2/26/25 during which there were no BP and HR measurement in the clinical record. RN J acknowledged there were BP and HR missing in the MAR and stated, I understand what you are saying. There's no excuse for it. She also acknowledged Resident 104 was receiving four BP medications which had the potential for severe hypotension if not checked. She stated the nurses can change the order when the MAR did not have entries to input BP and HR, but acknowledged they were not done prior to being brought up by the survey team (on 2/27/25). A request was made for an interview with Resident 104's physician (Physician A) on 2/28/25. During an interview on 2/28/25 at 10:55 a.m., Nursing Supervisor D (NS D) stated she just received a telephone call from Physician A who said she is not available for interview as she was in a conference. NS D stated Physician A wanted her to relay the message to the surveyor that Resident 104 was being followed by the cardiologist. NS D also stated that Physician A said she has had concerns about the care in the facility and that is the reason why she would not admit new patients to this facility until things are fixed. On 2/28/25 at 11:35 a.m., a telephone interview was conducted with the Medical Director ([NAME]). When asked about the expectation of staff obtaining and documenting the BP and HR for antihypertensive and cardiac medications, he stated, If there's a standing order, it should be documented. Ideally. During a concurrent interview and record review with NS D on 2/28/25 at 11:47 a.m., a review of Resident 104's BP summary in the electronic record indicated he had low BP readings (see below). NS D stated she could not tell if the BP readings were before or after metoprolol administration on 2/1, 2/8, and 2/13/25. She was asked to provide the exact timing of the metoprolol administration for those days. Date and time BP readings in mmHg - 1/7/25 at 1:40 a.m. 108/58 - 1/30/25 at 10:23 a.m. 101/50 - 2/1/25 at 10:20 a.m. 93/54 - 2/8/25 at 9:10 a.m. 91/56 - 2/13/25 at 8:52 a.m. 96/54 - 2/19/25 at 1:02 a.m. 95/54 During a follow-up interview with NS D on 3/1/25 at 4:07 p.m., she stated the electronic system only allowed a 14-day look back of medication administration times, so she could not provide the exact time the metoprolol was administered on those days. A review of an online article from the National Heart, Lung, and Blood Institute titled Low Blood Pressure, updated 3/14/22, indicated hypotension symptoms included: Confusion, dizziness or lightheadedness, fainting, feeling tired or weak, blurry vision, headache, neck or back pain, nausea, and heart palpitations. (https://www.nhlbi.nih.gov/health/low-blood-pressure, accessed 2/28/25) A review of the online publication titled Symptoms, Diagnosis and Monitoring of Arrhythmia dated 10/10/24, by the American Heart Association (www.heart.org), severe arrhythmia symptoms include: Fatigue or weakness, dizziness or lightheadedness, fainting or near-fainting spells, shortness of breath, chest pain, alternating fast and slow heart rate, sweating, and in extreme cases, collapse and sudden cardiac arrest. 2b. A review of the PI for digoxin, dated 2015, indicated Digoxin has a narrow therapeutic index [medication in which the therapeutic dose is very close to the toxic dose], increased monitoring of serum digoxin concentrations and for potential signs and symptoms of clinical toxicity is necessary when initiating, adjusting, or discontinuing drugs that may interact with digoxin . Monitor for signs and symptoms of digoxin toxicity and clinical response. Adjust dose based on toxicity, efficacy, and blood levels. On 2/28/25 starting at 2:30 p.m., a concurrent interview and review of the clinical records residents receiving digoxin was conducted with Minimum Data Set Coordinator B (MDSC) B. The following was identified: A. On 2/28/25 starting at 2:32 p.m., a review of Resident 38's clinical record with MDSC B indicated the resident had a physician's order for Digoxin Tablet 250 MCG [micrograms, unit of measurement], Give 1 tablet by mouth one time a day for heart failure check apical heart rate [or apical pulse or AP; heartbeat that is felt or heard at the apex (bottom) of the heart, typically on the left side of the chest] prior to each dose. Hold dose if heart rate is less than 60 and notify MD [medical doctor], dated 1/5/25. A review of Resident 38's January and February 2025 MARs indicated the nursing staff did not hold the resident's digoxin when he had the documented pulse (HR) of less than 60 bpm on: 1/20 (HR: 58); 1/26 (HR: 53); on 2/3 (HR: 59), on 2/5 (HR: 53), 2/7 (HR: 55), and 2/18/25 (HR: 59). MDSC B also reviewed the progress notes and stated there was no physician's notification on those days. She confirmed the physician's order was not followed. Furthermore, there was no comprehensive care plan developed for the resident's heart failure or digoxin use. MDSC B stated it should have been care planned. B. On 2/28/25 at 2:40 p.m., a review of Resident 111's clinical record with MDSC B indicated Resident 111 had a physician's order for Digoxin Oral Tablet 125 MCG . Give 1 tablet by mouth one time a day for Antiarrhythmic Hold if APICAL pulse <60 [bpm], dated 6/28/24. A review of Resident 111's February 2025 MAR indicated digoxin was documented as administered to the resident on 2/26/25, but there was no documented AP on that day. MDSC B verified this finding. She also confirmed there was no care plan developed for the use of digoxin, and stated there should have been a care plan developed. Also, the review of Resident 111's clinical record with MDSC B indicated no digoxin level since admission and ordered date of 6/28/24 (a period of 8 months). C. On 2/28/25 at 2:42 p.m., a concurrent interview and record review of Resident 287's clinical record with MDSC B indicated a physician's order for Digoxin Tablet 125 MCG Give 1 tablet by mouth one time a day for heart failure hold if pulse less than 70, dated 2/14/2025. MDSC B stated she could not find any care plan for the resident's heart failure or digoxin use. She confirmed there should have been a care plan developed. D. On 2/28/25 at 2:44 p.m., a review of Resident 10's clinical record indicated he had been receiving Digoxin Tablet 125 MCG Give 1 tablet by mouth one time a day for heart failure Hold dose if AP less than 60, since 4/24/2021. He also had a physician's order, dated 4/1/24, for laboratory blood tests including the digoxin level every 3 months, scheduled January, April, July, and October each year. MDSC B reviewed Resident 10's clinical record and the contracted laboratory website and stated she could only found one laboratory report conducted on 4/1/24. She confirmed there was no digoxin level done in July 2024, October 2024, or in January 2025. Also, MDSC B stated she could not find any care plan for the use of digoxin. She acknowledged the physician's order was not carried out and there should be a care plan for the resident's heart failure. E. On 2/28/25 at 3:40 p.m., a review of Resident 54's clinical record with MDSC B indicated a physician's order for Digoxin tablet 125 MCG Give 1 tablet by mouth one time a day for AFib [atrial fibrillation] hold if less than 60 [bpm] and notify M.D as needed, dated 9/6/2023. MDSC B stated she could not find the comprehensive care plan for AF or digoxin use. She confirmed there should have been a care plan developed. F. On 2/28/25 at 3:57 p.m., a concurrent interview and record review of Resident 121's clinical record with MDSC B indicated a physician's order for digoxin 125 mcg 1 tablet one time a day for AF, dated 10/18/24. MDSC B stated there was no care plan for Resident 121's AF or digoxin use. 2c. During a telephone interview with the CP on 2/28/25 at 4:12 p.m., the CP stated digoxin level should be monitored routinely, and he would make a recommendation for it every 6 months. When asked whether he had made a recommendation to draw a digoxin level for Resident 111 since she was admitted in June 2024, the CP stated he did not, and confirmed he should have. Regarding the review for the care plans related to medication use in the residents' clinical record, the CP stated, Sometimes I do but not too much. After reviewing his own record, the CP stated he did not make recommendation on care plans during the monthly medication regimen review for Residents 10, 38, 54, 111, 121, and 287. 44583 2d. A concurrent interview and record review of seven additional residents (Residents 19, 38, 60, 67, 72, 93, and 121) receiving amiodarone indicated: A. Review of Resident 121's clinical record titled, Admission Record, dated 2/28/25, indicated Resident 121 was admitted to the facility with diagnoses including hypertensive heart and chronic kidney disease (refers to a condition where high blood pressure damages both the heart and kidneys) with heart failure and stage 1 through stage 4 chronic kidney disease (occurs when kidneys work harder to filter blood and may stop working altogether), paroxysmal atrial fibrillation (a fast, irregular heartbeat that only lasts a few hours or days), and cardiomyopathy (a disease that affects the heart muscle, making it difficult for the heart to pump blood). Review of Resident 121's physician order, dated 12/20/24, indicated, Amiodarone . 100 MG Give 1 tablet by mouth one time a day for CHF [chronic heart failure, a condition where the heart can't pump enough blood to meet the body's needs]. Amiodarone was scheduled to be given daily at 9:00 a.m. During a concurrent interview with the Assistant Director of Staff Development (ADSD) and record review on 2/28/25 at 3:35 p.m., the ADSD reviewed Resident 121's physician's order and the February 2025 MAR, and confirmed there was no documentation from nursing that the amiodarone's BBW was being monitored. The ADSD further confirmed there was no documented BP and HR readings in the MAR from 2/1 to 2/27/25 prior to administration of amiodarone. ADSD also confirmed there was no care plan developed for Resident 121's amiodarone use. During a follow-up interview with MDSC B on 2/28/25 at 3:58 p.m., MDSC B stated nurses should check and document Resident 121's BP and HR prior to administration of amiodarone. MDSC [TRUNCATED]

Based on observation, interview and record review, the facility failed to provide care in accordance with professional standards of practice for three of 40 sampled residents, (Residents 34, 124 and 5), when: 1. Resident 34, had no documentation that her weights were being monitored for the last 3 months; 2. Resident 124's STAT (is derived from the Latin word 'Statim, which translates to immediately, and it denotes that order should be prioritized first since it is required promptly) order for x-ray ( a type of radiation that produces images of the inside of the body to diagnose and treat some conditions like bone injuries, tumors, and infections) to left knee was not carried out in a timely manner; and 3. Resident 5, the licensed nurse did not follow physician's order regardinging the prescribed frequency of water flushes during gastrostomy tube (GT, a tube inserved via the abdomen for feeding/medication administration) feeding. These failures had the potential for the residents, not to attain or maintain their highest practicable physical, mental and psychosocial well-being. Findings: 1.During an observation on 2/23/25 at 12:37 p.m., Resident 34 was sitting on her wheelchair in the hallway. Resident 34 was confused and could not respond to questions. Review of Resident 34's admission record (a document created during the resident's admission to the healthcare facility containing their personal details and medical history) indicated, Resident 34 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (blood flow to the brain is interrupted, causing brain tissue to die) due to unspecified occlusion (blockage or closing of an opening) or stenosis (narrowing of a tubular structure in the body) of unspecified carotid artery (large blood vessel located on either side of the neck), vascular dementia (brain damage caused by multiple strokes causing memory loss), unspecified severity without behavioral disturbance (range of conditions that involve disruptive or extreme behaviors), psychotic disturbance (loss of contact with reality), mood disturbance (mental health condition that affects primarily the emotional state) and anxiety (excessive worrying) and unspecified recurrent (happens repeatedly) major depressive disorder (persistent feelings of sadness or hopelessness). Review of Resident 34's order summary report (concise document that compiles all the orders placed for a resident) indicated, Resident 34 had an order for monthly weight check, one time a day every 1 month starting on the first for 1 day for monthly weight check every month per physician's order until discontinued. This was ordered on 3/22/24 and was started on 4/1/24. Review of Resident 34's weight records indicated, Resident 34 did not have record of her weights for 3 months. There were no weight records of Resident 34 for December 2024, January 2025 and February 2025. During a concurrent review of Resident 34's clinical records and interview with the assistant director of staff development (ADSD) on 2/28/25 at 1:01 p.m., the ADSD verified that there was no record and documentation that Resident 34 was weighed on December 2024, January 2025 and February 2025. The ADSD acknowledged that Resident 34 was last weighed on 11/4/24 and the order of Resident 34 was to weigh her every first day of the month which was not followed. During another interview with the ADSD on 2/28/25 at 1:55 p.m., the ADSD further acknowledged that they could not find any weight record of Resident 34 for December 2024, January 2025 and February 2025. The ADSD then stated that they will weigh Resident 34 right away. During an interview with the director of nursing (DON) on 2/28/25 at 5:35 p.m., the DON verified the finding that Resident 34 did not have weight records for December 2024, January 2025 and February 2025 and the order was not followed. She then stated that she will follow up on it. Review of the facility's policy titled, Medication and Treatment Orders, revised July 2016, indicated, Orders for medications and treatments will be consistent with principles of safe and effective order writing Review of the facility's policy and procedure titled, Weight Assessment and Intervention, revised March 2022, indicated, Resident weights are monitored for undesirable or unintended weight loss or gain Weights are recorded in each unit's weight record chart and in the individual's medical record 44583 2.Review of Resident 124's Admission Record, dated 2/25/2025, indicated Resident 124 was admitted to the facility with diagnoses including rhabdomyolysis (a condition where muscle tissue breaks down, releasing harmful substances into the bloodstream), morbid (severe) obesity (abnormal or excessive fat accumulation that presents a risk to health) due to excess calories, and difficulty walking. Review of Resident 124's admission minimum data set (MDS - a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 124's brief interview for mental status (BIMS, a tool used to assess cognition [knowing, learning, and understanding things]) score was 14 (a score of 13-15 indicates patient is cognitively intact). During a concurrent observation and interview with Resident 124 on 2/23/2025 at 11:05 a.m., inside Resident 124's room, Resident 124 was observed seated at the edge of his bed. Resident 124 stated he was still getting physical therapy and complained of left knee pain. Resident 124's left knee was observed swollen down to his left lower leg which was bigger compared to his right leg. Resident 124 stated he was scheduled to discharge out of the facility on Friday, 2/28/2025. During another concurrent observation and interview with Resident 124 on 2/25/2025 at 4:02 p.m., at the facility's common activity area, Resident 124 was observed seated and was watching television (TV). Resident 124 stated he walked from his room to the common activity area with the use of a rollator (a wheeled walker with a seat that helps people with balance issues or limited mobility walk longer distances). Resident 124's left leg was observed bigger than it was observed on 2/23/2025. Resident 124 stated, they will do an x-ray to my left knee. Review of Resident 124's physician order dated 2/25/2025, indicated, STAT X-ray to Left Knee r/t [related to] c/o [complain of] Pain one time only until 2/25/2025 23:59 [military time for 11:59 p.m.]. The order was entered on 2/25/2025 at 2:53 p.m. During an interview with minimum data set coordinator B (MDSC B) on 2/26/2025 at 8:51 a.m., MDSC B confirmed the nurse practitioner have seen Resident 124 on 2/25/2025 and have ordered a STAT x-ray to his left knee. MDSC B stated a STAT order should have been done within 4-6 hours since it was ordered. During a concurrent interview with licensed vocational nurse L (LVN L) and record review on 2/26/2025 at 9:54 a.m., LVN L reviewed Resident 124's radiology examination order form and confirmed the STAT x-ray of left knee order on 2/25/2025 was not completed yet. During a concurrent interview with DON and record review on 2/26/2025 at 10:13 a.m., DON reviewed Resident 124's nurse's documentations and confirmed the x-ray to left knee was not completed yet. DON further confirmed there was no documentation that nurses followed up the STAT x-ray to the diagnostic laboratory on 2/25/2025. DON stated a STAT order should have been done within 4 hours from the time it was ordered. During a review of the facility's policy and procedure titled, Request for Diagnostic Services, date revised 4/2007, indicated, Orders for diagnostic services will be promptly carried out as instructed by the physician's order. Emergency requests must be labeled stat (generally within 4 hours if possible) to assure that prompt action is taken. 46001 3. A review of Resident 5's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including dysphagia (Difficulty swallowing foods or liquids), oropharyngeal phase, unspecified severe protein-calorie malnutrition, gastrointestinal complications, and other artificial openings of gastrointestinal tract status. A review of Resident 5's clinical record indicated a physician's order, dated 6/7/2024, for enteral feeding every shift: Jevity 1.2 at 65 mL( milliliter, a unit of measurement) per hour for 22 hours (off from 8 a.m. to 10 p.m.), with a flush of 130 mL of free water every 6 hours. During an observation in Resident 5's room on 2/23/2025 at 1:21 p.m., Resident 5 was lying in bed with the GT feeding pump running. The feeding pump was set to flush 130 mL of water every four hours. During a concurrent observation and interview in Resident 5's room with the Director of Staff Development (DSD) on 2/26/2025 at 10:37 a.m., Resident 5 was lying in bed with the GT feeding pump running. The feeding pump was set to flush 130 mL of water every four hours. The DSD confirmed that the water flush setup was 130 mL every four hours. During a concurrent interview and record review with the Director of Staff Development (DSD) on 2/26/2025 at 10:58 a.m., the DSD reviewed Resident 5's physician's order and confirmed that the water flush should have been 130 mL every 6 hours. The DSD stated that nurses should have followed the physician's enteral feeding order. A review of the facility's policies and procedures, titled Enteral Feedings, indicated .preventing errors in administration, 1. Check the enteral nutrition label against the order before administration. Check the following information: a. Resident name, ID, and room number; b. Type of formula; c. Date and time formula was prepared. d. Route of delivery; e. Access site; f. Method (pump, gravity, syringe); and g. Rate of administration (ml/hour).2. on the formula label, document initials, date and time the formula was hung, and that the label was checked against the order .

Based on observation, interview, and record review, the facility failed to ensure the proper use of side or bed rails (adjustable rigid bars attached to the side of a bed) for 29 (Residents 21, 80, 302, 15, 40, 11, 68, 94, 23, 85, 106, 77, 27, 30, 12, 74, 4, 287, 29, 66, 91, 13, 299, 103, 75, 59, 53, 114, and 45) of 63 residents who used bed or side rails when: 1. There was no documentation of informed consents (a form in which residents are given important information, including possible risks and benefits, about a medical procedure or treatment) were obtained prior to bed/side rail use for four of 63 residents (Residents 91, 114, 45, and 59); 2. The Bed Rail Observation/Assessment was not updated in a timely manner for three of 63 residents (Residents 287, 29 and 53); 3. There were 18 of 63 residents (Residents 302,15, 40, 11, 94, 77, 27, 30, 12, 74, 287, 66, 91, 13, 103, 75, 59 and 53) who used bed rails without care plans; and 4. There was no physician orders obtained prior to the use of bed rails for 21 of 63 residents (Residents 21, 80, 302, 15, 40, 68, 94, 23, 85, 106, 77, 27, 30, 12, 74, 4, 287, 66, 13, 299, and 53). These failures had the potential to place the residents at risk of entrapment and serious injury. Findings: 1a During an observation on 2/24/2025 at 9:00 a.m., inside Resident 91's room, Resident 91 was not in her room. Resident 91's bed was observed with two upper bed rails installed and in upright position. During a concurrent observation and interview with minimum data set coordinator A (MDSC A) on 2/27/2025 at 8:42 a.m., inside Resident 91's room, Resident 91 complained that a staff removed her bed rails in the morning and stated she needed the bed rails. MDSC A confirmed Resident 91's bed rails were removed in the morning because they need to get a consent from the conservator. MDSC A further confirmed Resident 91 had been using the bed rails, but they couldn't find the consent. MDSC A stated a consent for bed rail use should have been obtained first prior to installation of bed rail and resident's use. During a concurrent interview with the regional director of clinical services (RDCS) and record review on 2/27/2025 at 10:49 a.m., the RDCS looked for Resident 91's bed rail consent for use and confirmed there was no consent found in Resident 91's medical records. The RDCS confirmed there was no documentation when the possible risks and benefits for bed rail use was explained to Resident 91's conservator prior to bed rail use. 1b. A review of Resident 114's admission record indicated Resident 114 was admitted to the facility on [DATE]. During an observation on 2/25/2025 at 1:32 p.m., inside Resident 114's room. Resident 114's bed had two upper bed rails installed and both in upright position. During a concurrent interview and record review with the RDCS on 3/3/2025 at 10:59 a.m., the RDCS reviewed Resident 114's bed rail consent and confirmed there was no signed consent found in Resident 114's medical records. The RDCS stated the consent should have been obtained prior to using the bedside rails. 1c. A review of Resident 45's admission record indicated Resident 45 was admitted to the facility on [DATE]. During an observation on 2/25/2025 with Certified Nursing Assistant O (CNA O) at 1:46 p.m., inside Resident 45's room. CNA O confirmed that Resident 45's bed had two upper bed rails installed and both in upright position. During a concurrent interview and record review with the RDCS on 3/3/2025 at 11:00 a.m., the RDCS reviewed Resident 45's bed rail consent and confirmed there was no signed consent found in Resident 45's medical records. The RDCS stated the consent should have been obtained prior to using the bedside rails. 1d. A review of Resident 59's admission record indicated Resident 59 was admitted to the facility on [DATE]. During an observation on 2/25/2025 with CNA O at 1:48 p.m., inside Resident 59's room. CNA O confirmed that Resident 59's bed had two upper bed rails installed and both in upright position. During a concurrent interview and record review with the RDCS on 3/3/2025 at 11:02 a.m., RDCS reviewed Resident 59's bed rail consent and confirmed there was no signed consent found in Resident 59's medical records.The RDCS stated the consent should have been obtained prior to using the bedside rails. 2a. During an observation on 2/23/2025 at 10:09 a.m., inside Resident 287's room, Resident 287 was in bed and observed to have two upper bed rails installed to her bed and in upright position. During a concurrent observation and interview with MDSC A on 2/27/2025 at 8:35 a.m., inside Resident 287, Resident 287 was observed in bed with two upper bed rails installed in bed and in upright position. MDSC A confirmed above observation and stated Resident 287 used the bed rails for repositioning. During a concurrent interview with the RDCS and record review on 2/27/2025 at 10:06 a.m., RDCS reviewed Resident 287's bed rail assessment/evaluation and confirmed it was last completed on 5/30/2023. The RDCS confirmed there was no latest bed rail assessment completed and stated it should have been updated quarterly. 2b. During an observation on 2/24/2025 at 8:57 a.m., inside Resident 29's room, Resident 29 was in bed, eating breakfast and observed two upper bed rails have been installed to her bed and in upright position. During a concurrent observation and interview with MDSC A on 2/27/2025 at 8:40 a.m., inside Resident 29's room, Resident 29 was in bed, with two upper bed rails installed and in upright position. MDSC A confirmed above observation. MDSC A stated nurses should do a bed rail evaluation assessment upon resident's admission and should be updated quarterly, and when there was a significant change in resident's status. During a concurrent interview with the RDCS and record review on 2/27/2025 at 10:38 a.m., the RDCS reviewed Resident 29's bed rail assessment dated [DATE] and confirmed there was no other bed rail assessment completed for Resident 29. The RDCS stated there should have been an updated bed rail assessment for Resident 29. 2c. A review of Resident 53's admission record indicated Resident 53 was admitted to the facility on [DATE]. During an observation with CNA O on 2/25/2025 at 1:50 p.m., inside Resident 53's room. CNA O confirmed that Resident 53's had two upper bed rails installed and both in upright position. During a concurrent interview and record review with the RDCS on 3/3/2025 at 11:04 a.m., the RDCS reviewed Resident 53's bed rail assessment/evaluation and confirmed there was no bed rail assessment completed until 2/26/2025. The RDCS stated it should have been completed prior to using the bedside rails. 3a. During the observation of Resident 302 on 2/23/25 at 11:30 a.m., Resident 302 had his bilateral half siderails up. Review of Resident 302's admission record indicated, Resident 302 was originally admitted to the facility on [DATE]. Review of Resident 302's care plans indicated, Resident 302's siderail care plan was just created on 2/27/25. The facility already observed and assessed Resident 302 for his siderails on 10/30/24. Resident 302 did not have a siderail care plan when he was using the side rails already. 3b. During the observation of Resident 15 on 2/23/25 at 11:32 a.m., Resident 15 had his bilateral half siderails up. Review of Resident 15's admission record indicated, Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's care plans indicated, Resident 15's siderail care plan was just created on 2/26/25. Resident 15 did not have a siderail care plan when it was observed on 2/23/25. 3c. During the observation of Resident 40 on 2/24/25 at 9:50 a.m., Resident 40 had his bilateral half siderails up. Review of Resident 40's admission record indicated, Resident 40 was admitted to the facility on [DATE]. Review of Resident 40's care plans indicated, Resident 40's siderail care plan was just created on 2/26/25. Resident 40 did not have a siderail care plan when it was observed on 2/24/25. 3d. During the observation of Resident 11 on 2/24/25 at 9:50 a.m., Resident 11 had his bilateral half siderails up. Review of Resident 11's admission record indicated, Resident 11 was readmitted to the facility on [DATE]. Review of Resident 11's care plans indicated, Resident 11's siderail care plan was just created on 2/26/25. Resident 11 did not have a siderail care plan when it was initially ordered on 11/22/23. 3e. During the observation of Resident 94 on 2/24/25 at 3:50 p.m., Resident 94 had his bilateral half siderails up. Review of Resident 94's admission record indicated, Resident 94 was readmitted to the facility on [DATE]. Review of Resident 94's care plans indicated, Resident 94's siderail care plan was just created on 2/26/25. Resident 94 did not have a siderail care plan when it was observed on 2/24/25. 3f. During the observation of Resident 77 on 2/23/25 at 12:30 p.m., Resident 77 had his bilateral siderails up. Review of Resident 77's admission record indicated, Resident 77 was readmitted to the facility on [DATE]. Review of Resident 77's care plans indicated, Resident 77's siderail care plan was just created on 2/26/25. The facility already observed and assessed Resident 77 for his bilateral siderails on 5/28/24. Resident 77 did not have a siderail care plan when he was using the siderails already. 3g. During the observation of Resident 27 on 2/23/25 at 12:35 p.m., Resident 27 had his bilateral siderails up. Review of Resident 27's admission record indicated, Resident 27 was readmitted to the facility on [DATE]. Review of Resident 27's care plans indicated, Resident 27's siderail care plan was just created on 2/26/25. The facility already observed and assessed Resident 27 for his bilateral siderails on 7/9/24. Resident 27 did not have a siderail care plan when he was using the siderails already. 3h. During the observation of Resident 30 on 2/23/25 at 12:35 p.m., Resident 30 had his bilateral siderails up. Review of Resident 30's admission record indicated, Resident 30 was admitted to the facility on [DATE]. Review of Resident 30's care plans indicated, Resident 30's siderail care plan was just created on 2/26/25. The facility already observed and assessed Resident 30 for his siderails on 4/23/24. Resident 30 did not have a siderail care plan when he was using the siderails already. 3i. During the observation of Resident 12 on 2/24/25 at 3:31 p.m., Resident 12 had her left siderail up. Review of Resident 12's admission record indicated, Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's care plans indicated, Resident 12's siderail care plan was just created on 2/26/25. The facility already observed and assessed Resident 12 for her siderail on 2/13/15. Resident 12 did not have a siderail care plan when she was using the siderail already. 3j. During the observation of Resident 74 on 2/23/25 at 12:40 p.m., Resident 74 had her bilateral siderails up. Review of Resident 74's admission record indicated, Resident 74 was admitted to the facility on [DATE]. Review of Resident 74's care plans indicated, Resident 74's siderail care plan was just created on 2/26/25. The facility already observed and assessed Resident 74 for her bilateral siderails on 4/11/24. Resident 74 did not have a siderail care plan when she was using the siderails already. During the concurrent record review of the clinical records of Residents 302,15, 40, 11, 94, 77, 27, 30, 12 and 74, and interview with the RDCS, on 2/28/25 at 10:37 a.m., the RDCS verified that Residents 302,15, 40, 11, 94, 77, 27, 30, 12 and 74 did not have side rail care plans when their side rails were initiated and already used by the residents. Their side rail care plans were just recently created. During the interview with the director of nursing (DON), on 2/28/25 at 5:35 p.m., the DON acknowledged the above findings and would follow up on them. 3k. During a concurrent interview with RDCS and record review on 2/27/2025 at 10:06 a.m., the RDCS reviewed Resident 287's list of care plans and confirmed there was no care plan developed for Resident 287 prior to bed rail use. 3l. During an observation on 2/24/2025 at 9:00 a.m., inside room [ROOM NUMBER]'s room, Resident 66 was in bed, just had breakfast and observed two upper bed rails were installed in the bed and in upright position. During a concurrent observation and interview with MDSC A on 2/27/2025 at 8:41 a.m., inside Resident 66's room, Resident 66 was in bed with two upper bed rails installed and in upright position. MDSC A confirmed above observation. During a concurrent interview with the RDCS and record review on 2/27/2025 at 10:45 a.m., the RDCS reviewed Resident 66's list of care plans and confirmed there was no care plan developed for Resident 66 prior to bed rail use. 3m. During a concurrent interview with the RDCS and record review on 2/27/2025 at 10:49 a.m., the RDCS reviewed Resident 91's list of care plans and confirmed there was no care plan developed for Resident 91 prior to bed rail use. 3n. During an observation on 2/24/2025 at 9:31 a.m., inside Resident 13's room, Resident 13 was in bed watching TV, and observed two upper bed rails were installed in her bed and in upright position. During a concurrent observation and interview with MDSC A on 2/27/2025 8:44 a.m., inside Resident 13's room, Resident 13 was in bed with two upper bed rails installed and in upright position. MDSC A confirmed above observation. During a concurrent interview with the RDCS and record review on 2/27/2025 at 10:55 a.m., the RDCS reviewed Resident 13's list of care plans and confirmed there was no care plan developed for Resident 13 prior to bed rail use. The RDCS stated care plan for bed rail use should have been developed prior to installation and use of bed rails. 3o. A review of Resident 103's admission record indicated Resident 103 was admitted to the facility on [DATE]. During an observation on 2/25/2025 at 1:34 p.m., inside Resident 103's room. Resident 103's bed was observed with two upper bed rails installed and in upright position. During a concurrent interview and record review with the RDCS on 3/3/2025 at 11:06 a.m., RDCS reviewed Resident 103's care plan and confirmed there was no care plan to address the bedside rails use until 2/26/2025. The RDCS stated Resident 103 should have a siderail care plan when it was initiated. 3p. A review of Resident 75's admission record indicated Resident 75 was admitted to the facility on [DATE]. During an observation on 2/25/2025 with CNA O at 1:52 p.m., inside Resident 75's room. CNA O confirmed that Resident 75's bed was observed with two upper bed rails installed and in upright position. During a concurrent interview and record review with the RDCS on 3/3/2025 at 11:04 a.m., the RDCS reviewed Resident 75's care plan and confirmed there was no care plan to address the bedside rails use until 2/26/2025. The RDCS stated Resident 75 should have a siderail care plan when it was initiated. 3q. A review of Resident 59's admission record indicated Resident 59 was admitted to the facility on [DATE]. During an observation on 2/25/2025 with CNA O at 1:48 p.m., inside Resident 59's room. CNA O confirmed that Resident 59's bed had two upper bed rails installed and both in upright position. During a concurrent interview and record review with the RDCS on 3/3/2025 at 11:04 a.m., the RDCS reviewed Resident 59's care plan and confirmed there was no care plan to address the bedside rails use until 2/27/2025. The RDCS stated Resident 59 should have a siderail care plan when it was initiated. 3r. A review of Resident 53's admission record indicated Resident 53 was admitted to the facility on [DATE]. During an observation on 2/25/2025 with CNA O at 1:50 p.m., inside Resident 53's room. CNA O confirmed that Resident 53's bed had two upper bed rails installed and both in upright position. During a concurrent interview and record review with the RDCS on 3/3/2025 at 11:04 a.m., the RDCS reviewed Resident 53's care plan and confirmed there was no care plan to address the bedside rails use until 2/26/2025. The RDCS stated Resident 53 should have a siderail care plan when it was initiated. 4a. During the observation of Resident 21 on 2/23/25 at 11:27 a.m., Resident 21 had her bilateral half siderails up. Review of Resident 21's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident), indicated, Resident 21 was initially admitted to the facility on [DATE]. Review of Resident 21's physician orders indicated, Resident 21's siderail order was just created on 2/26/25. Resident 21 did not have a siderail order when it was initiated and used. 4b. During the observation of Resident 80 on 2/23/25 at 11:27 a.m., Resident 80 had her bilateral siderails up. Review of Resident 80's admission record indicated, Resident 80 was admitted to the facility on [DATE]. Review of Resident 80's physician orders indicated, Resident 80's siderail order was just created on 2/26/25. Resident 80 did not have a siderail order when it was initiated and used. 4c. During the observation of Resident 302 on 2/23/25 at 11:30 a.m., Resident 302 had his bilateral half siderails up. Review of Resident 302's admission record indicated, Resident 302 was originally admitted to the facility on [DATE]. Review of Resident 302's physician orders indicated, Resident 302's siderail order was just created on 2/27/25. Resident 302 did not have a siderail order when it was initiated and used. 4d. During the observation of Resident 15 on 2/23/25 at 11:32 a.m., Resident 15 had his bilateral half siderails up. Review of Resident 15's admission record indicated, Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's physician orders indicated, Resident 15's siderail order was just created on 2/26/25. Resident 15 did not have a siderail order when it was initiated and used. 4e. During the observation of Resident 40 on 2/24/25 at 9:50 a.m., Resident 40 had his bilateral half siderails up. Review of Resident 40's admission record indicated, Resident 40 was admitted to the facility on [DATE]. Review of Resident 40's physician orders indicated, Resident 40's siderail order was just created on 2/26/25. Resident 40 did not have a siderail order when it was initiated and used. 4f. During the observation of Resident 68 on 2/24/25 at 10:00 a.m., Resident 68 had her bilateral siderails up. Review of Resident 68's admission record indicated, Resident 68 was readmitted to the facility on [DATE]. Review of Resident 68's physician orders indicated, Resident 68's siderail order was just created on 2/26/25. Resident 68 did not have a siderail order when it was initiated and used. 4g. During the observation of Resident 94 on 2/24/25 at 3:50 p.m., Resident 94 had his bilateral half siderails up. Review of Resident 94's admission record indicated, Resident 94 was readmitted to the facility on [DATE]. Review of Resident 94's physician orders indicated, Resident 94's siderail order was just created on 2/26/25. Resident 94 did not have a siderail order when it was initiated and used. 4h. During the observation of Resident 23 on 2/24/25 at 3:35 p.m., Resident 23 had his bilateral siderails up. Review of Resident 23's admission record indicated, Resident 23 was readmitted to the facility on [DATE]. Review of Resident 23's physician orders indicated, Resident 23's siderail order was just created on 2/26/25. Resident 23 did not have a siderail order when it was initiated and used. 4i. During the observation of Resident 85 on 2/24/25 at 3:35 p.m., Resident 85 had his bilateral siderails up. Review of Resident 85's admission record indicated, Resident 85 was readmitted to the facility on [DATE]. Review of Resident 85's physician orders indicated, Resident 85's siderail order was just created on 2/26/25. Resident 85 did not have a siderail order when it was initiated and used. 4j. During the observation of Resident 106 on 2/23/25 at 12:42 p.m., Resident 106 had her bilateral siderails up. Review of admission record of Resident 106 indicated, Resident 106 was readmitted to the facility on [DATE]. Review of the physician orders of Resident 106 indicated, the siderail order of Resident 106 was just created on 2/26/25. Resident 106 did not have a siderail order when it was initiated and used. 4k. During the observation of Resident 77 on 2/23/25 at 12:30 p.m., Resident 77 had his bilateral siderails up. Review of Resident 77's admission record indicated, Resident 77 was readmitted to the facility on [DATE]. Review of Resident 77's physician orders indicated, Resident 77's siderail order was just created on 2/26/25. Resident 77 did not have a siderail order when it was initiated and used. 4l. During the observation of Resident 27 on 2/23/25 at 12:35 p.m., Resident 27 had his bilateral siderails up. Review of Resident 27's admission record indicated, Resident 27 was readmitted to the facility on [DATE]. Review of Resident 27's physician orders indicated, Resident 27's siderail order was just created on 2/26/25. Resident 27 did not have a siderail order when it was initiated and used. 4m. During the observation of Resident 30 on 2/23/25 at 12:35 p.m., Resident 30 had his bilateral siderails up. Review of Resident 30's admission record indicated, Resident 30 was admitted to the facility on [DATE]. Review of Resident 30's physician orders indicated, Resident 30's siderail order was just created on 2/26/25. Resident 30 did not have a siderail order when it was initiated and used. 4n. During the observation of Resident 12 on 2/24/25 at 3:31 p.m., Resident 12 had her left siderail up. Review of Resident 12's admission record indicated, Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's physician orders indicated, Resident 12's siderail order was just created on 2/26/25. Resident 12 did not have a siderail order when it was initiated and used. 4o. During the observation of Resident 74 on 2/23/25 at 12:40 p.m., Resident 74 had her bilateral siderails up. Review of Resident 74's admission record indicated, Resident 74 was admitted to the facility on [DATE]. Review of Resident 74's physician orders indicated, Resident 74's siderail order was just created on 2/26/25. Resident 74 did not have a siderail order when it was initiated and used. 4p. During the observation of Resident 4 on 2/23/25 at 12:40 p.m., Resident 4 had her bilateral siderails up. Review of Resident 4's admission record indicated, Resident 4 was readmitted to the facility on [DATE]. Review of Resident 4's physician orders indicated, Resident 4's siderail order was just created on 2/26/25. Resident 4 did not have a siderail order when it was initiated and used. During the concurrent record review of the clinical records of Residents 21, 80, 302, 15, 40, 68, 94, 23, 85, 106, 77, 27, 30, 12, 74 and 4, and interview with the regional director of clinical services (RDCS), on 2/28/25 at 10:37 a.m., the RDCS verified that Residents 21, 80, 302, 15, 40, 68, 94, 23, 85, 106, 77, 27, 30, 12, 74 and 4, did not have side rail orders when their side rails were initiated and already used by the residents. Their side rail orders were just recently created. During the interview with the DON, on 2/28/25 at 5:35 p.m., the DON acknowledged the above findings and would check on these concerns. 44583 4q. During a concurrent interview with the RDCS and record review on 2/27/2025 at 10:06 a.m., the RDCS reviewed Resident 287's physician order and confirmed Resident 287 did not have an order for the use of bed rail prior to its installation and use. 4r. During a concurrent interview with the RDCS and record review on 2/27/2025 at 10:45 a.m., the RDCS reviewed Resident 66's physician order and confirmed Resident 66 did not have an order for use of bed rail prior to its installation and use. 4s. During a concurrent interview with the RDCS and record review on 2/27/2025 at 10:55 a.m., the RDCS reviewed Resident 13's physician order and confirmed Resident 13 did not have an order for use of bed rail prior to its installation and use. 4t. During an observation on 2/24/2025 at 10:36 a.m., inside Resident 299's room, Resident 299 was in bed, and there were two upper bed rails installed in her bed and in upright position. During a concurrent observation and interview with MDSC A on 2/27/2025 at 8:50 a.m., inside Resident 299's room, Resident 299 was in bed, with two upper bed rails installed in her bed and in upright position. MDSC A confirmed above observation. MDSC A stated after nurses have completed the bed rail assessment and determined resident had an indication to have bed rails, they should obtain a physician's order for bed rail use. During a concurrent interview with the RDCS and record review on 2/27/2025 at 11:08 a.m., RDCS reviewed Resident 299's physician order and confirmed Resident 299 did not have an order for use of bed rail prior to its installation and use. 46001 4u. A review of Resident 53's admission record indicated Resident 53 was admitted to the facility on [DATE]. During an observation on 2/25/2025 with CNA O at 1:50 p.m., inside Resident 53's room. CNA O confirmed Resident 53's bed had two upper bed rails installed and both in upright position. During a concurrent interview and record review with the RDCS on 3/3/2025 at 11:05 a.m., the RDCS reviewed Resident 53's physician orders and confirmed that Resident 53's siderail order was just created on 2/26/25. The RDCS stated Resident 53 did not have a siderail order when it was initiated. During a review of the facility's policy and procedure titled, Bed Safety and Bed Rails, date revised 8/2022, indicated, The resident's sleeping environment is evaluated by the interdisciplinary team [IDT, a group of health care professionals from diverse fields who work toward a common goal for residents]. Consideration is give to the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment .The use of bed rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, inlcuding .interdisciplinary evaluation, resident assessment, and informed consent. Periodic evaluation and assessment on use of bed rails or side rails will be done (e.g. quarterly). During a review of the facility's undated policy and procedure titled, Careplans, Comprehensive Person-Centered, indicated, The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representatvie, develops and implements comprehensive, person-centered care plan for each resident .Assessments of residents are ongoing .

Based on interview and record review, the facility failed to provide sufficient nursing staff on a 24-hour basis based on the Staffing Data Report submitted to the Centers for Medicare & Medicaid Services (CMS). This failure could potentially affect resident's care, health, and psychosocial well-being. Findings: A record review of the facility's Direct Care Service Hours Per Patient Day (DHPPD) from July 2024 to January 2025 indicated that 63 days had actual DHPPD below 3.5. 5 days in July 2024 7/13/2024 Actual DHPPD 3.38; 7/20/2024 Actual DHPPD 3.04 ;7/21/2024 Actual DHPPD 3.10; 7/27/2024 Actual DHPPD 3.25; 7/28/2024 Actual DHPPD 3.41. 8 days in August 2024 8/3/22024 Actual DHPPD 3.29; 8/4/2024 Actual DHPPD 3.35;8/11/2024 Actual DHPPD 3.19; 8/17/2024 Actual DHPPD 3.45;8/18/2024 Actual DHPPD 3.38;8/24/2024 Actual DHPPD 3.21; 8/25/2024 Actual DHPPD 3.27; 8/31/2024 Actual DHPPD 3.34. 8 days in September 2024 9/7/2024 Actual DHPPD 3.21; 9/14/2024 Actual DHPPD 3.16;9/15/2024 Actual DHPPD 3.17 9/21/2024 Actual DHPPD 3.27; 9/22/2024 Actual DHPPD 3.39; 9/28/2024 Actual DHPPD 3.31 9/29/2024 Actual DHPPD 2.83; 9/01/2024 Actual DHPPD 3.01. 14 days in October 2024 10/10/2024 Actual DHPPD 3.31;10/11/2024 Actual DHPPD 3.48;10/12/2024 Actual DHPPD 2.83 10/13/2024 Actual DHPPD 2.95;10/14/2024 Actual DHPPD 3.43;10/15/2024 Actual DHPPD 3.43 10/17/2024 Actual DHPPD 3.35;10/18/2024 Actual DHPPD 3.12;10/19/2024 Actual DHPPD 2.45 10/20/2024 Actual DHPPD 2.43;10/21/2024 Actual DHPPD 3.45;10/22/2024 Actual DHPPD 3.49 10/23/2024 Actual DHPPD 2.52;10/26/2024 Actual DHPPD 3.34. 9 days in November 2024 11/2/2024 Actual DHPPD 3.33;11/6/2024 Actual DHPPD 2.68;11/17/2024 Actual DHPPD 3.13 11/23/2024 Actual DHPPD 3.11;11/24/2024 Actual DHPPD 3.32;11/25/2024 Actual DHPPD 3.33 11/28/2024 Actual DHPPD 2.64;11/29/2024 Actual DHPPD 2.61;11/30/2024 Actual DHPPD 2.62 11 days in December 2024 12/1/2024 Actual DHPPD 3.17;12/7/2024 Actual DHPPD 3.38;12/8/2024 Actual DHPPD 3.30 12/12/2024 Actual DHPPD 3.44;12/14/2024 Actual DHPPD 3.26;12/15/2024 Actual DHPPD 3.14 12/21/2024 Actual DHPPD 3.43;12/25/2024 Actual DHPPD 3.47;12/22/2024 Actual DHPPD 2.81 12/30/2024 Actual DHPPD 3.45;12/31/2024 Actual DHPPD 3.47. 7 days in January 2025 1/1/2025 Actual DHPPD 3.46;1/2/2025 Actual DHPPD 3.4;1/4/2025 Actual DHPPD 3.01 1/5/2025 Actual DHPPD 2.47;1/18/2025 Actual DHPPD 3.26;1/19/2025 Actual DHPPD 3.15 1/26/2025 Actual DHPPD 3.25. During a concurrent interview and record review with the Staffing Coordinator (SC) on 3/3/2025 at 1:58 p.m., the SC reviewed the DHPPD records from July 2024 to January 2025. The SC confirmed that the actual DHPPD for the above 63 days were below the required 3.5 and acknowledged past and ongoing staffing challenges. The SC stated that the Direct Care Service Hours Per Patient Day (DHPPD) should have been 3.5. During an interview with the Administrator (ADM) on 3/3/2025 at 2:29 p.m., the ADM acknowledged that the facility had a workforce shortage waiver but stated that the facility should have provided no less than 3.5 direct care service hours per patient day. During a review of the facility's Certified Nursing Assistant (CNA) waiver from the California Department of Public Health (CDPH) dated June 18,2024 it indicated, Your request is approved, only as applicable to the required 2.4 CNA staffing standard, and valid from July 1, 2024, until June 30, 2025, under the following conditions .2. The facility shall provide no less than 3.5 direct care hours per patient day. A review of the All Facilities Letter (AFL) 21-11 dated March 17, 2021, indicated, The 3.5 DHPPD staffing requirement, of which 2.4 hours per patient day must be performed by CNAs, is a minimum requirement for SNFs (Skilled Nursing Facility). SNFs shall employ and schedule additional staff and anticipate individual patient needs for the activities of each shift, to ensure patients receive nursing care based on their needs. The staffing requirement does not ensure that any given patient receives 3.5 or 2.4 DHPPD; it is the total number of actual direct care service hours performed by direct caregivers per patient day divided by the average patient census.

Based on observation, interview, and record review, the facility failed to ensure the nursing staff demonstrated competency in the assessment and management of antihypertensive (medication to manage high blood pressure [BP]) and antiarrhythmic (medication to manage arrhythmia [abnormal or irregular heartbeats]) medications for 11 out of 40 sampled residents (Residents 10, 19, 38, 47, 60, 67, 72, 93, 104, 111, and 121). There were no documented BP and/HR before the medication administration, and physician's orders and prescribed hold parameters were not being followed. The failure had the potential for residents to suffer from undetected severe hypotension (low BP) and worsening of arrythmias. Also, the facility failed to ensure all nursing staffs were checked off their competencies to provide nursing care and medication pass trainings to assure resident safety, when one of five nurses reviewed did not have a record that she was checked off on nursing care competencies and medication pass trainings. The failure had the potential to compromise the safety of the residents and not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being. Findings: 1a. During a medication pass observation on 2/24/25 at 9:33 a.m., LVN C was observed preparing and administering 8 medications, including a tablet of losartan 50 mg, to Resident 47. During the concurrent interview and record review on 2/24/25 at 9:52 a.m., when asked about Resident 47's BP for the administration of losartan, LVN C stated a certified nursing assistant (CNA) had already taken it earlier that day. She reviewed Resident 47's clinical record which indicated the latest BP was obtained the day prior, on 2/23/25 at 16:08 (4:08 p.m.). LVN C stated she did not check the resident's BP earlier that morning. On 2/24/25 at 9:54 a.m., she returned to Resident 47's bedside and obtained her BP. It was 156/70 mmHg (normal BP is under 120/80 mmHg). After returning to the medication cart, LVN C stated, It was a mistake and she should have checked the BP before giving the losartan. A review of Resident 47's clinical record indicated a physician's order, dated 5/21/24, for losartan 50 mg, give 1 tablet one time a day for hypertension hold for systolic [BP] <110 [mmHg]. 1b. For Resident 104, he had the following physician's orders: - Valsartan (treat high blood pressure and heart failure) 40 mg 1 tablet twice daily for hypertension, dated 4/12/24. On 1/30/25, valsartan was discontinued and switched to Entresto (combination of valsartan and sacubitril, another antihypertensive medication) 24-26 mg twice daily. One 2/4/25, Entresto was reduced to one time a day for hypertension. Part of its order indicated to Check BP without specified frequency. Each of these medications was scheduled to be administered daily at 10 a.m. - Furosemide 20 mg, give 1.5 tablets (30 mg) one time a day for edema (swelling caused by a buildup of fluid in body tissues) and hypertension, dated 8/23/24. It was scheduled to be administered daily at 9 a.m. - Spironolactone 25 mg, give 1 tablet one time day for fluid retention, dated 12/26/24. It was scheduled to be administered daily at 9 a.m. - Metoprolol extended release (ER) 25 mg one time a day for hypertension, hold for systolic BP < [less than] 100 [mmHg], [HR] <60 [bpm], dated 4/12/24. It was scheduled to be administered daily at 10 a.m. (Normal HR is between 60 - 100 bpm). B. Amiodarone 200 mg, 1 tablet by mouth one time a day for arrhythmia, dated 4/12/24. It was scheduled to be administered daily at 10 a.m. C. Check BP Q [every] day one time a day 'call clinic if SBP is less than 100 [mmHg] consistently, dated 1/30/25. It was scheduled daily at 9 a.m. A review of Resident 104's January and February 2025 MARs indicated the nursing staff placed their initials and a check mark on in the entry for the Check BP one time a day without corresponding BP readings. There were no corresponding BP readings for the administration of furosemide, valsartan or Entresto, and spironolactone. Similarly, there was no documentation of corresponding BP and HR for the administration of metoprolol despite the physician's order to hold for SBP <100 mmHg and HR <60 bpm. Furthermore, there was no hold parameters for or corresponding measurement of BP and HR for the use of amiodarone. Further review of Resident 104's BP and HR summary indicated there were periods of BP and HR as long as 14 days: 1/11/25 to 1/26/25. During a concurrent interview and record review with the Director of Nursing (DON), the Infection Control Preventionist (IP), and Nurse Supervisor D (NS D) on 2/27/25 at 1:45 p.m., they reviewed Resident 104's clinical record and acknowledged the resident's BP and HR were not checked on a daily basis as per physician's order, and before administration of metoprolol; no BP checks done before the administration of Entresto, spironolactone, and furosemide; no hold parameters; and no BP and HR check for amiodarone . The IP and NS D stated the BP and HR should be checked at least daily. The DON, the IP, and NS D also verified there were gaps of multiple days where BP and HR were not checked daily and acknowledged the potential for resident to suffer from undetected severe hypotension and arrhythmias (such as too slow HR). During an interview with the DON on 2/27/25 at 4:33 p.m., she stated, The blood pressure and pulse were not consistently done . The MAR was not coded right so it's not on the MAR. She explained the MAR should be coded to require an input of the BP and/or HR with BP and cardiac (heart) medications. On 2/28/25 at 9:26 a.m. in the presence of the Assistant Director of Staff Development (ADSD), a review of Resident 104's February 2025 MAR with LVN G indicated she administered the metoprolol with the prescribed hold parameters, and documented she checked the BP on 2/5 and 2/6/25; however, there was no BP and HR measurement in the clinical record for both days. Both LVN G and the ADSD verified this finding. During a concurrent interview and record review with LVN H on 2/28/25 at 9:42 a.m., she reviewed with the surveyor Resident 104's February 2025 MAR and confirmed she documented the administration of metoprolol with ordered hold parameters, and did the daily BP on 2/25/26; however, there were no BP and HR measurement on 2/25/26 in Resident 104's clinical record. She stated, If the MAR doesn't say then I don't put in there unless I put in the progress notes. When asked to look up the progress notes, LVN H stated, I know I did not. During a concurrent interview and record review with LVN I on 2/28/25 at 9:55 a.m., a review of Resident 104's February 2025 MAR with LVN I indicated she documented she administered the metoprolol and did the daily BP check on 2/10, 2/11, 2/15, and 2/21/25 during which there were no documentation of daily BP and HR measurement. She stated, I checked them but not entered into the system because it didn't have entry to enter, but I always check them. In a concurrent interview and record review with Registered Nurse (RN) J on 2/28/25 at 10:11 a.m., a review of Resident 104's February 2025 MAR with RN J indicated she administered the BP medications, including the metoprolol; and the daily BP check, on 2/3, 2/4, 2/14, 2/22, 2/23, and 2/26/25 during which there were no BP and HR measurement in the clinical record. RN J acknowledged there were BP and HR missing in the MAR and stated, I understand what you are saying. There's no excuse for it. She also acknowledged Resident 104 was receiving four BP medications which had the potential for severe hypotension if not checked. She stated the nurses can change the order when the MAR did not have entries to input BP and HR, but acknowledged they were not done prior to being brought up by the survey team (on 2/27/25). 1c. Digoxin is an antiarrhythmic agent to treat heart failure and atrial fibrillation (AF; condition where the upper chambers of the heart [atria] beat irregularly and rapidly). A. A review of Resident 38's clinical record indicated the resident had a physician's order for Digoxin Tablet 250 MCG [micrograms, unit of measurement], Give 1 tablet by mouth one time a day for heart failure check apical heart rate [or apical pulse or AP; heartbeat that is felt or heard at the apex (bottom) of the heart, typically on the left side of the chest] prior to each dose. Hold dose if heart rate is less than 60 [bpm] and notify MD [medical doctor], dated 1/5/25. On 2/28/25 starting at 2:32 p.m., a review of Resident 38's January and February 2025 MARs with Minimum Data Set Coordinator B (MDSC B) indicated the nursing staff did not hold the resident's digoxin when he had the documented pulse (HR) of less than 60 bpm on: 1/20 (HR: 58); 1/26 (HR: 53); on 2/3 (HR: 59), on 2/5 (HR: 53), 2/7 (HR: 55), and 2/18/25 (HR: 59). MDSC B also reviewed the progress notes and stated there was no physician's notification on those days. She confirmed the physician's order was not followed. B. On 2/28/25 at 2:40 p.m., a review of Resident 111's clinical record with MDSC B indicated Resident 111 had a physician's order for Digoxin Oral Tablet 125 MCG . Give 1 tablet by mouth one time a day for Antiarrhythmic Hold if APICAL pulse <60 [bpm], dated 6/28/24. A review of Resident 111's February 2025 MAR indicated digoxin was documented as administered to the resident on 2/26/25, but there was no documented AP on that day. MDSC B verified this finding . C. On 2/28/25 at 2:44 p.m., a review of Resident 10's clinical record indicated he had been receiving Digoxin Tablet 125 MCG Give 1 tablet by mouth one time a day for heart failure Hold dose if AP less than 60 [bpm] since 4/24/2021. He also had a physician's order, dated 4/1/24, for laboratory blood tests including the digoxin level every 3 months, scheduled January, April, July, and October each year. MDSC B reviewed Resident 10's clinical record along with the contracted laboratory website, and stated she could only found one laboratory report conducted on 4/1/24. She confirmed there was no digoxin level done in July 2024, October 2024, or in January 2025. She acknowledged the physician's order was not carried out. 1d. A review of the Package Insert (PI, document included in the package of a medication that provides information about that drug and its use) for amiodarone, revised 10/2018, indicated it an antiarrhythmic medication to treat ventricular arrhythmias (life-threatening heart rhythm disturbance where the ventricles [lower chambers of the heart] quiver instead of contracting normally) and atrial fibrillation. The PI also indicated to monitor the patient's cardiac [heart] rhythm and blood pressure, and, if bradycardia ensues, a B-adrenergic agonist [a type of medication to increase HR] or a pacemaker may be used . A. Review of Resident 121's physician order, dated 12/20/2024, indicated, Amiodarone . 100 MG Give 1 tablet by mouth one time a day for CHF [chronic heart failure, a condition where the heart can't pump enough blood to meet the body's needs]. Amiodarone was scheduled to be given daily at 9:00 a.m. During a concurrent interview with the Assistant Director of Staff Development (ADSD) and record review of Resident 121's physician's order and February 2025 MAR on 2/28/25 at 3:35 p.m., the ADSD confirmed there was no documented BP and HR readings in the MAR from 2/1 to 2/27/25 prior to administration of amiodarone. During a follow-up interview with MDSC B on 2/28/25 at 3:58 p.m., MDSC B stated nurses should check and document Resident 121's BP and HR prior to administration of amiodarone. Review of Resident 121's blood pressure summary (undated) indicated Resident 121 had documentation of systolic BP of less than 110 mmHg as follows: BP: 108/78 on 2/1/25 at 9:04 a.m.; BP: 108/59 on 2/8/25 at 4:25 p.m.; and BP 91/62 on 2/9/25 at 1:46 a.m. B. Review of Resident 60's physician order, dated 2/1/25, indicated, Amiodarone . 200 MG Give 1 tablet by mouth one time a day for abnormal heart rhythm. Amiodarone was scheduled to be given daily at 9:00 a.m. During a concurrent interview with MDSC B and record review on 2/28/25 at 4:05 p.m., MDSC B reviewed Resident 60's physician order and the February 2025 MAR, and confirmed there was no documentation of Resident 60's BP and HR prior to administration of amiodarone from 2/1 to 2/28/25. Review of Resident 60's BP summary indicated Resident 60 had systolic BP less than 110 as follows: BP: 105/63 on 2/6/25 at 5:37 p.m.; BP: 105/70 on 2/20/25 at 4:18 p.m.; BP: 90/60 on 2/23/25 at 6:13 p.m.; BP 103/62 on 2/24/25 at 6:52 p.m.; and BP: 107/62 on 2/27/25 at 4:46 p.m. C. Review of Resident 67's physician order, dated 11/17/2020, indicated, Amiodarone . 200 MG Give 1 tablet by mouth one time a day for Arrythmia. Amiodarone was scheduled to be given daily at 9:00 a.m. During a concurrent interview with MDSC B and record review on 2/28/25 at 4:21 p.m., MDSC B reviewed Resident 67's physician order and February 2025 MAR, and confirmed nurses did not check Resident 67's BP and HR prior to administration of amiodarone from 2/1 to 2/27/25. D. Review of Resident 72's physician order, dated 2/11/25, indicated, Amiodarone .100 MG Give 1 tablet by mouth one time a day for bradycardia. Amiodarone was scheduled to be given daily at 9:00 a.m. During a concurrent interview with MDSC B and record review of Resident 72's physician order and February 2025 MAR on 2/28/25 at 4:26 p.m., MDSC B confirmed nurses did not obtain and document Resident 72's BP and HR prior to medication administration from 2/12 to 2/27/25. Further review of Resident 72's February 2025 MAR revealed Resident 72 had an order of 200 mg of amiodarone, dated 1/28/25, with parameter indicated, Hold for SBP less than 110 [mmHg] or HR less than 60 [bpm] The following was revealed: on 2/5/25, Resident 72's BP was 90/61, amiodarone was documented as given; on 2/6/25, Resident 72's BP was 105/73 with HR of 50 bpm, amiodarone was documented as given; and on 2/11/25, Resident 72's BP was 102/66, amiodarone was marked as given. During a concurrent interview with MDSC B and record review of Resident 72's February 2025 MAR on 2/28/25 at 4:26 p.m., MDSC B reviewed Resident 72's February 2025 MAR and confirmed amiodarone was given on 2/28/25 with BP of 95/87. MDSC B confirmed the nurse did not follow the parameters ordered by the physician. E. A review of Resident 19's physician order, dated 8/19/24, indicated for amiodarone 100 mg give 1 tablet by mouth one time a day for arrhythmia. Hold for SBP less than 110 or heart rate (HR) less than 60. The start date was 8/19/24. During a concurrent interview and record review of Resident 19's clinial record with the DON on 2/28/25, at 5:23 p.m., the DON reviewed Resident 19's physician order and MARs for December 2024, January, and February 2025. The DON confirmed no BP or HR readings were documented in the MAR from 12/1/24 to 2/27/25 prior to the administration of amiodarone. A review of Resident 19's BP summary from 1/26/25 to 2/28/25 indicated that Resident 19 had SBP less than 110: BP: 96/54 on 2/14/25 at 1:14 p.m.; BP: 95/51 on 2/27/25 at 7:30 p.m. A review of Resident 19's pulse summary from 1/2/25 to 2/28/25 indicated six instances of a recorded pulse rate (PR) below 60 in January 2025 and in February 2025, as follows: Date and time PR/ HR reading (bpm) 1/07/25 18:18 58 1/09/25 16:34 57 1/25/25 16:51 55 1/25/25 16:52 55 1/26/25 16:15 59 2/08/25 17:25 55 F. A review of Resident 38's physician order dated 1/4/25 indicated, Amiodarone . 200 MG Give 1 tablet by mouth two times a day for abnormal heart rhythm. Hold for SBP less than 110 or heart rate less than 60. The start date was 1/4/25. During a concurrent interview and record review of Resident 38's clinical record with the DON on 2/28/25, at 5:25 p.m., the DON confirmed that no BP or HR readings were documented in the MAR from 1/4/25 to 1/31/25 prior to the administration of amiodarone. A review of Resident 38's pulse rate summary from 1/4/25 to 2/28/25, indicated 15 recorded pulse rates below 60 in January 2025 and 16 instances in February 2025. G. A review of Resident 93's physician order, dated 2/3/25, indicated for amiodarone 200 mg, Give 1 tablet by mouth two times a day for abnormal heart rhythm. Hold for SBP less than 110 or heart rate less than 60. The start date was 2/3/25. During a concurrent interview and record review of Resident 93's clinical record with DON on 2/28/25, at 5:27 p.m., the DON reviewed Resident 93's physician order and the February 2025 MAR, and confirmed that no BP or HR readings were documented in the MAR from 2/4 to 2/27/25 before the administration of amiodarone. A review of Resident 93 's pulse rate summary indicated Resident 93 had a pulse rate below 60, which was 52 bpm on 2/9/25. A review of the facility's policy and procedures (P&P) titled Medication Administration, revised 4/2019, it indicated, Medications are administered in accordance with prescribers orders . The following information is checked/verified for each resident prior to administering medications . Vital signs, if necessary. 44185 2. During the medication pass observation on 2/24/25 at 9:17 a.m., Licensed Vocational Nurse C (LVN C), was observed giving medications to Resident 6. On 2/24/25 at 9:33 a.m., LVN C was also observed administering medications for Resident 47. Review of the facility's records of five nursing staffs' competency checks and medication pass trainings indicated, LVN C did not have a record that she was checked of her nursing care competencies and medication pass trainings. During an interview with the regional director of clinical services (RDCS) on 2/28/25 at 3:40 p.m., RDCS verified that the facility did not have a record that LVN C was checked of her nursing care competencies and medication pass trainings. Review of the facility's policy and procedure titled, Staffing, Sufficient and Competent Nursing, dated 2001, indicated, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment . Licensed nurses .to provide competent resident care services including .attaining or maintaining the highest practicable physical, mental and psychosocial well-being of each resident .assessing, evaluating, planning and implementing resident care plans . Competent staff .must demonstrate the skills and techniques necessary to care for resident needs including . Basic nursing skills . Competency requirements and training for nursing staff are established and monitored by nursing leadership with input from the medical director .

Based on observation, interview, and record review, the facility failed to provide appropriate care and services for indwelling catheter (a catheter which is inserted into the bladder [a sac-shaped muscular organ that stores the urine secreted by the kidneys],via the urethra [the tube through which urine leaves the body] and remains in place to drain urine) for one of three residents (Resident 46) with indwelling catheters when there was no documented indwelling catheter care for Resident 46 in some days and shifts in December 2024, January 2025 and February 2025. This failure had the potential for the resident to develop catheter associated urinary tract infection (CAUTI, an infection caused by a bacteria [germs] that get into the bladder or kidneys [a pair of organs that are on either side of the spine, just below the rib cage of a person's back ] related to catheter use). Findings: Review of Resident 46's clinical record titled, Admission Record, dated 2/25/2025, indicated Resident 46 was admitted to the facility with diagnoses including wedge compression fracture (a type spinal fracture that occurs when the front of a vertebra collapses, creating a wedge shape) of third lumbar vertebra (L3 is a bone in the middle of the lower back that helps support the upper body's weight), dementia (a progressive state of decline in mental abilities), infection and inflammatory reaction due to indwelling urethral catheter and encounter for palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness). Review of Resident 46's order summary report, the order dated 12/17/2024, indicated, Indwelling Urinary (Foley) Catheter Care: cleanse with soap and water every shift [days, evening and night shifts]. During an observation on 02/24/2025 at 8:53 a.m., inside Resident 46's room, Resident 46 was observed alert, but talking to self, with indwelling catheter connected to a urinary bag. Review of Resident 46's 12/2024 treatment administration record (TAR), indicated licensed nurses had no documentation of Resident 46's catheter care was provided in the following days and shifts:12/24 - day, and night shifts; 12/25 - day shift; 12/29 - night shift; 12/30 - evening, and night shifts; and 12/31 - evening shift. Review of Resident 46's 01/2025 TAR, indicated licensed nurses had no documentation of Resident 46's catheter care was provided in the following days and shifts: 01/01 - day, and evening shifts; 01/02 - day, and night shifts; 01/03 - night shift; 01/04 - evening, and night shifts; 01/06 - day shift; 01/08 - evening shift; 01/09 - evening, and night shifts; 01/10 - evening, and night shift; 01/11 - day, and night shift; 01/12 - night shift; 01/14 - day shift; 01/15 - day, and evening shifts; 01/16 - evening shift; 01/17 - day shift; 01/18 - evening shift; 01/19 - evening shift; 01/20 - evening shift; 01/22 - evening shift; 01/23 - night shift; 01/24 - evening, and night shifts; 01/25 - evening shift; 01/26 - day, and evening shifts; 01/27 - evening shift; 01/28 - evening, and night shifts; 01/29 - day shift; 01/30 - night shift; and 01/31 - evening, and night shifts. Review of Resident 46's 02/2025 TAR, indicated licensed nurses had no documentation of Resident 46's catheter care was provided in the following days and shifts: 02/01 - evening, and night shifts; 02/02 - evening, and night shifts; 02/04 - evening, and night shifts; 02/05 - evening, and night shifts; 02/06 - day, and evening shifts; 02/07 - evening, and night shifts; 02/08 - evening, and night shifts; 02/09 - evening, and night shift; 02/10 - evening shift; 02/11 - evening shift; 02/12 - evening shift; 02/13 - evening, and night shifts; 02/14 - evening shift; 02/15 - evening shift; 02/16 - evening, and night shifts; 02/17 - day shift; 02/18 - evening shift; 02/19 - day, and evening shifts; 02/20 - evening shift; 02/21 - day shift; 02/23 - day, and evening shifts; 02/24 - evening shift; and 02/25 - evening shifts. During a concurrent interview with minimum data set coordinator A (MDSC A) and record review on 02/26/2025 at 1:19 p.m., MDSC A reviewed Resident 46's admission records, order summary report and TARs for 12/2024, 01/2025, and 02/2025. MDSC A confirmed Resident 46 had indwelling catheter and had history of UTI. MDSC A further confirmed above missed documentations of Resident 46's indwelling catheter care. MDSC A stated if indwelling catheter care was not documented in the TAR, it was not done. During a concurrent interview with director of nursing (DON) and record review on 2/28/2025 at 9:45 a.m., DON reviewed Resident 46's TARs for 12/2024, 01/2025, and 02/2025 and confirmed above missed documentations of Resident 46's indwelling catheter care. DON stated nurses did not sign their names in some days and shifts in 12/2024, 01/2025, and 02/2025 for Resident 46's indwelling catheter care and confirmed if it was not signed and documented, the indwelling catheter care was not done. Review of Centers for Disease Control and Prevention's (CDC) Summary of Recommendations from the Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009) dated 3/25/2024, indicated, Proper Techniques for Urinary Catheter Maintenance .Use Standard Precautions, including the use of gloves and gown as appropriate, during manipulation of the catheter or collecting system .Routine hygiene (e.g. cleansing of the meatal surface .) is appropriate .System of documentation: Ensuring that documentation is accessible in the patient record and recorded in a standard format for data collection and quality improvement purposes is suggested .

Based on interview and record review, the facility failed to ensure the comprehensive care plans were developed and implemented for 11 of 40 sampled residents (Resident 10, 19, 38, 54, 67, 72, 93, 104, 111, 121, and 287 ). This failure placed the residents at risk of not being provided appropriate, consistent, and individualized care. Findings: 1. A review of Resident 104's admission record indicated he was admitted to the facility with diagnoses including heart failure (condition where the heart cannot pump enough blood to meet the body's needs). A review of the physician's orders indicated an order, dated 4/12/24, for amiodarone (a anti-arrhythmic medication, to treat irregular heart rhythms) 200 milligrams (mg, unit of measurement), 1 tablet by mouth one time a day for arrhythmia. A review of Resident 104's clinical record indicated no care plan was developed and implemented for Resident 104's arrhythmia and use of amiodarone. During a concurrent interview and record review with the Director of Nursing (DON), the Infection Control Preventionist (IP), and Nurse Supervisor D (NS D) on 2/27/25 at 1:45 p.m., they reviewed Resident 104's clinical record and confirmed there was no care plan developed for arrhythmia and use of amiodarone. They acknowledged it should have been developed. 2a. A review of Resident 38's clinical record indicated the resident was admitted to the facility with diagnoses including heart failure. He had a physician's order for Digoxin [an antiarrhythmic medication] Tablet 250 MCG [micrograms, unit of measurement], Give 1 tablet by mouth one time a day for heart failure, dated 1/5/25. On 2/28/25 starting at 2:32 p.m., a review of Resident 38's clinical record with the Minimum Data Set Coordinator B (MDSC B) indicated there was no comprehensive care plan developed for the resident's heart failure or digoxin use. MDSC B stated it should have been care planned. 2b. Resident 38 also had a physician's order, dated 1/4/25, for Amiodarone . 200 MG Give 1 tablet by mouth two times a day for abnormal heart rhythm. During a concurrent interview and record review with the DON on 2/28/25, at 5:25 p.m., the DON reviewed Resident 38's list of care plans and confirmed there was no care plan in place to address Resident 38's abnormal heart rhythm and amiodarone use. 3. A review of Resident 111's clinical record indicated she was admitted to the facility with diagnoses including paroxysmal atrial fibrillation (a fast, irregular heartbeat that only lasts a few hours or days). She had a physician's order for Digoxin Oral Tablet 125 MCG . Give 1 tablet by mouth one time a day for Antiarrhythmic dated 6/28/24. On 2/28/25 at 2:40 p.m. during a concurrent interview and record review with MDSC B, she reviewed Resident 111's list of care plans and stated there was no care plan developed for the use of digoxin. MDSC B stated there should have been a care plan developed. 4. A review of Resident 287's clinical record indicated the resident was admitted to the facility with diagnoses including atrial fibrillation (AF; condition where the upper chambers of the heart [atria] beat irregularly and rapidly). Resident 287 had physician's order for Digoxin Tablet 125 MCG Give 1 tablet by mouth one time a day for heart failure, dated 2/14/25. On 2/28/25 at 2:42 p.m., during a concurrent interview and record review with MDSC B, she reviewed Resident 287's list of care plans and stated she could not find any care plan for the resident's heart failure or digoxin use. She confirmed there should have been a care plan developed. 5. A review of Resident 10's clinical record indicated was admitted to the facility with diagnoses including heart failure. A review of the physician's order, dated 4/24/21 indicated, Digoxin Tablet 125 MCG Give 1 tablet by mouth one time a day for heart failure since 4/24/21. On 2/28/25 at 2:44 p.m., during a concurrent interview and record review with MDSC B, she reviewed the resident's list of care plans and stated she could not find any care plan for the use of digoxin. She acknowledged there should be a care plan for the resident's heart failure and digoxin use. 6. A review of Resident 54's clinical record indicated the resident was admitted with diagnoses including unspecified AF. She had a physician's order for digoxin tablet 125 mcg, 1 tablet by mouth one time a day for AF, dated 9/6/2023. On 2/28/25 at 3:40 p.m., during a concurrent interview and record review with MDSC B, she reviewed Resident 54's list of care plans and stated she could not find a care plan for AF or digoxin use. She confirmed there should have been a care plan developed. 7a. A review of Resident 121's clinical record indicated he was admitted to the facility with diagnoses including paroxysmal atrial fibrillation (a fast, irregular heartbeat that only lasts a few hours or days), and cardiomyopathy (a disease that affects the heart muscle, making it difficult for the heart to pump blood). A review of the physician's orders indicated an order for digoxin 125 mcg 1 tablet one time a day for AF, dated 10/18/24. On 2/28/25 at 3:57 p.m., during a concurrent interview and record review with MDSC B, she reviewed Resident 121's list of care plans, and stated there was no care plan for Resident 121's AF or digoxin use. 44583 7b. Resident 121 also had another physician's order, dated 12/20/24, for Amiodarone . 100 MG Give 1 tablet by mouth one time a day for CHF [chronic heart failure, a condition where the heart can't pump enough blood to meet the body's needs]. During a concurrent interview with the Assistant Director of Staff Development (ADSD) and record review on 2/28/2025 at 3:35 p.m., the ADSD reviewed Resident 121's physician order and list of care plans. The ADSD confirmed there was no care plan developed for Resident 121's amiodarone use. 8. Review of Resident 67's clinical record titled, Admission Record, dated 2/28/25, indicated Resident 67 was admitted to the facility with diagnoses including unspecified diastolic heart failure (a condition in which the heart's main pumping chamber becomes stiff and unable to fill with enough blood and reducing the amount of blood pumped out to the body), hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, and unspecified atrial fibrillation. Review of Resident 67's physician order, dated 11/17/2020, indicated, Amiodarone . 200 MG Give 1 tablet by mouth one time a day for Arrythmia. During a concurrent interview with minimum data set coordinator B (MDSC B) and record review on 2/28/25 at 4:21 p.m., MDSC B reviewed Resident 67's physician order and list of care plans, and confirmed there was no care plan developed for Resident 67's amiodarone use. 9. Review of Resident 72's clinical record titled, Admission Record, dated 2/28/25, indicated Resident 72 was admitted at the facility with diagnoses including nonrheumatic mitral valve prolapse (a heart condition that occurs when the mitral valve [a heart valve between the left upper chamber and left lower chamber of the heart] flaps bulge into the left atrium of the heart), left bundle-branch block (occurs when something blocks or disrupts the electrical impulse that causes the heart to beat), atherosclerotic heart disease of native coronary artery (a buildup of plaque in the coronary arteries that supply blood to the heart), bradycardia (a condition where the heart rate is abnormally slow, typically below 60 bpm), presence of cardiac pacemaker (a small device that's implanted in the chest to regulate the heart's rhythm and rate), presence of aortocoronary bypass graft (CABG - a surgical procedure that improves blood flow to the heart) and presence of coronary angioplasty implant and graft (a minimally invasive procedure that uses a balloon to widen a blocked artery, and a stent to keep it open). Review of Resident 72's physician order, dated 2/11/25, indicated, Amiodarone .100 MG Give 1 tablet by mouth one time a day for bradycardia. During a concurrent interview with MDSC B and record review on 2/28/25 at 4:26 p.m., MDSC B reviewed Resident 72's physician order and list of care plans, and confirmed there was no care plan developed for Resident 72's amiodarone used. MDSC B stated there should have been a care plan developed for Resident 72's amiodarone used which indicated about amiodarone's black box warning monitoring and the parameters of blood pressure (BP) and heart rate (HR) prior to administration of the medication. 46001 10. A Review of Resident 19' clinical record indicated Resident 19 was admitted to the facility on [DATE] with diagnoses including heart failure and unspecified atrial fibrillation. A review of Resident 19's physician order, dated 8/19/24, indicated for amiodarone 100 mg give 1 tablet by mouth one time a day for arrhythmia. Hold for SBP less than 110 or heart rate (HR) less than 60. The start date was 8/19/24. During a concurrent interview and record review with the DON on 2/28/25, at 5:23 p.m., the DON reviewed Resident 19's physician order and MARs ( medication administration record) for December 2024, January, and February 2025. The DON confirmed there was no care plan in place to address Resident 19's abnormal heart rhythm and amiodarone use. 11. A Review of Resident 93's clinical record indicated Resident 93 was admitted to the facility on [DATE] with diagnoses including essential hypertension, heart failure, and a personal history of sudden cardiac arrest. A review of Resident 93's physician order, dated 2/3/25, indicated for amiodarone 200 mg, Give 1 tablet by mouth two times a day for abnormal heart rhythm. The start date was 2/3/25. During a concurrent interview and record review with DON on 2/28/25, at 5:27 p.m., the DON reviewed Resident 93's list of care plans and confirmed there was no care plan in place to address Resident 93's abnormal heart rhythm and amiodarone use. A review of the facility's undated policy and procedures titled Care Plans, Comprehensive Person-Centered indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interview, and record review, the facility failed to ensure the provision of pharmaceutical services that included availability of medication, accurate and safe administration of medications, and accurate accountability of controlled substance (that can be easily abused and are under strict government control) when: 1. A medication was not available to administer to Resident 296 for 10 days, and the nursing staff failed to follow up with the pharmacy or notify the physician of the missing medication. This had the potential for untreated and worsening of the resident's medical condition. 2. Two non-crushable medications for Resident 296 were crushed during administration. This had the potential for the resident to suffer from adverse effects of the medications due to too fast delivery of the medication. 3. There was no person-centered, individualized approach for administering medications for Resident 6 who has trouble swallowing medications. This resulted in one of her medications being crushed and not meeting her needs. 4. For Resident 297, the facility did not have a system to ensure weekly narcotic patch was in place to ensure continued delivery of the medication and to prevent abuse of medication. 5. Controlled medications were not reconciled for 4 out of 6 residents (Residents 39, 81, 287, 294). This resulted in facility not having an accurate accountability and the potential for abuse/loss of controlled medications. Findings: 1. During a medication administration observation on 2/24/25 at 8:44 a.m. with Registered Nurse F(RN F), she stated she could not find Steglatro (oral medication to lower blood sugar levels in people with diabetes) to administer to the Resident 296. A review of Resident 296's clinical record indicated a physician's order, dated 1/30/25, for Steglatro Oral Tablet 5 MG . Give 1 tablet by mouth one time a day for diabetes. A review of Resident 296's February 2025 Medication Administration Record (MAR) indicated the nursing staff documented a 9 (meaning Other/See Nurses Notes) in the Steglatro entry on 2/9 - 2/13/25; 2/15 - 2/17/25; 2/19-2/20/25; and 2/24/25 (a total of 10 days). A review of the corresponding Nurses Notes for the above dates indicated: - 2/9/25 at 10:31 a.m. - medication not available. pending insurance clarification - 2/10/25 at 9:45 a.m. - waiting delivery - 2/11/25 8:10 a.m. - on order - 2/12/25 8:48 a.m. - reordered from pharmacy - 2/13/25 8:47 a.m.- reordered from pharmacy - 2/15/25 8:59 a.m.- on delivery - 2/1724 8:53 a.m.- - not available - 2/19/25 8:43 a.m.- no notes - 2/20/25 8:08 a.m.- No notes - 2/24/25 9:03 a.m. medication is not covered by insurance; recommendation for alternative faxed to be addressed with MD [medical doctor] - 2/24/25 9:26 a.m. - Note Text: Pharmacy informed staff that Steglatro not covered by insurance and to consider alternative Farxiga [medication for diabetes]. Dr. [name] made aware and medication changed as per pharmacy recommendation. During a concurrent interview and record review with Nursing Supervisor D (NS D) on 2/24/25 at 2:06 p.m., she stated she called the pharmacy and was informed they sent a 2-week and a 3-day supply since the order date on 1/30/25. She was just informed by the pharmacy this morning that the medication was not covered by the insurance, and the pharmacy recommended an alternative medication. NS D reviewed Resident 296's clinical record and February 2025 MAR. She confirmed the resident missed 10 days of the medication, and there was no documented evidence the staff called the pharmacy to follow up and informing the physician of the missing medication. A review of the facility's policy and procedures titled Pharmacy Services Overview, dated 4/2019, indicated: 4. Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. 5. Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration. 2. During the medication administration observation with RN F above, on 2/24/25 at 8:43 a.m., RN F was observed preparing 9 medications, including a tablet of metoprolol (medication to to treat high blood pressure) extended release (ER, medication is formulated so that the drug is released slowly over time) 25 milligrams (mg, unit of measurement), to give to Resident 296. RN F was observed crushing all the tablets and poured the crushed contents into a medicine cup. RN F stated Resident 296, likes them all crushed together. RN F added a spoonful of yogurt to the crushed powder and spoon-fed the mixture to Resident 296 at his bedside. During an interview on 2/24/25 at 9:02 a.m., RN F stated that metoprolol ER shouldn't be crushed, but it was. A review of Resident 296's physician orders included the following: - Metoprolol Succinate ER tablet 25 mg, give 1 tablet by mouth one time a day for high blood pressure, dated 1/30/25 - Protonix tablet delayed release 40 mg, give 1 tablet by mouth one time a day for acid indigestion, start date 1/30/25. A review of drug resource, DailyMed (https://dailymed.nlm.nih.gov), indicated, Metoprolol succinate extended-release tablets are scored on both sides and can be divided; however, do not crush or chew the whole or half table and Do not split, crush, or chew PROTONIX For Delayed-Release Tablets. During an interview with Resident 296 on 2/25/25 at 9:01 a.m., he stated his medications are crushed, all the time. Resident 296 stated that he does not remember the reason his medications are crushed, but said he likes them crushed. During another interview with RN F on 2/25/25 at 9:08 a.m. RN F stated that Resident 296, always takes his meds crushed. RN F acknowledged metoprolol ER should not be crushed due to being extended released. During a concurrent interview and record review with NS D and RN F on 2/25/25 at 9:15 a.m., RN F stated Resident 296 would chew the medications if given in whole tablets. RN D acknowledged the Metoprolol ER and Protonix tablets are not crushable. During an telephone interview with the Consultant Pharmacist (CP) on 2/27/25 at 11:21 a.m., he stated metoprolol ER and Protonix tablets cannot be crushed. A review of the facility's policy titled, Crushing Medications, revised April 2018, indicated Medications shall be crushed only when it is appropriate and safe to do so, consistent with physician orders 1. The medical director and director of nursing services, in conjunction with the consultant pharmacist, shall identify appropriate indications and procedures for crushing medications. 3. During a medication administration observation on 2/24/25 at 9:17 a.m., Licensed Vocational Nurse (LVN) C was observed preparing four medications for Resident 6. The medications included a tablet of potassium chloride (to treat low potassium level in the blood) ER 20 milliequivalents (mEq, a unit of measure). On 2/24/25 at 9:22 a.m., at Resident 6's bedside, LVN C was observed administering the medications to Resident 6, in whole pills, with applesauce. The resident swallowed the applesauce but not the medications. She pushed the large pills out of her mouth using her tongue. LVN C took the rejected pills from the resident's mouth. On 2/24/25 at 9:26 a.m., LVN C returned to the medication cart and stated the rejected medications were the potassium ER tablet, a Tylenol 500 mg tablet, and docusate sodium (stool softener) 250 mg tablet. She disposed of the medications and retrieved new ones from the medication cart, crushed them into a fine powder, and mixed with applesauce. On 2/24/25 at 9:29 a.m., LVN C returned to Resident 6's bedside and administered the medication-applesauce mixture to the resident. During a concurrent interview with LVN C at 2/24/25 at 10:02 a.m. and a review of the pharmacy label for potassium ER 20 mEQ tablet indicated its manufacturer is Manufacturer A, and a warning label indicating May be Broken or Allowed to Disintegrate In Water (Stir Well) Before Swallowing. Rinse Down With Water, But Do Not Chew, All of The Remaining Particles. LVN C acknowledged it should not be crushed. A review of Manufacturer A's drug information for potassium chloride ER tablet, revised 3/2023, indicated, To take each dose without crushing, chewing or sucking the tablets. A review of Resident 6's clinical record indicated a physician's order, dated 2/23/24, for Potassium Chloride ER Tablet Extended Release 20MEQ Give 1 tablet by mouth one time a day for supplement. During concurrent interview and record review with another nurse, LVN H, on 2/25/25 at 1:46 p.m., she confirmed she crushed and administered the potassium ER tablet to Resident 6 earlier this morning. LVN H stated the pharmacy label indicated it could be dissolved in water, so she thought it could be crushed. A review of Resident 6's clinical record indicated no care plans for swallowing or whether or not medications were to be crushed. There was no swallowing evaluation identified. During an interview with the Director of Staff Development (DSD) on 2/25/25 at 1:55 p.m., she stated, The doctor told us that you could mix the [potassium] tablet with water, but it takes forever. The DSD also stated Resident 6 had a regular nurse in the past who knew how to give her the potassium tablet, but with registry nurses, they may not know how to give it to her. During a telephone interview with the CP on 2/27/25 at 11:21 a.m., he stated potassium ER tablet should not be crushed. A review of the facility's policy titled, Crushing Medications, revised April 2018, indicated Medications shall be crushed only when it is appropriate and safe to do so, consistent with physician orders . 1. The medical director and director of nursing services, in conjunction with the consultant pharmacist, shall identify appropriate indications and procedures for crushing medications. 2. The nursing staff and/or consultant pharmacist shall notify any attending physician who gives an order to crush a drug that the manufacturer states should not be crushed a. The attending physician or consultant pharmacist must identify an alternative medication and/or dosage form . 4. A review of Resident 297's clinical record indicated she was admitted to the facility with diagnoses including fracture of the right pubis (flat, triangular bone that forms the front part of the right hip bone and pelvis). Her Minimum Data Set (MDS, a care area assessment and screening tool), dated 2/25/25, indicated she had a BIMS score of 10 (Brief Interview for Mental Status, a test given by medical professionals that helps determine a patient's cognitive understanding, scored from 1 to 15), which indicated his cognitive condition was moderately impaired. Resident 297 had a physician's order, dated 2/23/25, for Buprenorphine Transdermal Patch [a narcotic skin patch used to treat severe and persistent pain that requires an extended treatment period] Weekly 5 MCG/HR [micrograms per hour] Apply 1 patch transdermally in the morning every 7 day(s) for pain and remove per schedule. During an interview with Resident 297 at her bedside on 2/26/25 at 2:35 p.m., when asked about her buprenorphine patch, Resident 297 stated a physician at the hospital applied it on her before she left the hospital. She uncovered her left neckbone/upper chest to show the surveyor the patch but it was not there. She stated it does not work for her but it was there before arriving to the facility. She stated she had a shower yesterday and it may have fallen off during the shower. During a concurrent interview and record review with LVN K on 2/26/25 at 2:38 PM, LVN K reviewed Resident 297's clinical record and confirmed the resident arrived with a hospital-applied patch on 2/21/25. During another interview with Resident 297 in the presence of LVN K on 2/26/25 at 2:46 p.m., Resident 297 stated she had a new patch applied by the hospital doctor before arriving in the facility. She had a shower yesterday and she did not know what happened to the patch as she had forgotten about it. During another interview with LVN K on 2/26/25 at 2:59 p.m., when asked if there was a system of daily checking of patch placement for weekly patch such as buprenorphine, LVN K stated there was no such thing as she has been here for 2 years. She said it would make sense to have such system for narcotic patches. During an interview with NS D on 2/26/25 at 3:39 p.m., she stated currently there was no process for daily patch placement check but there should be. NS D acknowledged lost or misplaced narcotic patch would result in disruption in delivery of the medication which would lead to uncontrolled pain management, and the potential for abuse/misuse. A review of the Prescribing Information for buprephenone patch, revised June 2014, indicated the patch is intended to be worn for 7 days . If your patch falls off later, but before 1 week (7 days) of use, throw it away properly . and apply a new patch at a different skin site. 5. During the survey, the controlled drug record (CDR, an inventory sheet) for 6 residents receiving PRN (as needed) controlled (narcotic) medications was requested for review. During an interview with the DON on 2/25/25 at 11:53 a.m., she stated any time a resident requests a PRN narcotic medication, the nurse assesses the resident, checks the physician's order and reads the instructions in the computer, removes the medication from the narcotic drawer, administers the medication to the resident, and documents the administration on the MAR. On 2/25/25 starting at 12 noon, during a concurrent interview and record review with the DON and the Medical Record Director (MRD), they verified the following: a. Resident 39 had a physician's order, dated 7/22/24, for Norco (a combination of hydrocodone with acetaminophen, a narcotic for pain) 5-325 mg, 1 tablet every 6 hours as needed for pain. A review of Resident 39's CDR for Norco 5-325 mg and the October 2024 MAR with the two staff indicated a nursing staff removed 1 tablet of Norco on 10/2/24 at 1 p.m. without documenting the administration on the MAR. b. Resident 294 had a physician's order, date 2/4/25, for Norco 5-325 mg, give 1 tablet by mouth every 4 hours as needed for severe pain. A review of Resident 294's CDR for Norco 5-325 mg and February 2025 MAR with the two staff indicated, on 2/22/25 at 10 a.m., a nursing staff removed 1 tablet from the CDR without documenting the administration on the MAR. c. Resident 287 had a physician's order for Norco 5-325 mg,1 tablet by mouth every 6 hours as needed for moderate pain, start date 2/13/25. A review of Resident 287's CDR for Norco 5-325 mg and the February 2025 MAR with the DON and the MRD indicated, on 4 occasions, the nursing staff removed the medication and signed out of the CDR but did not document the administration on the MAR: on 2/14/25 at 3:26 p.m. and 9:40 p.m.; on 2/15/25 at 0050 a.m.; and on 2/20/25 at 2:49 p.m. d. Resident 81 had a physician's order for oxycodone (a potent narcotic for pain) 10 mg, 1 tablet by mouth every 6 hours as needed for severe pain, start date 1/24/25. A review of Resident 81's CDR for oxycodone 10 mg and the February 2025 MAR with the DON and MRD showed, on 6 occasions, the nursing staff signed out of the CDR but did not document the administration on the MAR: on 2/14/25 at 3:42 p.m. and 10:59 p.m.; on 2/16/25 at 9 p.m.; on 2/19/25 at 11:20 a.m. and 11 p.m.; and on 2/22/25 at 1 p.m. During the interview and record review above, on 2/25/25 at 12:20 p.m., the DON confirmed the above findings and stated the facility has been made aware of this issue during the survey, and started the in-service with the nursing staffs. She confirmed the controlled medications for these four residents were not fully accounted for. A review of the facility's P&P titled, Medication Administration, revised April 2019, indicated in part, . the individual administering the medication records in the resident's medical record: a. The date and time of the medication was administered . g. The signature and title of the person administering the drug.

Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR) for 7 out of 34 sampled residents (10, 38, 54, 104, 111, 121, and 287) and one non-sampled Resident 296. Also, the facility failed to respond to the CP's recommendation for Resident 296. This failures resulted in unnecessary medications for the residents including duplicate therapy and inappropriately monitored medication use for the residents. Findings: 1. During the medication administration observation with RN F above, on 2/24/25 at 8:43 a.m., RN F was observed preparing 9 medications, including a tablet of metoprolol (medication to to treat high blood pressure) extended release (ER, medication is formulated so that the drug is released slowly over time) 25 milligrams (mg, unit of measurement), to give to Resident 296. RN F was observed crushing all the tablets and poured the crushed contents into a medicine cup. RN F stated Resident 296, likes them all crushed together. During an interview on 2/24/25 at 9:02 a.m., RN F stated that metoprolol ER shouldn't be crushed, but it was. A review of Resident 296's physician orders included the following: - Metoprolol Succinate ER tablet 25 mg, give 1 tablet by mouth one time a day for high blood pressure, dated 1/30/25 - Protonix tablet delayed release 40 mg, give 1 tablet by mouth one time a day for acid indigestion, start date 1/30/2025. - May crush medications (or open capsules) as indicated per pharmacy protocol, dated 1/29/2025. A review of drug resource, DailyMed (https://dailymed.nlm.nih.gov), indicated, Metoprolol succinate extended-release tablets are scored on both sides and can be divided; however, do not crush or chew the whole or half tablet and Do not split, crush, or chew PROTONIX For Delayed-Release Tablets. During an interview with Resident 296 on 2/25/25 at 9:01 a.m., he stated his medications are crushed, all the time. Resident 296 stated that he does not remember the reason his medications are crushed, but said he likes them crushed. During a concurrent interview and record review with NS D and RN F on 2/25/25 at 9:15 a.m., RN F stated Resident 296 would chew the medications if given in whole tablets. RN D acknowledged the Metoprolol ER and Protonix tablets are not crushable. During an telephone interview with the Consultant Pharmacist (CP) on 2/27/25 at 11:21 a.m., he stated he reviewed the residents' medication regimen from 2/1 to 2/3/25 for this month. He stated metoprolol ER and Protonix tablets cannot be crushed. Given Resident 296's order for may crush medications, the CP was asked if he made a recommendation for the staff not to crush the metoprolol and Protonix during the February 2025 MRR, he stated he did not but will pay more attention in the future. 2. A review of Resident 296's clinical record indicated he had physician's orders for two medications, Protonix and omeprazole (both belong to medication class called proton pump inhibitors, to treat acid reflux), as follows: - Protonix tablet delayed release 40 mg, give 1 tablet by mouth one time a day for acid indigestion, start date 1/30/25. - Omeprazole 20 mg, 1 tablet by mouth one time a day for gastric indigestion, dated 1/30/25. Both medications were ordered on the same day and scheduled to be administered at the same time, at 6 a.m. During a telephone interview with the CP on 2/27/25 at 11:21 a.m., he reviewed his own record and stated the pharmacy made a recommendation to discontinue omeprazole on 1/30/25, the day the orders were made. The CP stated he did not know what happened to the recommendation. During a concurrent interview and record review with the Director of Nursing (DON), the Infection Control Preventionist (IP), and Nurse Supervisor D (NS D) on 2/27/25 at 1:45 p.m., the IP provided the said recommendation from the pharmacy, dated 1/30/25, which read, The use of the above GI [gastrointestinal] medications [omeprazole and Protonix] may be considered duplicate therapy and contribute to polypharmacy and unnecessary medication use with an increased risk of side effects. RECOMMENDATION: Please consider discontinuing omeprazole. The IP stated the Assistant DON is responsible for following up all the recommendations from the CP, but she was not available for interview. The DON acknowledged this recommendation was not acted upon as Resident 296 continued to receive duplicate therapy until it was brought up by the surveyor today (almost a month later.) 3. A review of Resident 104's admission record indicated he was admitted to the facility with diagnoses including pleural effusion (condition where excess fluid accumulates in the pleural space, the thin cavity between the lungs and the chest wall), heart failure, pulmonary edema (condition where excess fluid accumulates in the lungs, causing difficulty breathing), and unspecified peripheral vascular disease (slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel). On 2/27/25, a review of Resident 104's physician's orders, and January and February 2025 MARs, indicated the following orders and administration times: A. Four routine antihypertensive (to lower BP) medications: - Valsartan (treat high blood pressure and heart failure) 40 mg 1 tablet twice daily for hypertension, dated 4/12/24. On 1/30/25, valsartan was discontinued and switched to Entresto (combination of valsartan and sacubitril, another antihypertensive medication) 24-26 mg twice daily. One 2/4/25, Entresto was reduced to one time a day for hypertension. Each of these medications was scheduled to be administered daily at 10 a.m. - Furosemide 20 mg, give 1.5 tablets (30 mg) one time a day for edema (swelling caused by a buildup of fluid in body tissues) and hypertension, dated 8/23/24. It was scheduled to be administered daily at 9 a.m. - Spironolactone 25 mg, give 1 tablet one time day for fluid retention, dated 12/26/24. It was scheduled to be administered daily at 9 a.m. - Metoprolol extended release (ER) 25 mg one time a day for hypertension, hold for systolic BP < [less than] 100 [mmHg], [HR] <60 [bpm], dated 4/12/24. It was scheduled to be administered daily at 10 a.m. (Normal HR is between 60 - 100 bpm). B. Amiodarone (medication to manage irregular or abnormal heart rhythms) 200 mg, 1 tablet by mouth one time a day for arrhythmia, dated 4/12/24. It was scheduled to be administered daily at 10 a.m. C. Check BP Q [every] day one time a day 'call clinic if SBP is less than 100 [mmHg] consistently, dated 1/30/25. It was scheduled daily at 9 a.m. A review of the Package Insert (PI, document included in the package of a medication that provides information about that drug and its use) for amiodarone, revised 10/2018, indicated it an antiarrhythmic medication to treat ventricular arrhythmias (life-threatening heart rhythm disturbance where the ventricles [lower chambers of the heart] quiver instead of contracting normally) and atrial fibrillation. The PI also indicated to monitor the patient's cardiac rhythm and blood pressure, and, if bradycardia ensues, a B-adrenergic agonist [a type of medication to increase HR] or a pacemaker may be used . A review of Resident 104's January and February 2025 MARs indicated the nursing staff placed their initials and a check mark on in the entry for the Check BP one time a day with no corresponding BP readings. There were no corresponding BP readings for the administration of furosemide, valsartan or Entresto, and spironolactone. Similarly, there was no documentation of corresponding BP and HR for the administration of metoprolol despite the physician's order to hold for SBP <100 mmHg and HR <60 bpm. Furthermore, there was no hold parameters for or corresponding measurement of BP and HR for the use of amiodarone. Further review of Resident 104's BP and HR summary indicated: - Resident 104's BP was not checked for 14 days from 1/11/25 to 1/26/25; for 3 days from 1/26/25 to 1/30/25; for 7 days from 2/1/25 to 2/8/25; for 2 days from 2/9/25 to 2/12/25; for 5 days from 2/13/25 to 2/18/25; and for 6 days from 2/19/25 to 2/26/25. - Resident 104's HR measurement was not obtained for 14 days from 1/11/25 to 1/26/25; for 4 days from 1/26/25 to 1/30/25; for 11 days from 2/1/25 to 2/13/25, and for 8 days from 2/19/25 to 2/27/25. During a concurrent interview and record review with the Director of Nursing (DON), the Infection Control Preventionist (IP), and Nurse Supervisor D (NS D), on 2/27/25 at 1:45 p.m., they reviewed Resident 104's clinical record and acknowledged the resident's BP and HR were not checked on a daily basis as per physician's order, and before administration of metoprolol; no BP checks done before the administration of Entresto, spironolactone, and furosemide; no hold parameters; and no BP and HR check for amiodarone . The IP and NS D stated the BP and HR should be checked at least daily. The DON, the IP, and NS D also verified there were gaps of multiple days (as stated above) where BP and HR were not checked daily and acknowledged the potential for resident to suffer from undetected severe hypotension and arrhythmias (such as too slow HR). They also verified there was no care plan developed to address the resident's heart failure and amiodarone use. During a telephone interview with the CP on 2/27/25 at 3:30 p.m., he stated residents receiving amiodarone should receive routine HR monitoring, and Resident 104 receiving four antihypertensive medications had a risk of hypotension. When asked whether he had identified and made a recommendation for the nursing staff to include HR and BP monitoring for the use of his antihypertensive and antiarrhythmic medications for Resident 104, the CP stated he did not and confirmed he should have. 4. A review of the PI for digoxin, dated 2015, indicated Digoxin has a narrow therapeutic index [medication in which the therapeutic dose is very close to the toxic dose], increased monitoring of serum digoxin concentrations and for potential signs and symptoms of clinical toxicity is necessary when initiating, adjusting, or discontinuing drugs that may interact with digoxin . Monitor for signs and symptoms of digoxin toxicity and clinical response. Adjust dose based on toxicity, efficacy, and blood levels. A. On 2/28/25 starting at 2:32 p.m., a review of Resident 38's clinical record with Minimum Data Set Coordinator B (MDSC B) indicated the resident had a physician's order for Digoxin Tablet 250 MCG [micrograms, unit of measurement], Give 1 tablet by mouth one time a day for heart failure. dated 1/5/25. MDSC B reviewed Resident 38's list of care plans and confirmed there was no comprehensive care plan developed for the resident's heart failure or digoxin use. MDSC B stated it should have been care planned. B. On 2/28/25 at 2:40 p.m., a review of Resident 111's clinical record with MDSC B indicated she had a physician's order for Digoxin Oral Tablet 125 MCG . Give 1 tablet by mouth one time a day for Antiarrhythmic, dated 6/28/24. MDSC B reviewed Resident 111's clinical record and stated there had been no digoxin level since admission and ordered date of 6/28/24 (a period of 8 months) and had no care plan for the use of digoxin. C. On 2/28/25 at 2:42 p.m., a concurrent interview and record review of Resident 287's clinical record with MDSC B indicated a physician's order for Digoxin Tablet 125 MCG Give 1 tablet by mouth one time a day for heart failure, dated 2/14/2025. MDSC B reviewed the resident's list of care plans and stated she could not find any care plan for the resident's heart failure or digoxin use. She confirmed there should have been a care plan developed. D. On 2/28/25 at 2:44 p.m., a review of Resident 10's clinical record indicated he had been receiving Digoxin Tablet 125 MCG Give 1 tablet by mouth one time a day for heart failure Hold dose if AP less than 60, since 4/24/2021. He also had a physician's order, dated 4/1/24, for laboratory blood tests including the digoxin level every 3 months, scheduled January, April, July, and October each year. MDSC B reviewed Resident 10's clinical record and the contracted laboratory website, and stated she could only found one laboratory report conducted on 4/1/24. She confirmed there was no digoxin level done in July 2024, October 2024, or in January 2025. Also, MDSC B stated she could not find any care plan for the use of digoxin. She acknowledged the physician's order was not carried out and there should be a care plan for the resident's heart failure. E. On 2/28/25 at 3:40 p.m., a review of Resident 54's clinical record with MDSC B indicated a physician's order for Digoxin tablet 125 MCG Give 1 tablet by mouth one time a day for AFib [atrial fibrillation] dated 9/6/2023. MDSC B stated she could not find the comprehensive care plan for AF or digoxin use. She confirmed there should have been a care plan developed. F. On 2/28/25 at 3:57 p.m., a concurrent interview and record review of Resident 121's clinical record with MDSC B indicated a physician's order for digoxin 125 mcg 1 tablet one time a day for AF, dated 10/18/24. MDSC B reviewed the resident's list of care plans and stated there was no care plan for Resident 121's AF or digoxin use. During a telephone interview with the CP on 2/28/25 at 4:12 p.m., he stated digoxin level should be monitored routinely, and he would make a recommendation for it every 6 months. When asked whether he had made a recommendation to draw a digoxin level for Resident 111 since she was admitted in June 2024, the CP stated he did not, and confirmed he should have. Regarding the review for the care plans related to medication use in the residents' clinical record, the CP stated, Sometimes I do but not too much. After reviewing his own record, the CP stated he did not make recommendations on care plans during the monthly MRR for Residents 10, 38, 54, 104, 111, 121, and 287. A review of the facility's P&P titled Pharmacy Services - Role of the Consultant Pharmacist, revised 4/2019, indicated, The consultant pharmacist shall provide consultation on all aspects of pharmacy services in the facility and collaborate with the facility and medical director to: a. Develop, implement, evaluate, and revise (as necessary) the procedures to support resident quality of life such as safe, individualized medication administration programs . The Consultant Pharmacist will provide .Appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medications and pharmacy services, including medication irregularities, and pertinent resident-specific documentation in the medical record, as indicated. A review of the facility's P&P titled Medication Regimen Review, dated 5/2019, indicated the CP reviews the MRR for each resident at least monthly, and The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication-related problems, medication errors and other irregularities . The medication regimen and associated treatment goals involve collaboration with the resident, family members, and the interdisciplinary team (IDT). As such, the MRR includes review of the resident's . stated preferences, the comprehensive care plans and information provided about the risks and benefits of the medication regimen.

Based on interview and record review, the facility failed to ensure three out of 28 sampled residents (Residents 45, 104, and 107) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when: 1. Resident 45 received as-needed (PRN) lorazepam (brand name: Ativan; medication to treat agitation and anxiety) beyond 14 days without the physician-documented clinical rationale and a specified duration for the extended period. 2. Resident 107 received Depakote (a medication to treat mood disorder) and quetiapine (brand name: Seroquel, an anti-psychotic medication) without the facility staff monitoring for their side effects, and without laboratory monitoring for A1c (measures your average blood glucose level over the past 3 months) and lipid panel (a blood test that measures the levels of various fats [lipids] in the bloodstream) related to Seroquel use. 3. Resident 104 received PRN lorazepam exceeding 14 days without the physician-documented clinical rationale and a specified duration for the extended period; received PRN Seroquel beyond 14 days; and received routine Seroquel with inappropriate indication and inaccurate behavior monitoring for its use. The failures resulted in unnecessary psychotropic medications for the residents, which had the potential for increased risks associated with psychotropic medication use that include but not limited to sedation, respiratory depression, falls, constipation, anxiety, agitation, abnormal involuntary movements, and memory loss. Findings: 1. A review of Resident 45's clinical record indicated she was admitted with diagnoses including unspecified anxiety disorder. A review of her physician's orders included the following: a. Lorazepam 0.5 mg, give 1 tablet by mouth at bedtime for anxiety manifested by (m/b) inability to relax, dated 10/23/24 b. Lorazepam 0.5 mg, Give 1 tablet by mouth every 24 hours as needed for anxiety DO NOT DISCONTINUE PRN ORDER, dated 11/22/24 (3 months ago). There is not documented evidence in Resident 45's clinical record indicating the rationale why the resident needed the PRN lorazepam beyond 14 days, nor did the order itself had a specified duration. During a concurrent interview and review of Resident 45's clinical record with the Director of Nursing (DON), the Director of Staff Development (DSD), and the Social Service Director (SSD) on 2/27/25 at 10:47 a.m., they all acknowledged PRN lorazepam are limited to 14 days. The SSD stated the order was written by the physician assistant (PA) to do not discontinue. The staff present could not provide any documentation of the rationale for extending the PRN beyond 14 days, and the order itself did not indicate a duration of how long the order was for. 2. A review of Resident 107's clinical record indicated she was admitted to the facility with diagnoses including unspecified dementia (a condition characterized by memory loss). A review of Resident 107's physician orders included the following: a. Depakote 250 mg, 1 tablet by mouth two times a day for mood liability manifested by poor impulse control, dated 2/14/25 b. Quetiapine 12.5 mg by mouth two times a day for dementia m/b by aggressive verbal behaviors, dated 5/11/24 (7 months ago). A review of Resident 107's clinical record indicated there had been no monitoring for the side effects of Depakote since ordered date of 2/14/25; and of quetiapine since 1/9/25. Also, there had been no monitoring for the resident's lipid panel or A1c. A review of the Drug Information (https://dailymed.nlm.nih.gov/dailymed) for quetiapine indicated antipsychotics have been associated with metabolic [related to physical and chemical] changes. These metabolic changes include hyperglycemia [high blood glucose], dyslipidemia [abnormal levels of lipids in the bloodstream]. It indicates to monitor for glucose regularly in patients with diabetes or at risk for diabetes and fasting blood lipid at the beginning of, and periodically, during treatment. During a concurrent interview and record review with Nursing Supervisor D (NS D) on 2/26/25 at 5:13 p.m., she reviewed Resident 107's clinical record and verified the absence of side effect monitoring for Depakote and quetiapine. She stated she does not see why the monitoring for quetiapine was stopped on 1/9/25 (more than a month ago) while the resident continued to receive the medication. Regarding the A1c and lipid panel monitoring, she acknowledged antipsychotic medications could lead to changes in blood glucose and lipids, and stated she would need to look further. During a follow-up interview on 2/27/25 at 10:17 a.m., NS D stated she looked through the entire record for Resident 107 and could not find any A1c or lipid panel blood test results. She also stated she did not see any recommendations from the consultant pharmacist. 3. A review of Resident 104's clinical record indicated he was admitted to the facility with diagnoses including unspecified anxiety disorder and unspecified depression. A review of Resident 104's physician orders included the following: a. Lorazepam 1 mg, 1 tablet by mouth every 24 hours as needed for anxiety, dated 7/5/24 (seven months ago). b. Seroquel 25 mg, give 1 tablet at bedtime as needed for insomnia. To be given in addition to 25 mg tab routine if still unable to sleep. Do not discontinue PRN PRN order, dated 9/27/24 (5 months ago). c. Seroquel 50 mg (Quetiapine), Give 1 tablet by mouth at bedtime for depression per [psychiatrist's name], dated 11/1/24 A review of Resident 104's care plan, dated 10/23/24, indicated the resident uses of seroquel as for insomnia due to altered mental status unable to sleep at night. A review of Resident 104's February 2025 MAR indicated the nursing staff monitored for episodes of aggressive behavior for use of Quetiapine every shift . dated 7/23/24. During a concurrent interview and record review with the DON, the Infection Control Preventionist (IP), and Registered Nurse J (RN J) on 2/27/25 at 1:30 p.m., they acknowledged Resident 104's clinical record had no physician-documented rationale why PRN lorazepam order was extended beyond 14 days. The order itself had no specified duration for the extended period. Similarly, the PRN Seroquel was written 5 months ago while the federal regulation indicated a maximum of 14 days. Regarding the routine Seroquel use, the DON verified the indication was for depression while the staff monitored for aggressive behavior, and its care plan was for altered mental status unable to sleep at night. She also acknowledged the indication of altered mental status and insomnia are not appropriate indications for antipsychotic medication use. A review of the facility's policy and procedures (P&P) titled Psychotropic Medication Use, dated 7/2022, indicated, Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days. (1) For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. (2) For psychotropic medications that ARE antipsychotics: PRN orders cannot be renewed . A review of the facility's P&P titled Antipsychotic Medication Use, dated 12/2016, indicated: The Attending Physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms ., Antipsychotic medications will not be used if the only symptoms are one or more of the following . insomnia and Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the Attending Physician . Metabolic: increase in total cholesterol/triglycerides, unstable or poorly controlled blood sugar .

Based on observation, interview, and record review, the facility had a medication error rate of 12.12% when four medication errors were observed out of 33 opportunities during medication administration for three out of six residents (Residents 6, 47, and 296). Resident 296 and Resident 6 received crushed medications when the manufacturer indicated not to crush; senna (a laxative) was missed for Resident 6; and Resident 47 received the wrong dose of vitamin C. This failure resulted in residents not receiving medications as prescribed and/or according to manufacturers' specifications, and had the potential to result in residents not receiving the full therapeutic benefit of their medications or experiencing negative health outcomes. Findings: 1. During a medication administration observation and interview on 2/24/25 at 8:43 a.m., registered nurse F (RN F) was observed preparing 9 medications, including a tablet of metoprolol (medication to to treat high blood pressure or hypertension) extended release (ER, medication is formulated so that the drug is released slowly over time) 25 milligrams (mg, unit of measurement), to give to Resident 296. RN F was observed crushing all the tablets and poured the crushed contents into a medicine cup. RN F stated Resident 296, likes them all crushed together. RN F added a spoonful of yogurt to the crushed powder and spoon-fed the mixture to Resident 296 at his bedside. During an interview on 2/24/25 at 9:02 a.m., RN F stated that metoprolol ER shouldn't be crushed, but it was. During an interview with Resident 296 on 2/25/25 at 9:01 a.m., he stated his medications are crushed, all the time. Resident 296 stated that he does not remember the reason his medications are crushed, but said he likes them crushed. During another interview with RN F on 2/25/25 at 9:08 a.m. RN F stated that Resident 296, always takes his meds crushed. RN F acknowledged metoprolol ER should not be crushed due to being extended released. A review of Resident 296's clinical record indicated a physician's order, dated 1/30/25, for Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG Give 1 tablet by mouth one time a day for HTN [hypertension]. During an telephone interview with the Consultant Pharmacist (CP), he stated metoprolol ER should not be crushed due to its formulation. A review of drug resource, DailyMed (https://dailymed.nlm.nih.gov), indicated, Metoprolol succinate extended-release tablets are scored on both sides and can be divided; however, do not crush or chew the whole or half table. 2. During a medication administration observation on 2/24/25 at 9:17 a.m., Licensed Vocational Nurse (LVN) C was observed preparing four medications, a total of 6 pills, for Resident 6. The medications included a tablet of potassium chloride (to treat low potassium level in the blood) ER 20 milliequivalents (mEq, a unit of measure). On 2/24/25 at 9:22 a.m., at Resident 6's bedside, LVN C was observed administering the medications to Resident 6, in whole pills, with applesauce. The resident swallowed the applesauce but not the medications. She pushed the large pills out of her mouth using her tongue. LVN C took the medications from the resident's mouth. On 2/24/25 at 9:26 a.m., LVN C returned to the medication cart and stated the rejected medications were the potassium ER tablet, a Tylenol 500 mg tablet, and docusate sodium (stool softener) 250 mg tablet. She disposed of the medications and retrieved new ones from the medication cart, crushed them into a fine powder, and mixed with applesauce. On 2/24/25 at 9:29 a.m., LVN C returned to Resident 6's bedside and administered the medication-applesauce mixture to the resident. During a concurrent interview with LVN C at 2/24/25 at 10:02 a.m. and a review of the pharmacy label for potassium ER 20 mEQ tablet indicated its manufacturer is Manufacturer A, and a warning label indicating May be Broken or Allowed to Disintegrate In Water (Stir Well) Before Swallowing. Rinse Down With Water, But Do Not Chew, All of The Remaining Particles. LVN C acknowledged it should not be crushed. A review of Manufacturer A's drug information for potassium chloride ER tablet, revised 3/2023, indicated, To take each dose without crushing, chewing or sucking the tablets. A review of Resident 6's clinical record indicated a physician's order, dated 2/23/24, for Potassium Chloride ER Tablet Extended Release 20MEQ Give 1 tablet by mouth one time a day for supplement. During a telephone interview with the CP on 2/27/25 at 11:18 a.m., he stated potassium ER tablet should not be crushed. A review of the facility's policy titled, Crushing Medications, revised April 2018, indicated Medications shall be crushed only when it is appropriate and safe to do so, consistent with physician orders 1. The medical director and director of nursing services, in conjunction with the consultant pharmacist, shall identify appropriate indications and procedures for crushing medications. 3. During a medication administration observation with LVN C for Resident 6 (as above) on 2/24/2025 at 9:17 a.m., there were a total of 4 medications (total of 6 pills). The number of pills was verified with LVN C before she entered Resident 6's room. A review of Resident 6's clinical record indicated a physician's order for Senna Tablet 8.6 MG Give 2 tablet by mouth two times a day for constipation, dated 1/11/2020. It was scheduled daily at 9 a.m. Senna was not observed prepared and given to Resident 6 during the morning medication administration by LVN C on 2/24/25. During a concurrent interview and record review with LVN C on 2/24/25 at 11:50 a.m., she reviewed Resident 6's physician's orders and acknowledged senna was not administered. She stated, I will go give it now. A review of the facility's policy titled, Medication Administration, revised April 2019, indicated Medications are administered within one (1) hour of their prescribed time, unless otherwise specified . 4. During a medication administration observation on 2/24/25 at 9:33 a.m., LVN C was observed preparing and administering 10 medications, including 2 tablets of vitamin C 500 mg (total 1,000 mg), to Resident 47. A review of Resident 47's clinical record indicated a physician's order, dated 5/30/24, for Vitamin C Oral Tablet 500 MG . Give 1 tablet by mouth two times a day for Supplement. On 2/24/25 at 11:45 a.m., during a concurrent interview and review with LVN C, she reviewed Resident 47's vitamin C order, then looked through the medication cart. She showed the surveyors the Vitamin C 500 mg bottle, which she had used earlier for Resident 47. She stated she thought the Vitamin C bottle label read 250 mg, that was the reason why she gave 2 tablets. LVN C confirmed she gave twice the ordered dose. A review of the facility's policy titled, Medication Administration, revised April 2019, indicated, Medications are administered in accordance with prescriber orders .

Based on interview and record review, the facility failed to ensure supervision and assistance were provided for one of three sampled residents (Resident 1), who was dependent on staff for transferring, when Resident1 was left sitting in her wheelchair in her room and fell on the floor on 2/19/2024 without staff watching and/or supervising her. This failure resulted in Resident 1 falling on the floor and sustaining a laceration (a deep cut or tear in skin) on her forehead that required hospital transfer on 2/19/2024 where she had 18 stitches (a way doctors can close certain types of cuts). Findings: A review of Resident 1's face sheet (a document that gives a resident's information) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including unspecified dementia (a range of?neurological conditions affecting the brain including loss of the ability to think, remember, and reason to levels that affect daily life and activities), difficulty in walking, muscle weakness, and history of falling. A review of Resident 1's Fall Risk assessment, dated 11/21/2023, indicated a score of 22 (score of 16-42 indicates high risk of falling), Resident 1 was at high risk of falling. A review of Resident 1's care plan, initiated on 3/2/2023, indicated Resident 1 had an Activities of daily living (ADLs, a person's daily self-care activities) self-care performance deficit related to impaired balance and limited mobility . TRANSFER The resident has [sic] requires staff participation with transfers. A review of Resident 1's admission minimum data set (MDS, an assessment tool) dated 11/21/2023 indicated a brief interview for mental status (BIMS, cognition [includes memory, problem-solving, and thinking skills] level) score of 8 (score of 8-12 indicates moderate cognitive impairment). A review of Resident 1's MDS section GG, dated 11/21/2023, indicated Resident 1's level of performance was coded 1 which indicated Resident 1 was dependent, and helpers did all of the effort, the resident did none of the effort to complete the activities; and Resident 1 required assistance of 2 or more helpers to complete the activities of bed mobility, transfer, and toileting. A review of Resident 1's Interdisciplinary Team's (IDT, team composed of members from different departments involved in resident's care) Fall Follow up notes dated 2/20/2024, indicated, the resident was found lying on her right side next to her wheelchair in her room, bleeding from right forehead and hand noted . Several minutes prior to the incident, the resident participated in group activities and was assisted back to her room via wheelchair . resident was sent to the hospital via 911 per physician's order for further evaluation and treatment as indicated .the resident's previous fall incident was about a month ago with no injury noted . The staff had been providing redirection and assistance with ADLs .Resident appeared to have tried to self-transfer without staff assistance and lost balance . Prior lntervention(s) : Preventive measures prior to event: frequent checks for needs, assistance with ADLs and re-direction as needed . Resident returned on the same day with sutures to scalp. A review of Resident 1's clinical records from the hospital, titled emergency room (ED) Physician Report, dated 2/19/2024, indicated that .patient (Resident 1) was presenting to the ED via ambulance after an unwitnessed fall .Patient (Resident 1) was found on the ground after she had fallen out of her wheelchair. The patient was noted to have a large laceration to her forehead and scalp. No other injuries were noted . During an interview with the MDS coordinator (MDSC) on 6/13/24 at 10:30 a.m., the MDSC reviewed Resident 1's MDS section GG, and she confirmed Resident 1 was dependent, required helpers (staff) to do all of the effort, the resident did none of the effort to complete the activities. Resident 1 required the assistance of 2 or more helpers(staff) to complete the activities of bed mobility, transfer, and toileting. During an interview with the Activity Director (AD) on 6/13/24 at 2:42 p.m., the AD confirmed the concerned activity staff C (AS C) who brought Resident 1 back to her room no longer work in the facility. The AD stated the activity staff should not leave residents alone in their room without notifying nursing staff. During a phone interview with Registered Nurse (RN) A on 6/13/24 at 3:04 p.m., RN A recalled Resident 1 falling inside her room on 2/19/2024 around noon time. RN A stated the AS C brought Resident 1 back to her room without notifying the nursing staff. RN A confirmed that Resident 1's MDS and ADL care plan indicated Resident 1 needed helpers to help with the transfer. RN A further stated Resident 1 was at risk of falling and should not have been left alone in her room. she also stated Resident 1 returned from the hospital on the same day (2/19/2024) with 18 stitches on her forehead. During a phone interview with CNA B on 6/13/24 at 3:57 p.m., CNA B confirmed she was the assigned CNA for Resident 1 on 2/19/2024. CNA B confirmed that Resident 1 cannot transfer by herself and required staff help during wheelchair-to-bed transfer. CNA B stated AS C brought Resident 1 back to her room without informing her. When CNA B came to Resident 1' room to answer the call light, Resident 1 already fell on the floor. CNA B further stated that the AS C should not have left Resident 1 alone in her room. During an interview with the Director of Nursing (DON) on 6/13/24 at 4:11 p.m., the DON reviewed Resident 1's MDS and ADL care plan. The DON confirmed that Resident 1 was a high risk for falling and needed help with the wheelchair to bed transfer. The DON stated that the AS C should have stayed with Resident 1 and notified the CNAs and/or nurses that Resident 1 was back in her room. A Review of the facility's undated policy and procedure (P&P) titled Falls and Fall risk, Managing, the P&P indicated, .several possible interventions may be identified considering resident fall risks, and the staff may prioritize certain interventions based on the circumstances .

Based on interview and record review the facility failed to ensure care and services were provided in accordance with professional standards of practice in performing accurate skin assessment to help prevent pressure ulcers (injury to skin and tissue below the skin caused from prolonged pressure on the skin) and provide necessary pressure treatment for one of three residents when staff failed to identify the presence of pressure ulcers for Resident 1. This failure resulted in Resident 1 not receiving pressure ulcer treatment and nursing interventions to aid in wound healing. When Resident 1 was transferred to a hospital's emergency department (ED) on 11/17/23, an unstageable pressure injury (unable to determine the stage; staging/classification system uses depth to classify ulcers) to the coccyx (tailbone) and deep tissue pressure injury (intact or non-intact skin with persistent, deep red, maroon, or purple discoloration) to the left ankle were identified in the ED upon initial physical assessment. Findings: 1. Review of Resident 1's face sheet (summary page of a patient's important information), printed 2/9/24 indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including meningitis (infection and inflammation of the membranes surrounding the brain and spinal cord) and neuromuscular dysfunction of the bladder (loss of bladder control due to brain, spinal cord, or nerve problems). Review of Resident 1's Nursing - Admission/Readmission Evaluation/Assessment, dated 11/6/23 indicated Resident 1 did not have wounds or skin integrity (condition of skin's barrier) concerns present on admission. Review of Resident 1's Braden Scale for Predicting Pressure Sore Risk, dated 11/6/24 indicated the resident's score was 17. A score of 15-18 indicated she was at risk for developing a pressure sore. Review of Resident 1's IDT (interdisciplinary team, a group of health care professionals from diverse fields who work toward a common goal for residents) Conference Notes, dated 11/8/23 indicated the resident had no pressure ulcers and she was at risk for skin breakdown due to age and immobility. Review of Resident 1's Nursing - Daily Skilled Charting Forms (documentation including symptoms review [head to toe review of any symptoms a person is experiencing] and assessment of the body systems [such as neurological (mental status and alertness), cardiovascular (examination of the heart), respiratory (examination of lungs and breathing), skin (examination of color, skin integrity), etc.], dated 11/7/23 to 11/16/23, documented by Licensed Vocational Nurse A (LVN A) indicated the Outcomes of Physical Assessment/Observation (performing a physical assessment includes the techniques of inspection [to look at something carefully], palpation [the method of using fingers or hands to touch and feel to examine a body part], percussion [the technique of examining body parts by tapping it with the fingers or an instrument to produce a sound/vibration], and auscultation [listening to the sounds of the body] to gather data) were the following: -Respiratory: breath sounds, clear; -Digestive Status: Bowel sounds, present; -Integumentary (skin) Status: Not Applicable (N/A); Further review of the Daily Skilled Charting forms dated from 11/7/23 to 11/16/23, documented by LVN A, the daily assessments did not indicate Resident 1 had skin issues. There were no check marks on the following check boxes to describe Resident 1's skin status: skin color normal, warm, dry, cool, chills, intact, cyanosis (bluish discoloration due to lack of circulation or oxygen), redness, jaundiced (yellow discoloration), pallor (pale appearance), clammy (moist/sweaty), flushing of skin (reddening of the face or neck area), rash/itching, edema (swelling), burns, and wounds. The only box checked for skin status was N/A. Review of Resident 1's progress notes from 11/6/23 to 11/17/23 indicated there was no documented evidence staff identified any skin issues or pressure ulcers for Resident 1. There was no documented evidence staff implemented nursing interventions to treat skin issues or pressure ulcers to aid in wound healing. Review of Resident 1's Order Summary Report, date range 11/6/23 to 11/17/23 indicated there were no orders for pressure ulcer treatment. Review of Resident 1's SNF (Skilled Nursing Facility) to Hospital Transfer form, dated late entry (documented on a later date) on 11/28/23, indicated the resident was transferred to the hospital on 11/17/23 (time not specified) due to hypotension (low blood pressure) and tachycardia (increased heart rate). The form also indicated Resident 1 had no pressure ulcers/injuries. Review of Resident 1's hospital Emergency Department (ED) Physician Notes, dated 11/17/23 at 5:31 p.m., indicated the Physical Examination identified Resident 1 had a decubitus ulcer (pressure ulcer). Review of Resident 1's hospital History and Physical (formal document created by a physician based on patient interview, physical exam, and summary of tests) dated 11/17/23 indicated, [Patient 1] came to [hospital] . pressure ulcer on sacrum [bone at the base of the spine] noted on admission, nursing will photograph. Review of Resident 1's hospital Wound Care Photo, dated 11/17/23 indicated three pictures were taken of Resident 1's coccyx wound in the ER (emergency room , ED) on 11/17/23. Review of Resident 1's hospital Wound Care Photo, dated 11/17/23 indicated one picture was taken of Resident 1's left outer ankle wound in theER on [DATE]. Review of Resident 1's hospital Wound Care Note, dated 11/18/23 indicated Resident 1 had two wounds discovered on 11/17/23: -Resident 1's Wound 1 was an unstageable pressure injury on the coccyx, measuring 2.5 centimeters (cm, unit of measurement) by 3.5 cm x 0.2 cm. The wound bed had slough [dead tissue], peeling skin, dark non blanchable [discoloration of the skin that does not turn white when pressed] tissue and clean non gran [absence of granulation, which is an important component in the wound healing process] pink tissue. -Resident 1's Wound 2 was a deep tissue pressure injury to the left lateral ankle. Wound 2 was described as Dark non blanchable tissue over Lat [lateral, to the side] malleolus [ankle bone] with boggy [soft, abnormal texture of tissue] blistered center. During interviews from 3/18/24 to 3/28/24 with LVNs and certified nursing assistants (CNA) who cared for Resident 1, the LVNs and CNAs stated they did not remember pressure ulcers identified for Resident 1. During an interview with LVN A on 4/2/24 at 3:22 p.m., LVN A confirmed she completed the Daily Skilled Charting Forms for Resident 1 on the above dates remotely (not physically present, working from a location other than the place where the residents currently reside), including the skin assessments. LVN A stated she was not physically present in the facility when she documented Daily Skilled Chartings for Resident 1 and other residents since November 2023. LVN A also stated she based her assessment documentations including the symptoms review (head to toe review of any symptoms a person is experiencing), assessment of the body systems (such as respiratory [examination of lungs and breathing], skin [requires inspection and palpation to determine color, skin integrity], etc.) and pain assessments from the previous progress notes of nurses, MD (doctor of medicine), and PT/OT (physical therapy and occupational therapy). LVN A acknowledged that the assessment should not be based on the documents of others, but she should be physically present to perform the resident's assessment herself. During an interview on 5/16/24 at 2:42 p.m. with the human resources/payroll manager (HRPM), the HRPM stated LVN A is a regional minimum data set (MDS) nurse. The HRPM stated LVN A's work is done remotely. When asked whether LVN A had a signed job description for the regional MDS nurse, HRPM stated there was none. During an interview on 5/16/24 at 3:40 p.m., the director or nursing (DON) stated when doing a physical assessment, including documentation for Daily Skilled Charting, it should be done while staff was present in the facility. During an interview on 6/4/24 at 1:40 p.m., the DON acknowledged Resident 1's Daily Skilled Charting Forms, dated 11/7/23 to 11/16/23 indicated N/A was checked for integumentary status for Resident 1. She also stated she would not be documenting breath sounds and bowel sounds without physically assessing the resident. The DON further stated if Resident 1 had any problems that day, she expected it to reflect in the Daily Skilled Charting documentation. Review of an article from the National Library of Medicine, Physical Assessment Competencies for Nurses: A Quality Improvement Initiative, published 4/17/22 indicated, Physical assessment is a basic but essential nursing skill. Being able to assess the patient's current condition can help identify early changes. Knowledge of a patient's clinical status and usual behaviors gained through a full (head?to?toe) physical assessment is a key influence on a nurse's ability to recognize subtle changes in a patient's condition. Review of an article, LVN Scope of Practice in California 2024: A Comprehensive Guide, dated 3/7/24 from the National Career College website indicated, While LVNs can perform basic health assessments, conducting comprehensive physical examinations and developing care plans are the responsibilities of RNs [Registered Nurses] and physicians. Review of the facility's policy, Charting and Documentation, dated 2001 indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial (involves the interaction between a person's thoughts and behaviors with a social environment) condition, shall be documented in the resident's medical record . The following information is to be documented in the resident medical record: a. Objective observations . Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Review of the facility's Job Description: MDS Coordinator LPN [Licensed Practical Nurse]/LVN, dated 7/2020 indicated, The primary purpose of you job position is to provide direct nursing care to residents . Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident . Perform charting duties as required and in accordance with established charting and documentation policies and procedures.

Based on interview and record review, the facility failed to obtain and implement medication orders from the acute hospital for one of three sampled residents (Resident 1). In addition, the attending physician (AP, doctor assigned to the resident while the resident is in the facility) and nurse practitioner failed to identify that Resident 1 was not receiving the medication necessary to maintain his health and well-being. These failures resulted in Resident 1's hospitalization with conditions including, but not limited, to altered mental status, hypoglycemia (low blood sugar), seizures (electrical disturbances in the brain that cause changes in behavior, movements or feelings) and adrenal crisis (a life-threatening condition that occurs when there is not enough cortisol, which is secreted by the adrenal gland). Findings: Review of Resident 1's clinical record indicated he was originally admitted to the facility on [DATE]. He had the diagnoses of hypothyroidism (the thyroid gland does not produce enough hormones), hypopituitarism (the pituitary gland does not produce enough hormones), type 2 diabetes mellitus (DM, disease that impairs the body's ability to regulate blood sugar) and diabetes insipidus (disorder that causes an imbalance of fluids in the body). Further review of Resident 1's record indicated the facility sent him to the acute hospital on 11/18/2020, and he returned to the facility on [DATE]. Review of Resident 1's Discharge Summary, provided by the acute hospital and dated 12/3/2020, indicated Resident 1 was to continue taking Levothyroxine (also known as Synthroid, medication used to treat hypothyroidism) 0.1 milligrams (mg, unit of dose measurement) by mouth once daily. Review of Resident 1's medication administration record (MAR) indicated the facility did not administer levothyroxine from the time Resident 1 returned to the facility on [DATE] to 1/10/2021. During an interview with the director of nursing (DON) on 3/5/2021 at 11:17 a.m., she explained that when Resident 1 returned to the facility on [DATE], the acute hospital did not send Resident 1's medication orders. She explained that in this situation, the admitting nurse should contact the resident's AP to obtain medication orders. The DON stated that licensed nurse A (LN A) was the nurse who readmitted Resident 1 on 12/3/2020. Review of Resident 1's clinical record indicated there were no medication orders from the acute hospital when he returned to the facility on [DATE]. There was no documentation in the clinical record that the facility contacted Resident 1's AP to obtain the medication orders. Further review of the clinical record indicated there was no documentation explaining how the facility determined what medication orders to implement. During an interview and concurrent record review with LN A on 3/5/2021 at 11:28 a.m., she reviewed Resident 1's clinical record and confirmed there were no medication orders from the acute hospital when he returned to the facility on [DATE]. When asked if she attempted to contact the hospital to obtain Resident 1's medication orders, LN A stated she did not remember calling the hospital. LN A explained she was supposed to contact the resident's AP to obtain medication orders, but stated she did not remember if she did this. LN A reviewed Resident 1's clinical record and confirmed there was no documentation indicating she contacted the AP to obtain Resident 1's medication orders on 12/3/2020. When asked how she determined what medication orders to carry out and implement for Resident 1, LN A stated she did not remember. During a follow-up interview with the DON on 3/5/2021 at 2:00 p.m., she stated her understanding was that LN A called Resident 1's AP to obtain the medication orders and she did not call the hospital to obtain the orders. Review of Resident 1's record indicated nurse practitioner B (NP B) saw the resident on 12/10/2020, 12/29/2020 and 1/7/2021. The MD/NP/PA Progress Notes for the aforementioned dates were reviewed. On all of these Progress Notes, under the section titled Impression & Plan, NP B documented, Levothyroxine Sodium Tablet 100 MCG [100 micrograms, equivalent of 0.1 mg] PO [by mouth] QD [every day]. During an interview with NP B on 3/19/2021 at 1:37 p.m., she confirmed that when visiting residents in the facility, she should review what medications they are taking. When asked if she reviewed Resident 1's MAR when she visited him on the above dates, NP B stated, I should review. When asked if she was aware the facility was not administering levothyroxine to Resident 1, NP B stated, I don't think so. Review of Resident 1's 12/2020 Progress Notes indicated the AP documented a Physician History and Physical (H&P) on 12/6/2020. There was no documentation indicating the AP reviewed what medications Resident 1 was taking. Resident 1's 12/2020 Order Summary Report was reviewed. There was no order for Levothyroxine on this report. Further review of the report indicated there was a physician signature dated 1/1/2021. During an interview with the AP on 3/25/2021 at 12:46 p.m., he confirmed the Physician H&P documentation on 12/6/2020 indicated he saw Resident 1 on that date. The AP stated he would normally review medications when visiting his residents, but he did not remember if he was able to review Resident 1's medications on 12/6/2020. The AP acknowledged that if he noticed Resident 1 was not receiving levothyroxine, he would have started the medication. The AP stated he did not know why Resident 1's levothyroxine was not continued, but acknowledged the resident should have been receiving this medication. He stated he did not remember facility staff calling him to obtain medication orders for Resident 1 on 12/3/2021. The AP confirmed if facility staff informed him that the acute hospital did not send Resident 1's medication orders, he would have advised the facility to contact the hospital to obtain the orders. He did add, however, that it is sometimes hard to contact the hospital. When asked about Resident 1's signed 12/2020 Order Summary Report, the AP stated he did not remember seeing that there was no order for Levothyroxine. He stated that most likely he did not notice. Further review of Resident 1's Discharge Summary from the acute hospital, dated 12/3/2020, indicated that in addition to continuing levothyroxine, Resident 1 was to do the following: 1) Continue Exenatide (medication used to treat DM) 2 mg injected subcutaneously (SQ, into the tissue layer between the skin and the muscle) once every week; 2) Continue Hydrocortisone (medication used to reduce inflammation) 10 mg 4 tabs (40 mg) by mouth every morning; 3) Continue Hydrocortisone 10 mg 2 tabs (20 mg) by mouth every evening; 4) Continue Insulin Glargine (long-acting medication used to control blood sugar) 15 units (u, unit of dose measurement) injected SQ every evening; 5) Discontinue Insulin Lispro (rapid-acting medication used to control blood sugar) 100 units per milliliter (u/ml, unit of dose measurement) injected SQ three times daily with meals; and, 6) Discontinue Insulin Detemir (also known as Levemir, long-acting medication used to control blood sugar) 100 u/ml SQ every evening. Further review of Resident 1's MAR indicated the following from 12/3/2020 to 1/10/2021; 1) Resident 1 did not receive Exenatide 2 mg injected SQ once every week; 2) Resident 1 received Hydrocortisone 10 mg 2 tabs (20 mg) by mouth every morning instead of 40 mg by mouth every morning; 3) Resident 1 received Hydrocortisone 10 mg by mouth every evening instead of 20 mg by mouth every evening; 4) Resident 1 did not receive Insulin Glargine 15 units injected SQ every evening; 5) Resident 1 continued to receive insulin aspart (another rapid-acting medication used to control blood sugar) 100 u/ml 18 units injected SQ before meals; and, 6) Resident 1 continued to receive insulin Detemir 100 u/ml 82 units injected SQ at bedtime. Review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool) documentation, dated 1/10/2021, indicated Resident 1 had a fall. He was also noted to have altered level of consciousness and personality change. Review of Resident 1's Progress Note, dated 1/10/2021, indicted the AP gave an order to send the resident to the acute hospital. Review of Resident 1's ED (emergency department) Physician Notes from the acute hospital, dated 1/10/2021, indicated Resident 1 had altered mental status and had a possible seizure in the ambulance prior to arriving at the ED. The notes further indicated, Per EMS [emergency medical services], the patient's blood sugar was 52 when they picked him up. According to ED Physician Notes, Resident 1 was unresponsive and snoring when he came into the ED. Review of Resident 1's H&P from the acute hospital, dated 1/10/2021 indicated, I carefully reconciled meds comparing discharge med list from [acute hospital] to SNF [skilled nursing facility] med list. I no longer see levothyroxine, insulin has changed significantly (levemir [detemir] 82 up from 15 u, premeal insulin 18 u added). The H&P further indicated, #Hypoglycemia #Type II DM - I no longer see Exenatide on home med list. Current insulin regimen markedly up from Nov [November] discharge - hypoglycemia could be related to adrenal insuff[iciency]. #Hypothyroid - unclear why not on levothyroxine, will resume and check tsh [thyroid stimulating hormone, determines whether the thyroid gland is functioning properly]. The H&P had an addendum, dated 1/11/2021, that indicated Resident 1 had a repeat 1-minute seizure overnight during hypoglycemic periods (periods of low blood sugar). Review of Resident 1's Discharge Summary from the acute hospital, dated 1/29/2021, indicated he was an inpatient (stayed in the hospital) from 1/10/2021 to 1/29/2021. The Discharge Summary indicated Resident 1's seizure was likely hypoglycemia related. The Discharge Summary also indicated, #Central Hypothyroidism - presentation likely due at least significantly due to lack of Synthroid for about 2 months resulting in relative adrenal crisis. Review of the facility's policy titled Admission Process, revised 9/2012 indicated, Conduct an admission assessment (history and physical), including: d. Current medications and treatments. The policy further indicated, Verify medication orders with the Attending Physician as necessary. Review of the facility's undated policy titled Physician Visits and Services indicated, The Attending Physician must perform relevant tasks at the time of each visit, including a review of the resident's total program of care and appropriate documentation. The policy further indicated, Non-physician practitioners (Physician Assistant, Nurse Practitioner) may perform required visits (initial and follow-up), sign orders and sign certifications/re-certifications as permitted by state and federal regulations.

Based on observation, interview and record review, the facility failed to ensure one of 24 sampled residents (2) was adequately assessed for proper transfer method. Prior to a transfer, two staff members failed to properly place Resident 2's electric wheelchair from the bed to the chair, failed to ensure the wheelchair toggle switch was in the "off" position prior to the transfer and failed to correctly perform a transfer with Resident 2 who had right-sided weakness. On 2/16/14, Resident 2 was transferred from the bed to the wheelchair. Her electric wheelchair spun around, causing Resident 2 to fall out of the wheelchair, land on the floor and sustain a right orbital (eye) fracture and subdural hematoma. The failure of the facility to adequately implement proper transfer techniques caused Resident 2's fracture. Findings: Clinical record review on 4/21/14 for Resident 2 documented she was admitted to the facility on ,[DATE], with [DIAGNOSES REDACTED]. Review of Resident 2's minimum data set (MDS, an assessment tool) dated 12/24/13, indicated she was alert, oriented and was able to make her needs known. Resident 2 was totally dependent for transfers with two staff members and had functional limitations to one arm and leg. Clinical record review for Resident 2 also indicated she was on Plavix 75 milligrams once daily by mouth (a blood thinner medication to help prevent stroke). Review of the website of Plavix (www.drugs.com/Plavix) indicated patients on Plavix are advised to avoid activities that may increase their risk of bleeding or injury. Review of Resident 2's care plan with a revised date of 1/14, to address her self-care deficits related to her right side weakness, showed she was totally dependent on the staff for transfers and required a mechanical lift (a device to transfer a person from one surface to another). Review of Resident 2's Progress Notes dated 2/16/14 at 11:30 a.m., noted two certified nursing assistants (CNAs) called a licensed nurse into her room. Resident 2 was found lying face down on the floor with her right arm next to her body, complaining of right arm pain. Her head was turned facing left with red blood coming from a right temporal (the right side of her forehead) and her right eye was swollen and bleeding. A pressure dressing was applied to Resident 2's forehead to stop the bleeding. During the transfer from the bed to the electric wheelchair, the resident's arm hit the control switch and while sitting in the wheelchair, the wheelchair began spinning, hitting one CNA while the resident fell to the floor. Per a follow-up note the same day at 9 p.m., Resident 2 stated when she was transferred to the electric wheelchair, her left hand hit the control button and the wheelchair began to spin around, causing the resident to fall out of the wheelchair and hit her head. The resident stated the wheelchair should have been turned off (prior to her transfer). On 2/16/14 at 11:45 a.m., Resident 2 was transferred to the emergency room for an evaluation. Review of Resident 2's Transfer Form dated 2/16/14, documented that when the resident was being transferred from the bed to the electric wheelchair, while she was being seated, her arm hit the switch and the resident fell face down onto the floor. Review of Resident 2's computerized tomography (CT, X-ray) scan dated 2/16/14, revealed Resident 2 sustained a fracture of the floor of the right orbit (eye socket) with a right orbital hematoma (bleeding), intraorbital (in the eye socket) fluid and air, and some evidence of a very small fracture of the medial (middle) wall of the right orbit. There was acute blood filling the majority of the right maxillary sinus (a groove on the bone in the nose). Review of The Merck Manual [DIAGNOSES REDACTED].merckmanuals.com) on closed head injury revealed hematomas often occur with head trauma from falls and motor vehicle crashes. These hematomas often occur in elderly patients (especially in those taking anticoagulant drugs). Review of Resident 2's hospital emergency room Discharge Instructions dated 2/16/14, showed she had a facial fracture. Instructions included Bactrim DS (an antibiotic) one tablet, twice daily by mouth for 7 days. Review of Resident 2's Investigation Report dated 2/18/14, stated CNAs F and G transferred Resident 2 into her electric wheelchair when the resident's hand accidentally hit the electric control, causing the wheelchair to spin and the resident to fall out of the wheelchair. On 4/21/14 at 3 p.m., an interview was conducted with CNA F. She stated Resident 2 was alert, oriented and able to make her needs known. CNA F stated Resident 2 could not move her right arm (independently) and was unsure if the resident was able to move her right leg. She stated on 2/16/14, Resident 2 was transferred from the bed to her electric wheelchair, with the assistance of CNA G. She said the electric wheelchair was positioned to Resident 2's right side, and when the resident went to reposition herself in the wheelchair, the resident's left hand hit the control joy stick and the wheelchair spun around two times. CNA F stated Resident 2 "flew" forward out of the wheelchair and had blood on her forehead. When CNA F was asked the procedure used to lift Resident 2 off the bed, she stated she lifted the resident from under the resident's arm and pivoted the resident to the right (weak side). She stated she was unaware Resident 2 required a mechanical lift transfer. When CNA F was asked the reason the wheelchair was not positioned to Resident 2's left side (strong side), she stated there was no room. She stated after Resident 2's fall on 2/16/14, a sticker was placed outside the resident's door to alert the staff a mechanical lift was needed for transfers. During an interview on 4/21/14 at 3:20 p.m., the director of nurses (DON) stated Resident 2 is alert and oriented, with periods of forgetfulness. She stated on 2/16/14, when CNAs F and G were transferring Resident 2 from the bed to the wheelchair, the resident accidentally hit the joy stick with her hand, the wheelchair spun around 360 degrees and the resident fell out of the wheelchair. The DON stated the wheelchair power button was turned on. On 4/22/14 at 7:40 a.m., an interview was conducted with Resident 2. She stated she was unable to move her right arm and leg and on 2/16/14, two CNAs were transferring her from the bed to the electric wheelchair. Resident 2 stated, "The wheelchair spinned around and I flew out of the wheelchair and hit my head against the bookcase." Resident 2 stated the CNAs should have been "smart enough to turn the wheelchair off when they transferred me. I bled like a pig." During an interview on 4/22/14 at 8:45 a.m., the physical therapist stated the proper procedure to transfer a resident with right sided weakness is to place the wheelchair on the left side (stronger side). He was unaware of the reason Resident 2 was transferred from the bed to her wheelchair with the wheelchair positioned on her right side (weaker). During an interview on 4/23/14 at 7 a.m., the director of staff development (DSD) said she was aware Resident 2's wheelchair was turned on during the transfer on 2/16/14. When the DSD was asked if Resident 2's fall from the wheelchair on 2/16/14 could have been prevented if the wheelchair was turned off, she stated "absolutely." During an observation on 4/23/14 at 11:12 a.m., accompanied by the director of clinical operations, Resident 2's wheelchair had a toggle switch, located on the left arm rest under the joy stick. The wheelchair toggle switch had to be pushed down to turn on the power and when the toggle switch was placed in the "on" position, amber lights lit up in front of the joy stick. On 4/23/14 at 11:15 a.m., an interview was conducted with CNA G. She stated on 2/16/14, she assisted CNA F with transferring Resident 2 from the bed to the electric wheelchair. CNA G stated she stood on the right side of the resident (paralyzed side) and CNA F stood on the resident's left side. She stated they both (CNAs F and G) placed one hand under each of the resident's armpits and the other hand on the resident's pants to pivot her from the bed to the chair. CNA G stated no gait belt was used. She stated Resident 2's buttocks almost touched the chair, but before the resident was totally sitting in the chair, the wheelchair turned clockwise and the resident landed on the floor with her head hitting the bookcase. CNA G stated Resident 2 had a lot of bleeding by her right eye. When CNA G was asked if the wheelchair was in the proper position, she stated "think not." She stated the wheelchair was on Resident 2's paralyzed side and should have been positioned on her strong side. When CNA G was asked the reason she assisted with the transfer knowing the wheelchair was not in the correct position, she stated because the wheelchair was already in place. The "Quickie S-525: User Instruction Manual" was reviewed and Section VI General Warning it stated: Heed all warnings in this section. If you fail to do so a fall, tip-over or loss of control may occur and cause severe injury to you or others. Under VII N indicates to avoid a fall, always turn off the power before you transfer to and from your wheelchair. If you fail to do so, you may touch the joystick and cause your chair to move when you do not expect it. The joystick controls the direction and speed of your chair and the chair will move faster the more you move the joystick away from the neutral position (center). The manual refers to the word "warning" to a hazard or unsafe practice that may cause severe injury or death to patient or to other persons. Review of the National Institute for Occupational Safety and Health website (www.cdc.gov/niosh/docs) documented for safe resident handling from the bed to the chair when the resident has impaired upper extremity strength, use a full-body sling (lift) and two caregivers should be used. If the resident has partial weight-bearing capacity, transfer toward the stronger side. Review of the facility's policy "Accidents and Supervision to Prevent Accidents" revised 4/28/11, stated the facility should provide an environment that is free from accident hazards over which the facility has control. The facility is to communicate the interventions to relevant staff, assigning responsibility to appropriate trained individuals implementing and documenting interventions. The facility is to assess the resident to determine the resident's degree of mobility and physical impairment and the proper transfer method. Resident 2's head injury and right eye orbital fracture was a direct result of two staff members transferring the resident from the bed to the electric wheelchair.

Based on interview, observation and record review, the facility failed to follow their policy and procedure for five of 14 sampled residents (32, 33, 35, 31, and 34). Residents 32, 33, 35, 31, and 34 had a fall risk score of 65 or above (a score of 45 or higher = high risk). The facility did not have a system in place to alert the staff of residents with a high risk for falls. This has the potential for residents to have increased falls and/or injuries. Findings: 1. Clinical record review on 6/11/14, for Resident 32 showed she was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident 32's Patient Nursing Evaluation dated 6/1/14, showed her fall risk assessment had a score of 65. The fall risk assessment documented to add risk factors for fall to the care plan and to refer to the Falling Star Program. Review of Resident 32's care plan problems did not address her referral to the Falling Star Program. An observation on 6/12/14 at 7:50 a.m., revealed a star magnet on the exterior door frame of Resident 32's room (where three residents resided) and a small star next to Resident 32's name plaque. Registered nurse (RN) 1 confirmed Resident 32 had a star magnet and a small star next to the resident's name. 2. Clinical record review on 6/11/14, for Resident 33 showed she was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident 33's Patient Nursing Evaluation dated 4/6/14, documented her fall risk assessment had a score of 90. Review of Resident 33's care plan problems did not address her referral to the Falling Star Program. Review of Resident 33's physician's orders [REDACTED]. During an interview on 6/11/14 at 1:25 p.m., licensed vocational nurse (LVN) K stated Resident 33's pad alarm was discontinued on 5/22/14 because the resident had not fallen. During an interview on 6/11/14 at 1:35 p.m., registered nurse (RN) L stated she was unable to locate documentation or an assessment to show the reason Resident 33's pad alarm was discontinued on 5/22/14. She confirmed Resident 33 was a high risk for falls. During an interview on 6/11/14 at 2:15 p.m., certified nursing assistant (CNA) M stated Resident 33 was confused most of the time. She stated she had witnessed Resident 33 attempt to climb out of bed approximately once a week. 3. Clinical record review on 6/11/14, for Resident 35 documented she was admitted to the facility with [DIAGNOSES REDACTED]. a. Review of Resident 35's Change of Condition form dated 5/28/14, documented Resident 35 had an unwitnessed fall. The resident was found on the floor by her bedside. Resident 35's Post Fall Evaluation dated 5/28/14 had interventions in place at the time of the fall which included a low bed, call bell in place and an alarm. The Interdisciplinary Team's (IDT) recommendation was to discontinue the administration of Buspar (antianxiety medication). Review of Resident 35's Patient Nursing Evaluation dated 6/1/14, showed her fall risk assessment had a score of 80. b. On 6/4/14, a second Change of Condition form for Resident 35 showed the resident was found sitting on the floor and to continue the use of the pad alarm, and obtain an X-ray. Review of Resident 35's Post Fall Evaluation dated 6/5/14 had interventions in place at the time of the fall included an alarm to alert the staff when Resident 35 attempted to get out of bed unattended. Review of Resident 35's Physician's Progress Notes dated 6/6/14, documented Resident 35 was found on the floor out of bed on 5/28/14 and 6/4/14. (The facility's Managing Fall Risk policy dated 2/28/14, identified a fall as an unintentional change in position coming to rest on the ground, floor or onto the next lower surface.) The physician's assessment included Resident 35 had [DIAGNOSES REDACTED]. Review of Resident 35's Progress Notes dated 6/2/14 and 6/3/14, showed the licensed nurses documented Resident 35 had increased confusion. On 6/4/14 at 5 a.m., Resident 35 was transferred to a bed, down the hallway, 14 rooms away from the nurses' station, where the same day at 6:45 p.m., she was found on the floor. On 6/5/14, a Post Fall Evaluation documented IDT's recommendation was to transfer Resident 35 closer to the nurses' station and on 6/6/14 at 5 p.m., the resident was transferred to a room located 4 rooms away from the nurses' station. Review of Resident 35's care plan problems dated 5/28/14 and 6/4/14, to address her problem related to falls did not address her referral to the Falling Star Program. Review of the facility's policy titled "Managing Fall Risk" dated 2/18/14, showed the staff would use a multi-interventional Falling Star Program to utilize fall prevention and management practices. Components for managing residents with a fall risk should include environmental safety, but not limited to floor mats. If a resident has been determined a high risk for falls, initiate the fall risk program: weekly IDT meetings, falling star magnet on door frame, yellow arm band, and care plans to address the falling stars. During an interview on 6/11/14 at 10:45 a.m., LVN K stated Resident 35 was admitted to the facility with a history of falls and a fractured left hip. She stated Resident 35 had increased confusion and impulsiveness. During an observation on 6/11/14 at 11:05 a.m., Resident 35 was lying in a low bed and a pad alarm was in place. No floor mats were visible in Resident 35's room and no star magnet was located outside her door or next to her name. Resident 35 was not interviewable. During an interview on 6/11/14 at 11:10 a.m., RN L stated floor mats are only used when a resident gets out of bed unassisted. She was unable to answer the reason Resident 35 did not have floor mats in place. RN L stated probably no one thought about placing floor mats. In addition, she confirmed Resident 35 had no star magnet or star next to her name. RN L stated the stars were not placed to identify Resident 35 was a high risk for falls because the resident recently moved into that room. During an interview on 6/11/14 at 11:15 a.m., the central supply attendant stated she was responsible for the floor mats used for the residents. When she was asked the number of floor mats the facility had, she stated "a lot." The central supply attendant stated she currently had no floor mats in storage, as they were all in use. During a follow-up interview on 6/11/14 at 11:20 a.m., when RN L was asked the reason Resident 35 did not have floor mats after she was found on the floor next to her bed on 5/28/14 and 6/1/14, she stated it was an oversight. She stated placing floor mats on both sides of the bed would have been an appropriate intervention. During an observation on 6/11/14 at 12:50 p.m., Resident 35 was lying in her bed. A star had been placed next to her name. No floor mats were visible. During an observation on 6/11/14 at 1:45 p.m., Resident 35 was sitting on the side of the bed, attempting to get out of bed. No staff members were present, and no alarm was sounding. During an observation on 6/12/14 at 7:55 a.m., Resident 35 sat on the side of the bed. No alarm was sounding. CNA N was notified of Resident 35 attempting to climb out of bed. During an interview on 6/11/14 at 11:25 a.m., with the administrator and the director of nurses (DON). They stated if a resident was a high risk for falls, a star was placed outside the resident's door. The DON stated a floor mat would be placed if prior interventions had not worked. She stated Resident 35 did not have a star magnet on the outside of her door because the resident was moved to that room this weekend. The DON stated she would now place a star magnet. On 6/11/14 at 1:25 p.m., an interview was conducted with the central supply attendant. She stated currently she had no floor mats in stock. When she was asked what the facility would do if a new resident was required to have a floor mat, she stated she would probably take a floor mat away from a resident who had two floor mats in place. On 6/11/14 at 1:45 p.m., accompanied by the central supply attendant, the facility had six residents using only one floor mat and one floor mat was stored in the maintenance director's office. No other floor mats were visible. During an interview on 6/11/14 at 3:10 p.m., the DON stated residents only have one floor mat in place because either the bed is against the wall, the other bed is too close to the bed or other items are stored on one side of the bed preventing the residents from having two floor mats. On 6/11/14 at 3:25 p.m., the administrator and DON stated they were unable to locate the Fall Star Program policy and procedure. During a follow-up interview on 6/12/14 at 6:55 a.m., the administrator stated the facility did not have a falling star program policy and procedure. During an interview on 6/12/14 at 7:08 a.m., when CNA O was asked how she identified if a resident was a high risk for falls, she stated the bed if a low bed and the resident had a TAB (device attached to the resident that sounds an alarm when the resident gets up unattended) alarm in place. She did not mention a star magnet or a yellow wrist band. 4. The clinical record for Resident 31 was reviewed on 6/12/14. The Minimum Data Set (MDS, an assessment tool) dated 3/17/14 indicated Resident 31 had weakness on both sides of her body on her upper and lower extremities. The Patient Nursing Evaluation dated 3/10/14 documented Resident 31 fall score of 90, indicating she was a high risk for falls and should be referred to the Falling Star Program. The Post Fall Evaluation Form dated 5/23/14 documented Resident 31 had an unwitnessed fall and the resident was found on the floor next to her bed on the floor mat. During an observation during the initial tour on 6/11/14 at 8:30 a.m., Resident 31 was observed in her bed with an alarm attached to her nightgown. There was no fall mattress observed on either side of Resident 31's bed. During an observation on 6/11/14 at 1:30 p.m., there was no fall mattress observed on either side of Resident 31's bed. During an interview and observation with LVN H on 6/12/14 at 10:10 a.m., she stated the Falling Star Program was used when residents were at a high risk for falls. She stated a star is placed outside of the resident's room, alarms are placed on the resident while in bed and when up in a wheelchair and there should be a fall mattress placed at the bedside. She stated the resident had everything except the fall mattress at the bedside. She stated she did not know where the fall mattress was. During an interview and observation with CNA I on the same date at 10:15 a.m., she stated Resident 31 was placed on the falling star program because she was at high risk for falls. She stated there was a star located outside the room of Resident 31 and a fall alarm was placed on the resident's clothes when she was up in the wheelchair. CNA I stated when she arrived this morning there was no fall mattress located on the floor next to Resident 31's bed and the resident was in the bed. After looking in the resident's room, there was no fall mattress and she did not know where it was. 5. The clinical record for Resident 34 was reviewed on 6/12/14. The MDS dated [DATE] indicated Resident 34 had right hip surgery and was receiving physical therapy. The Patient Nursing Evaluation dated 5/16/14 documented Resident 34's fall score of 80 indicating she was a high risk for falls and should be referred to the Falling Star Program. On 6/5/14 the therapy department requested a pad alarm for the bed, due to the resident getting up to use the bathroom against therapy advice. The physician agreed to the request on 6/9/14. The Physician's Progress Notes dated 6/9/14 indicated a pad alarm to prevent the resident from getting up. On 6/11/14 at 10:45 p.m., there was a physician's telephone order for a pad alarm for the bed as requested by therapy. Written was the resident getting up to use restroom against therapy advice. During an observation and interview with CNA J on 6/12/14 at 12:10 p.m., she stated she was not sure if Resident 34 was considered to be a high risk for falls, and if the resident were a high risk for falls she would have a falling star on the door to her room. CNA J stated there was no falling star on the door to her room and having the star would let staff know she was on the falling star program. She stated there was no pad alarm on Resident 34's bed and she was not aware there should be one. She stated there was no pad alarm on the bed since she arrived for her shift that morning. During an observation and interview with LVN K on the same date at 12:15 p.m., she stated she was not aware there was an order for [REDACTED]. She stated if the resident was a high risk for falls the bed should be placed in the lowest position, and a star should be placed outside of the resident's room. She stated if the pad alarm is ordered it should be on the resident's bed. LVN K stated there was no star located on the door to the resident's room and there was no pad alarm on the resident's bed. She stated the medication administration record (MAR) would also have the order for the pad alarm written on it. After review of the MAR for June 2014, she stated there was nothing written on the MAR indicating the resident had a pad alarm.

Based on interview and record review, the facility failed to update and implement the nursing care plans with interventions for two of four sampled residents (3 and 1) to ensure residents received adequate supervision to prevent the residents from falls. On 5/27/11, Resident 3 was left unsupervised on the commode (a raised toilet seat which was placed over the toilet) in the bathroom. Resident 3 fell resulting in a broken femur (thigh bone) which required a periprosthetic fracture repair (repair of a fracture around the previous fractured hip repaired with a joint replacement implant). On 3/18/11, the pad alarm (a pad placed in a chair or bed that emits a sound when a resident gets up) was not activated and Resident 1 tried to get up and go to the bathroom by himself. Resident 1 fell resulting in a fractured left hip which required surgical repair. Findings: 1. Resident 3 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 6/1/11 indicated she had severe cognitive impairment (a condition in which a person has problems with memory, language, or another mental function that is severe enough to be noticeable to other people). Record review was done on 6/9/11. The History and Physical from the local acute care hospital indicated Resident 3, who had dementia, lived in an assisted living facility and had an unwitnessed fall on 5/14/11 resulting in a fractured right hip necessitating surgical repair. A review of the Nurses Notes dated 5/19/11 indicated Resident 3 was admitted to the facility at 11:00 a.m. for rehabilitation after the surgical repair of the fractured right hip and that she was unable to appropriately answer any questions. At 1:30 p.m., she was found on the floor complaining of right knee pain. Resident 3's Nursing Care Plan, Cognitive Loss, dated 5/20/11 indicated she had a history of [REDACTED]. Resident 3's Nursing Care Plan, Accident and Injuries, dated 5/20/11, indicated she had impaired balance. Resident 3's Physical Therapy Care Plan, dated 5/20/11, indicated she had weakness, unsteady gait, falls and a fractured right hip. Approaches in Resident 3's Fall Care Plan, dated 5/19/11, included notifying the physician, monitoring every shift, notifying the family, X-rays, and neurological checks (an assessment made by a medical professional on someone with a head injury) for seventy-two hours. Resident 3's Accident and Injuries Care Plan, dated 5/20/11, indicated to provide adequate lighting, keep the call light within reach, keep the floor free of spills, keep the bed locked and in a low position, encourage the use of proper footwear, and eliminate room clutter. The Nurses Notes dated 5/19/11 also indicated a pad alarm was in place on the bed. There was nothing in the Nursing Care Plans to indicate the resident should not be left unsupervised if she was not in a wheelchair or her bed with a pad alarm in place. A PT (physical therapy) evaluation, dated 5/21/11, indicated Resident 3 was able to follow directions but was forgetful. During an interview on 6/9/11 at 11:30 a.m., certified nurses assistant A (CNA A) stated Resident 3 had finished eating dinner in the dining room on 5/27/11 and had returned to her room in her wheelchair. She asked to go to the bathroom and CNA A assisted her onto the commode. CNA A stated Resident 3 asked to have a few more minutes so CNA A left her unsupervised on the commode and went to pick up a tray from another resident. When she returned two to three minutes later, Resident 3 had fallen off the commode and broken her femur. The Nurses Notes, dated 5/27/11 at 8:00 p.m., indicated Resident 3 had an unwitnessed fall in the bathroom and the wound on the right hip opened and bled. 911 was called. She was taken to the acute care hospital. The History and Physical, dated 5/28/11, indicated she had a periprosthetic fracture of the right hip and her previous right hip wound opened. During an interview on 6/10/11 at 1:10 p.m., licensed nurse B (LN B) stated Resident 3's care plan should have been updated to indicate she should not be left unsupervised, given her problems with confusion and falling, and after she fell the first time in the facility a few hours following her admission for rehabilitation after surgical repair of a broken hip. During an interview on 6/9/11 at 2:20 p.m., the director of nurses (DON) stated pad alarms should be care planned and that once a pad alarm is in place, the care plan should also include instructions not to leave the resident unsupervised when not in a wheelchair or bed with a pad alarm in place. 2. Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] indicated he had severe cognitive impairment (difficulty making day to day decisions). Record review was done on 8/18/11. The Fall Risk Evaluation dated 2/8/11 indicated Resident 1 was at high risk for falls. Resident 1's Nursing Care Plan, Risk for Falls, dated 2/8/11, indicated he had a history of [REDACTED]. Approaches in Resident 1's Fall Care Plan included locking the bed and wheelchair brakes before transfers, wearing nonskid footwear when transferring or ambulating, encouraging the resident to request assistance in transferring and/or ambulating when needed, promoting adequate sleep and rest, encouraging the use of recommended assistive devices, providing cueing and supervision as needed, teaching the resident to change position slowly, ensuring the room is tidy and the floor is free of clutter, and orienting the resident to his surroundings as frequently as needed. The Nurses Notes dated 2/9/11 indicated Resident 1 was at high risk for falls since he wanted to go to the bathroom himself and that a pad alarm was in place. There was nothing in the Nursing Care Plan to indicate that a pad alarm had been placed on Resident 1's bed, that the pad alarm was to be activated when the resident was in bed, and that the resident should not be left unsupervised if he was not in a wheelchair or his bed with a pad alarm in place. On 2/18/11, the Nurses Notes indicated Resident 1 turned off the pad alarm and slipped and fell while he was walking outside of his room. No injuries were noted. Resident 1's Nursing Care Plan, Falls, was updated on 2/18/11 to remind the resident to call for help if needed. Resident 1's Nursing Care Plan, Risk for Falls, was updated on 2/21/11 to obtain an order from the physician for a physical therapy evaluation and treatment as indicated. No additional approaches were delineated including the use of a pad alarm. The Nurses Notes dated 3/18/11 at 8:05 a.m. indicated Resident 1 had an unwitnessed fall. He was found on the floor laying on his left side and bleeding from the left side of his forehead. He complained of left hip pain. His physician and family were notified and he was transferred to the acute care hospital at 8:39 a.m. where a fractured left hip was diagnosed . During an interview on 8/19/11 at 2:10 p.m., Resident 1 stated he knew he was supposed to ask for help but sometimes he did not ask. The Post Fall Evaluation dated 3/18/11 indicated Resident 1 was in bed and got up to go to the bathroom unassisted. The bed pad alarm was not activated at the time of the fall. During an interview on 8/19/11 at 2:30 p.m. with the director of staff development (DSD), she stated the pad alarm should have been activated while the resident was in bed. Review of the facility's policy dated 10/31/09, "Care Plans", indicated "a comprehensive care plan is developed that is consistent with the resident's specific conditions, risks, needs, behaviors and preferences...The team of qualified persons monitors the resident's condition and effectiveness of the care plan interventions and revises the care plan quarterly, annually, with a significant change assessment or more frequently as needed." The facility failed to revise the nursing care plans to ensure Residents 3 and 1 were supervised when they were not in a wheelchair or bed with a pad alarm in place and to ensure Resident 1 had a pad alarm that was activated while he was in bed so the staff would be alerted when he got out of bed without calling for assistance. Resident 3 fractured her femur on 5/27/11 after she was left sitting on the commode unsupervised. The local acute care hospital consultation report, dated 5/28/11, indicated the resident would go to surgery for [REDACTED].

Based on interview and record review, the facility failed to follow a physician's order for one of 14 sampled residents (1). The facility failed to follow an order to send Resident 1's results of a basic metabolic panel (BMP, set of tests that gives information about glucose and calcium levels in the blood, how the kidneys are functioning and electrolytes and fluid balance) to a nephrologist (physician who treats kidney disease) daily. Monitoring the daily laboratory blood work would help the nephrologist determine the possible need for more [MEDICAL TREATMENT] (a medical procedure to remove waste from the body). Findings: Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. The Nursing assessment dated [DATE] indicated Resident 1 was alert and oriented and had a [MEDICAL TREATMENT] port (a tube inserted into a blood vessel through which [MEDICAL TREATMENT] can be performed) in the right upper chest and had been dialyzed (had a previous [MEDICAL TREATMENT] treatment) at the acute care hospital before admission to the facility. Resident 1's clinical record was reviewed on 5/11/11. The physician's order dated 5/9/11 indicated BMP everyday until 5/16/11. FAX (facsimile, send over a telephone line) results of blood work to nephrologist. The BMP results dated 5/9/11 indicated the laboratory results were sent to Resident 1's primary care physician and the nephrologist. The BMP results dated 5/10/11 indicated copy to medical doctor (MD). The creatinine level (blood test, measurement of kidney function) was 3.23 (High) with a reference range as 0.61-1.24 mg/dL (unit of measurement). During an interview with licensed nurse A (LN A) on 5/11/11 at 8:40 a.m., she stated Resident 1 had a [MEDICAL TREATMENT] port to his right upper chest area and his laboratory blood work was being monitored daily to see if further [MEDICAL TREATMENT] was needed. During an interview with the director of nurses (DON) on 5/11/11 at 10:10 a.m., she stated if the nurse sent the results to the nephrologist as ordered it should be documented on the treatment administration record (TAR, Flow Sheet Record), in the nurses notes or on the laboratory results sheet. She also stated she was not sure if the laboratory results for Resident 1 were sent to the nephrologist or primary care physician after reviewing the laboratory results with the words "copy to MD on 5/10/11" written on it. During an interview and record review with licensed nurse B (LN B) on 5/11/11 at 10:20 a.m., she stated she had sent the results of Resident 1's BMP to the primary care physician only, and she did not remember if she sent the results to the nephrologist. She also stated if the results were sent to the nephrologist it would be documented on the TAR because it was written as a physician's order and then placed on the TAR. After reviewing the May 2011 TAR (Flow Sheet Record) she stated it was sent to the primary care physician only and not the nephrologist as ordered.

Based on interview and record review, the facility failed to implement a physician's order dated 11/6/10 for a daily basic panel (panel of tests that gives information about the current status of the kidneys, blood sugar and electrolyte balance including potassium levels) to follow the creatinine level and failed to recognize the risk of giving potassium to a resident with [MEDICAL CONDITION] (higher than normal level of potassium in the blood which can have symptoms such as irregular heartbeat, nausea, and weakness) for one of three sampled residents (A). Resident A had an elevated urea nitrogen (BUN, blood test to measure kidney function), creatinine level (blood test, measurement of kidney function) and potassium level. Resident A was admitted to the acute care hospital on [DATE] with a [DIAGNOSES REDACTED]. Findings: Resident A was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment tool) dated 11/9/10 indicated Resident A was independent in cognitive skills for daily decision making and was receiving occupational and physical therapy after surgery for [REDACTED]. Resident A's record was reviewed on 3/17/11 and 4/7/11. The transfer record from the acute care hospital dated 11/6/10 with "additional orders" written at the top of the sheet, indicated an order for [REDACTED]. There was no documentation on the transfer record indicating the orders were transcribed, noted and carried out. According to http://www.sh.lsuhsc.edu/policies/ policy_manuals_ms_word/Nursing/N-43.pdf, "Transcribing orders: when orders are transcribed, they must be dated, timed, and signed off by a licensed nurse using full legal signature. Signing off orders signifies that the nurse has checked to see that the order has been properly taken off/initiated. If the order is unclear the ordering physician shall be notified for clarification before the order can be carried out." During an interview and record review with the director of nursing (DON) on 4/7/11 at 12:25 p.m., she stated her expectations would be "any paperwork and orders that come with the resident should be transcribed, noted and carried out". She stated the order was missed and not carried out because there were only two basic panels drawn with creatinine levels on 11/7/10 and 11/15/10. She also stated it was a standard of nursing practice to transcribe, note and carry out a physician's order. The resident progress notes dated 11/13/10 at 9 p.m., indicated the physician visited Resident A and examined the resident with new orders for [MEDICATION NAME] (diuretic, causes the kidneys to get rid of water and salt from the body) 40 milligrams by mouth daily and K-dur (potassium) 10 milliequivalent by mouth once daily secondary to lower leg extremity 3 (three) plus non-[MEDICAL CONDITION]. The note indicated the physician was notified concerning Resident A's elevated potassium level of 5.3 with an expected normal range of 3.5-5.1 mmol/L (millimoles per liter) drawn on 11/7/10 and the nurse was waiting for instructions from the physician. The physician telephone orders dated 11/14/10 indicated okay to give potassium as ordered, physician aware of elevated potassium level and to draw a comprehensive metabolic panel (CMP) on Friday (11/19/10). Even though Resident A's potassium level was elevated ([MEDICAL CONDITION]), the Medication Administration Record [REDACTED] According to "Essentials of General Surgery" by Peter Lawrence, page 56: [MEDICAL CONDITION] is uncommon if the kidney function is normal. Serum BUN, creatinine and urine output should be measured. The primary goal of the treatment of [REDACTED]. The simplest measures are to restrict potassium. On 11/15/10, Resident A's discharge summary indicated he developed [MEDICAL CONDITIONS] (elevated potassium level in the blood) as noted on lab report 11/7/10, was transferred via ambulance to the acute care emergency room as the resident had a decrease in level of consciousness, weakness and was unable to speak. The Broadcast Report dated 11/15/10 indicated a high panic level for urea nitrogen (BUN) level of 218, a high-level creatinine of 18.37, and a high panic level for potassium of 8.9. The laboratory sheet indicated Resident A was transferred to the acute care emergency room this a.m., 11/15/10 and the laboratory results were faxed to the physician and the acute care hospital. The acute care hospital's History and Physical (H&P) dated 11/15/10 indicated the patient received [MEDICATION NAME] (used to treat excessive amounts of potassium in the body) in response to his [MEDICAL CONDITION]. The acute care hospital H & P indicated the [DIAGNOSES REDACTED]. The acute care hospital Progress Record written by the renal consultant dated 11/15/10 at 2:50 p.m. to 3:40 p.m., indicated Resident A was transferred from the facility to the emergency room (ER) "due to 'flu-like symptoms' poor appetite, nausea and vomiting and malaise for about a week", showed [MEDICAL CONDITION] with a BUN of 221, creatinine of 17.44, and a potassium of 9.1. At the facility, the resident did not do well when on 11/7/10 the resident had a high potassium of 5.3, BUN of 58 and creatinine of 5.7, ordered [MEDICATION NAME] ([MEDICATION NAME]) and KCL on 11/14/10. Transferred to ER today due to increased weakness. According to http://www.medicinenet.com/kidney _failure/article.htm, "The kidneys have the ability to monitor the amount of body fluid, the concentrations of electrolytes like sodium and potassium, and the acid-base balance of the body. They filter waste products of body metabolism, like urea from protein metabolism and uric acid from DNA breakdown. Two waste products in the blood can be measured: blood urea nitrogen (BUN) and creatinine. In acute [MEDICAL CONDITION], kidney function is lost rapidly and can occur from a variety of insults to the body". The facility failed to implement a physician's order for a daily basic panel ordered on [DATE]. Resident A had abnormal laboratory results, two emesis and swelling of his lower extremities within a week's time. There was no evidence nurses recognized the signs and symptoms of [MEDICAL CONDITION] (nausea and weakness) and gave the ordered KCL even though Resident A had an elevated potassium level. Resident A went to the acute care hospital emergency roiagnom on [DATE] when he developed acute weakness and confusion. He was diagnosed with [REDACTED].

Based on observation, interview, and record review, the facility failed to prevent an accident for one of three sampled residents (1). Resident 1 fell while unsupervised in her room on [DATE]. The resident had a physician's orders [REDACTED]. The facility failed to reassess and implement new interventions, such as a pad alarm in a wheelchair when Resident 1 had repeated falls. Resident 1 sustained a fracture of the neck and died as a result of the fall on [DATE]. Findings: Resident 1 was admitted with [DIAGNOSES REDACTED]. The [DATE] Minimum Data Set (MDS) assessment indicated she had memory problems and needed assistance to transfer and ambulate. The MDS indicated she had fallen in the past ,[DATE] days. Resident 1's record was reviewed on [DATE]. A ,[DATE] fall prevention care plan indicated Resident 1 was at risk for falls due to a prior history of falls, visual impairment, use of medications, dementia, impaired physical mobility, and impaired judgment. The goal was reduced risk of injury with falls. Interventions included the use of a bed pad alarm (a flat pad which is pressure sensitive and will cause an attached device to emit a sound if a person moves off the pad), a restorative nurse aide program (a schedule of exercises to improve walking), and supervision as needed. physician's orders [REDACTED]." A [DATE] post fall evaluation form indicated Patient 1 fell while trying to go the bathroom from her bed and sustained an injury. A [DATE] post fall evaluation form indicated Patient 1 fell while trying to walk unassisted from the bed to the bathroom at 5:45 a.m. and sustained an injury. The Summary of Interdisciplinary Team (IDT) section of the [DATE] post fall evaluation form indicated to assist Patient 1 to the bathroom between 5 a.m. and 6 a.m., and to ensure the alarm was on. A post-fall evaluation form dated [DATE] indicated Resident 1 fell while trying to go to the bathroom from her wheelchair without assistance or supervision. The form indicated X-rays were done to assess pain in her right knee, left hip, and pelvis. The Summary of IDT (interdisciplinary team) section of the [DATE] post fall evaluation form indicated, "Will continue with bed pad alarm." However, the form indicated on [DATE] Resident 1 fell after leaving her wheelchair, not her bed. An [DATE] post-fall evaluation indicated the resident fell at 1:10 p.m. while walking unassisted. The form indicated Resident 1 was found on the floor in front of the bathroom on her right side with a large amount of blood from an apparent head wound. The form indicated an alarm was not in use at the time of the fall. The form indicated "911" was called. A nurse's note dated [DATE] at 1:30 p.m. indicated Resident 1 was pronounced dead by emergency medical personnel at 1:23 p.m. The note indicated a sheriff arrived at 1:40 p.m., and a coroner came to Resident 1's room at 2:40 p.m. During an interview on [DATE] at 9:10 a.m. licensed nurse A (LN A) stated she was called to Resident 1's room on Sunday, [DATE] around 1:10 p.m. by certified nurse assistant A (CNA A) and CNA B. She stated she entered the room and saw Resident 1 on the floor lying on her right side, up against the bathroom door and about two to three feet from her wheelchair, with blood on the floor around Resident 1's head. She stated she immediately called out to another staff member to summon paramedics. She stated Resident 1 said "Help" several times. LN A stated Resident 1 then started to show purple discoloration of her right arm and right side of her face, and began to breathe in an abnormal manner, slow and shallow. She stated paramedics entered the room and then Resident 1 died . LN A stated when she first entered the room she observed a tab alarm (a dark plastic device about three inches tall by two and one-half inches wide and about one inch deep containing a speaker) hooked to the back of Resident 1's wheelchair. LN A stated she observed the tab alarm lanyard and clip (a cord with a pin on one end and a clip on the other, about 18 inches long) draped over the back of the chair and dangling to the front. LN A stated the pin was not pulled from the tab alarm. She stated the tab alarm had not gone off. LN A stated the usual procedure was to clip the lanyard to the resident's clothing. She stated when the resident stood up and/or moved forward, the lanyard would pull the pin out of the speaker box, setting off the alarm and alerting staff. LN A stated she asked CNA B if she placed the clip and CNA B stated she placed the clip on Resident 1's clothing that morning. During an interview on [DATE] at 1:40 p.m., CNA C stated on [DATE] she served a lunch tray to Resident 1, who was seated in her wheelchair with a small portable table in front of her. She stated Resident 1 was alone in the room. She stated the resident had a call light near her, but did not observe whether or not the tab alarm clip was attached to Resident 1's clothing. CNA C stated she had seen Resident 1 pulling at her clip and trying to remove it on several previous occasions, the most recent on [DATE]. CNA C stated Resident 1 was unsteady on her feet but tried to walk. CNA C stated after leaving the meal tray, she and CNA D moved to the adjacent room to serve lunch trays to other residents. She stated between three to five minutes after leaving Resident 1's room, CNA A called out loudly for help. She stated she went to Resident 1's room and saw her on the floor. During an interview on [DATE] at 2:20 p.m., CNA B stated she was assigned to care for Resident 1 on [DATE]. She stated Resident 1 needed help to walk. She stated Resident 1 was wearing black pants and a blouse. She stated she secured the tab alarm clip to Resident 1's blouse that morning, and observed it in place at 10:45 a.m. when Resident 1 was in the hallway. CNA B said, "Sometimes the clip comes off." During an interview on [DATE] at 10:30 a.m., CNA A stated he was helping in the assisted dining area at lunchtime on [DATE]. He stated he took some laundry in a bag down the hallway and past Resident 1's room. He stated he observed Resident 1 on the floor and called for help. He said CNA C and CNA D were in an adjacent room. He stated Resident 1 sometimes removed the tab alarm clip from her clothing. He stated when it occurred, "we put it back on." He stated nursing staff knew Resident 1 removed her alarm clip. CNA A stated a chair pad alarm (an alarm which sounds when pressure is removed from a pad placed on the seat of a chair) was useful for residents who were able to disarm the tab alarm. During an interview and record review on [DATE] at 11:20 a.m., the director of nurses (DON) reviewed the [DATE] post-fall evaluation form. She stated new interventions were not recommended after this fall. She stated existing interventions were not modified. The DON reviewed the [DATE] post-fall evaluation form. She stated the mobility alarm was not clipped in place on Resident 1 at the time of the fall, but should have been. The DON reviewed the ,[DATE] fall prevention care plan and stated the use of a mobility alarm was not on the care plan but should have been. She stated Resident 1's behavior of removing her mobility alarm clip should have been addressed on the care plan but was not. She said the more reliable chair pad alarm was not used for Resident 1 but could have been. On [DATE], a review of Resident 1's [DATE] preliminary Certificate of Death indicated cause of death was a fracture of the neck following a fall with an impact to the forehead. On [DATE] a review of the [DATE] facility policy and procedure, "Accidents and Supervision to Prevent Accidents" indicated the facility provided supervision and assistive devices to each resident to prevent avoidable accidents. The policy indicated this included identification and evaluation of hazards and risks and implementation of interventions to reduce hazards and risks. The policy indicated the process included monitoring to ensure interventions were implemented correctly and consistently, evaluating the effectiveness of interventions, modifying or replacing interventions as necessary, and evaluating new interventions when necessary to make them more effective in addressing hazards and risks. The facility failed to provide supervision and assistive devices to prevent an avoidable accident for Resident 1. The facility did not evaluate the effectiveness of interventions to prevent falls and failed to modify or replace interventions as necessary. Resident 1 had an unsteady gait and poor judgment and was able to remove her mobility alarm. She fell on [DATE], [DATE], and [DATE]. After the fall on [DATE], new interventions were not tried. Subsequently on [DATE], Resident 1 got out of her wheelchair while unsupervised, fell , fractured her neck, and died .