Every finding on record at Saratoga Retirement Community Health Center

Based on observation, interview, and record review, the facility failed to ensure the nurse staffing information was posted clearly visible in a prominent place that was readily accessible to residents and visitors. This failure had the potential to result in nurse staffing misinformation about resident's care. Findings: During a concurrent observation and interview on 4/25/25, at 11:33 a.m., with the Director of Nursing (DON), in nurse station 1 (NS 1), the nurse staffing information was posted on the wall behind the nurse's station. The DON confirmed the observation and stated the location of the nurse staffing information was not visible to the residents and should be in front of the nurse's station. The DON further stated that the nurse staffing information should be visible for all the residents to see. During a concurrent observation and interview on 4/25/25, at 11:37 a.m., with the DON, in nurse station 2 (NS 2), the nurse staffing information was posted behind on the wall behind the nurse's station. The DON confirmed the observation and stated it should not be posted on the wall but in front of the nurse's station. During an interview on 4/25/25, at 11:47 a.m., with the Certified Nursing Assistant (CNA), she stated she posted the nurse staffing information on the wall behind the nurse's station. The CNA stated she usually post the nurse staffing information in front of the nurse's station, but some residents was removing the nurse staffing information.

Based on observation, interview, and record review, the facility failed to ensure proper food handling techniques in the kitchen when several wet metal containers were stacked while still wet and dry storage room walk-in refrigerator, and freezer had expired and unlabeled food. There se failures had the potential to expose 62 residents receiving food from the kitchen to food-borne illness. Findings: During an observation and subsequent interview with the director of dining (DD) on [DATE] at 10:43 a.m., the following items were observed in the walk-in refrigerator and freezer: -unlabeled four bags of green beans -unlabeled four bags of chicken breast filets -unlabeled one bag of hash brown -one container of goat cheese with an expiration date of [DATE] -one large container of sugar with an expiration date of [DATE]. The DD acknowledged the above observations. During the same kitchen observation and subsequent interview, with the DD, on [DATE] at 10:43 a.m., there were nine metal containers on the storage racks which were still wet. These were acknowledged as being wet by the DD, and the registered dietitian (RD). During an interview, with the RD, on [DATE] at 11:23 a.m., while leaving the kitchen, when asked what the RD thought about the observations, she stated the observations were not good. During a review of the facility's policy and procedure (P&P) titled General Storage Standards, revised ,d+[DATE], the P&P indicated PROCEDURE: .6. Storage containers need to be appropriate for product needs, labeled, and dated.7. Frozen items should be wrapped or in commercial cartons, dated, and labeled.16. All potentially hazardous foods must be labeled with a date sticker as soon as the package is opened, or the item is prepared. Only such items that have a date sticker less than seven days old will remain on our shelves for consumption by the residents. During a review of the facility's policy and procedure (P&P) titled Dish Room Operations, reviewed ,d+[DATE], the P&P indicated .6. Clean dish storage: This is the cart and shelves used to store clean items prior to being put away for use. Dishes should remain in this area, unstacked, until completely dry.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure physician's orders were followed related to supplemental oxygen administration for 1 (Resident #12) of 1 sampled resident reviewed for respiratory care. Findings included: A facility policy titled, Oxygen/Respiratory Therapy & Safety, last revised 01/2020, revealed, Policy: It is the policy of the Company that: a. Oxygen/respiratory equipment will be operated, cleaned and maintained to optimize functions, safety and prevent infections. b. Oxygen therapy is provided in accordance with physician orders. Procedure: Obtaining orders and documentation: 1. All oxygen and oxygen saturation orders and/or parameters are clarified on admission. 2. Oxygen orders and saturation documentation will be documented on the resident's Medication & Treatment Record. An Admission Record revealed the facility admitted Resident #12 on 11/18/2021. According to the Admission Record, the resident had a medical history that included Alzheimer's disease and chronic obstructive pulmonary disease (COPD). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/06/2024, revealed Resident #12 had a Staff Assessment for Mental Status (SAMS), which indicated the resident was severely impaired in cognitive skills for daily decision making. The MDS indicated the resident was dependent on staff for activities of daily living and used oxygen therapy Resident #12's care plan, included a focus area initiated 11/23/2023, that indicated the resident had altered respiratory status related to COPD, seasonal rhinitis, and chronic rhinitis. Interventions specified the resident's supplemental oxygen setting should be at 2 liters per minute (LPM) by way of nasal canula (NC), continuous and may be increased to 3-4 LPM if the resident's oxygen saturation level fell below 93%. Resident #12's Order Summary Report, which contained active orders as of 01/06/2025, revealed an order dated 06/24/2024, for continuous, supplemental oxygen at 2 LPM by way of a NC and could be increased to 3-4 LPM, if the resident's oxygen saturation level fell below 93%. During an observation on 01/06/2025 at 1:06 PM, Resident #12's supplemental oxygen concentrator was set to provide 1.5 LPM. During an observation on 01/07/2025 at 8:19 AM, Resident #12's supplemental oxygen concentrator that was located at the resident's bedside was set to provide 1.5 LPM. Certified Nurse Aide #2, who was present in the resident's room, verified the resident's supplemental oxygen concentrator was set at 1.5 LPM. On 01/07/2025 at 8:22 AM, the Infection Preventionist (IP) accompanied the surveyor in Resident #12's room and acknowledged the resident's supplemental oxygen concentrator was set at 1.5 LPM. The IP stated it was her expectation that the supplemental oxygen setting be checked once a shift and confirmed the resident's supplemental oxygen concentrator should be set to provide 2 LPM. The IP sated Licensed Vocational Nurse (LVN) #1 was the nurse assigned to the resident's care. During an interview on 01/07/2025 at 2:15 PM, LVN #1 confirmed Resident #12 was on supplemental oxygen by way of a NC and the physician's order was for 2 LPM. LVN #1 said he was informed by another staff member during the morning hours on 01/07/2025, that resident's supplemental oxygen was set at 1.5 LPM. LVN #1 stated after he checked the physician's orders, he corrected the resident's supplemental oxygen flow rate. LVN #1 stated he checked the residents he was assigned to when he arrived on shift, to include their supplemental oxygen settings, but did not have time on 01/07/2025. LVN #1 reported, I was busy with another resident. LVN #1 confirmed a resident's supplemental oxygen should be administered according to the physician's order. During an interview on 01/08/2025 at 8:27 AM, the Director of Nursing (DON) stated she was informed Resident #12's supplemental oxygen was set incorrectly on 01/07/2025. The DON stated the process was nurses should check the physician's orders to ensure supplemental oxygen was administered according to the physician's order. The DON stated she expected the physician's orders to be followed, and supplemental oxygen should be administered at the flow rate ordered. During an interview on 01/08/2025 at 8:49 AM, the Health Services Director confirmed it was her expectation that physician's orders were followed.

Based on observation, interview, and record review, the facility failed to initiate an investigation regarding an allegation of abuse for one of three sampled residents (Resident 1). This failure had the potential to affect the resident ' s safety and protection from harm. Findings: A review of Resident 1 ' s medical record indicated she had diagnoses including delusional disorder (a type of psychotic disorder. Its main symptom is the presence of one or more delusions), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with one ' s daily activities), and pseudobulbar affect (a condition that's characterized by episodes of sudden uncontrollable and inappropriate laughing or crying). A review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 11/30/22, indicated Resident 1 had a brief interview of mental status (BIMS) score of 13 (indicates cognitively intact). During an interview and a record review on 12/23/22 at 2:00 p.m. with the Director of Nursing (DON) and the Administrator (ADM). The DON demonstrated Resident 1 ' s handwriting on a piece of paper, indicated [name] is a suspect. I was raped can ' t stand all these high voices. Review of Resident 1 ' s care plan, potential to claim different individuals committed assaults revised 12/23/22, indicated resident wrote her son was a suspect. During a telephone interview with the DON on 1/20/23 at 11:34 a.m., the DON confirmed that Resident 1 wrote [name] is a suspect. The DON stated [name] was Resident 1 ' s son and the statement was a part of Resident 1 ' s delusion. The DON stated it was not investigated because it was not an allegation. A review of the facility ' s policy and procure titled Abuse Policy, revised 1/2020, indicated a prompt and thorough investigation is the process used to determine what happened. The charge nurse at the scene will immediately begin the investigation upon notification of an incident and /or alleged abuse. As the investigation continues root cause(s) will, if at all possible, be identified. The information gained will entered into the resident ' s electronic health record (EHR).

Based on observation, interview, and facility document review, the facility failed to follow proper sanitation and food handling practices when: 1. There were food remains on a food container in dry storage area; 2. There was an outdated food item in dry storage area; and 3. Steam table pans were stacked and stored wet. These failures had the potential to cause food contamination and food-borne illness to 63 of 64 residents who received their food from the kitchen. Findings: 1. During the initial kitchen tour on 10/17/22 at 9:50 a.m., a plastic container of peanut butter with peanut butter remains on the lid and opening area were observed in the dry storage area of the kitchen. The registered dietitian (RD) confirmed the observation and stated food containers in dry storage area should be maintained free from food remains. Review of the facility policy General Food storage Standards revised 10/2022, indicated All storage areas should be maintained (good sanitation standards and basic cleanliness and environmental upkeep) to prevent rodent and insect infestation. 2. During the initial kitchen tour on 10/17/22 at 9:59 a.m., a light Italian dressing with an expiration date of 7/12/22 observed in the dry storage area of the kitchen. The RD confirmed the observation and stated the dressing should have been discarded. Review of the facility policy General Food storage Standards revised 10/2022, indicated Any food items that reach their expiration date will be discarded. 3. During the initial kitchen tour on 10/17/22 at 10:04 a.m., three metal steam table pans of various sizes were observed stacked on the counter under the steam table. One pan was upside down and stored by itself. Two pans were upside down and stacked on top of other pans. All three pans were wet on the outside surfaces of the pans. The RD confirmed the pans were wet and she stated the pans should have been air dried before stacked and stored. Review of the facility policy Dish Room Operations revised 10/2022, indicated Clean dish storage: This is the cart and shelves used to store clean items prior to being put away for use. Dishes should remain in this area, unstacked, until completely dry. According to the 2017 Food and Drug Administration (FDA) Food Code, Section 4-901.11 Equipment and Utensils, Air-Drying Required, After cleaning and sanitizing, equipment and utensils: shall be air-dried . According to the FDA Food Code 2017 Annex 4-901.11 items must be allowed to drain and to air-dry before being stacked or stored.

Based on observation, interview, and record review, the facility failed to ensure the planned menu was followed for seven residents on Pureed diet (texture modified diet for people who have difficulty chewing and swallowing) and nine residents on Mechanical soft diet (texture modified diet for people who have difficulty chewing and swallowing). This failure had the potential to result in not meeting the nutritional needs of the residents. Findings: Review of the facility menu California Diet Guide Sheet for Tuesday 10/18/2022 lunch indicated the followings; sweet chili roasted chicken pureed # 8 Scoop (1/2 cup) for the Pureed diet and 4 oz (ounce, a unit of weight) for the Mechanical soft diet. During an observation of the lunch meal service on 10/18/22 at 11:52 a.m. in the kitchen, food service worker J (FSW J) used # 12 scoop (1/3 cup, 2.7 oz) to serve the pureed and the mechanical soft sweet chili roasted chicken. During a concurrent observation and interview on 10/18/22 at 12:15 p.m., FSW J confirmed the observation. During an interview and concurrent record review on 10/18/22 at 12:20 p.m., the registered dietitian (RD) confirmed above observation and reviewed the facility menu California Diet Guide Sheet for Tuesday 10/18/22 lunch. The RD confirmed FSW J did not follow the menu for serving sizes. The RD acknowledged the planned menu should be followed.

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of four sampled residents (Resident 39). This failure had a potential to endanger the health or safety of the resident. Findings: A review of Resident 39's Admission Record indicated that Resident 39 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 39's Minimum Date Set (MDS, a standardized assessment tool) dated 10/22 indicated her cognition was intact. During an observation on 10/18/2022 at 12:44 P.M., in Resident 39's room, Resident 39 was sitting in her wheelchair with the bed to her left. The call light was placed on the bed. Resident 39 was reaching for the call light with her right hand but could not get it. Resident 39 stated her left side was weak and she could not move her left arm. She further stated the call light was placed too far for her right hand to reach. During a concurrent observation and interview with the Licensed Vocational Nurse (LVN) D on 10/18/2022 at 12:46 P.M., in resident 39's room. The LVN D confirmed that Resident 39 could not reach the call light with her right hand when the light was placed on her left weak side, and he stated the call light should be within reach all the time. During an interview with the Director of Nursing (DON) on 10/21/2022 at 9:30 A.M., the DON stated the call light should be placed on residents' strong side and should be within reach all the time. A review of the facility's Policy revised on 1/2020 titled Call light indicated it is the policy of the company to assure that residents always have a method of calling for assistance and that staff answers the residents' calls in a timely and professional manner .when leaving the room, place the call light within easy reach of the resident in bed or chair.

Based on observation, interview, and record review, the facility failed to store and dispose of multiple expired and unlabeled medications properly in one of two medication rooms, and one of two medication carts. These failures had the potential to result in unsafe administration of medications. Findings: During a concurrent observation and interview with the Licensed Vocational Nurse (LVN) A on 10/17/2022 at 9:51 A.M., in nursing station 1's medication room, observed that two boxes of eight vials of [MEDICATION(S)] (a man-made version of human [MEDICATION(S)]) in the medication refrigerator did not have a label. The LVN A stated all the medications should be labeled with residents' name, date of birth, room number, and doctor's order. During a concurrent observation and interview with the LVN A on 10/17/2022 at 10:10 A.M., in nursing station 1's medication room, observed that a vial of [MEDICATION(S)] ([MEDICATION(S)] PPD, diluted) in the medication refrigerator was opened on 9/9/2022. The LVN A confirmed this medication was expired after 30 days of opening, and the last day to use it should be 10/9/2022. During a concurrent observation and interview with the LVN A on 10/17/2022 at 10:15 A.M., in nursing station 1's medication room, observed that three boxes of 21 patches of [MEDICATION(S)] (a prescription medicine used to treat [CONDITION(S)] and moderate-to-severe primary [CONDITION(S)]), provided by Resident 24's family,were expired in 7/2022. The LVN A stated those expired patches should be discarded in 7/2022. During a concurrent observation and interview with the LVN A on 10/17/2022 at 10:27 A.M., in nursing station 1's medication cart 1, the open date of an [MEDICATION(S)] (a drug used to treat asthma) inhaler for Resident 30 was 8/29/2022, and the expiration date was 9/29/2022.The LVN A confirmed it was expired and should be removed from the cart. During a follow-up interview with the LVN A on 10/19/2022 at 2:59 P.M., she stated residents could be sick if they have expired medications, and medications without labels could cause wrong medication administration. During an interview with the Director of Nursing (DON) on 10/21/2022 at 9:30 A.M., She stated medications should be labeled and dated, and the expired medications should be moved from the storage room and medication carts on time. A review of the facility's Policy and Procedure revised 5/16/2018 titled Medication Storage in The Faculty indicated all expired medication will be removed from the active supply and destroyed in the facility, regardless of the amount remaining.

Based on observation, interview, and record review, the facility failed to provide care and service in accordance with professional standards of practice for four of 16 sampled residents (Resident 33, 28, 21 and 9) when: 1. Resident 33's dermasaver to legs and wound dressing on left second toe were not administered as ordered; 2. staff did not document behavior observation and medication side effects monitoring on time for Resident 28, 21, and 9. These failures had the potential to affect the residents' care and jeopardize their health and well-being. Findings: 1.a. Review of Resident 33's clinical record indicated she was admitted [DATE] and had the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 33's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse with normal saline. 2. Pat dry. 3. Apply [MEDICATION(S)]. 4. Cover with calcium alginate. 5. Secure with dry dressing. As needed for wound care AND every day shift. During an observation on 10/18/22 at 11:47 a.m. in Resident 33's room, while Resident 33 was sitting up in her wheelchair, the resident had an open wound on her left second toe with clear drainage. There was no treatment dressing observed on left second toe wound. During an observation on 10/18/22 at 3:18 p.m., while Resident 33 was lying in her bed, there was dried blood stains on the top bed sheet and no treatment dressing observed on the left second toe wound. During a concurrent observation and interview with registered nurse F (RN F) on 10/18/22 at 3:18 p.m., RN F confirmed the observation. RN F further reviewed Resident 33's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent interview and record review with licensed vocational nurse G (LVN G) on 10/18/22 at 3:24 p.m., LVN G stated she did not do Resident 33's left second toe wound treatment today. LVN G further reviewed Resident 33's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 1.b. Review of Resident 33's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 10/20/22 at 10:20 a.m. in Resident 33's room, while Resident 33 was sitting up in her wheelchair, she was wearing the Geri sleeves to arms, but there was no dermasaver applied to legs. During a concurrent observation and interview with LVN D on 10/20/22 at 10:31 a.m., LVN D confirmed the observation. LVN D further reviewed Resident 33's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the director of nursing (DON) on 10/20/22 at 12:08 p.m., the DON acknowledged Resident 33 should have the dermasaver applied to legs and stated she could not find the dermasaver in the resident's room. Review of the facility's policy Medication and Treatment Administration, revised 01/2020, indicated, Medications and treatments shall be administered as prescribed. 2. A review of Resident 28's October Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .) medication were not documented on 10/12/2022 evening shift. A record review of Resident 21's October MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident 9's October MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a phone interview with the Licensed Vocational Nurse (LVN) I on 10/20/2022 at 1:45 P.M., she stated that she forgot to document the monitoring for medication side effects and behavior observation for station 3 residents, including Resident 28, Resident 9, and Resident 21 on 10/12/2022 evening shift. During an interview with the Assistant Director of Nursing (ADON) on 10/21/2022 at 9:30 A.M., the ADON confirmed the above missed documentations and stated that the staff should finish the documentation on time. A review of the facility's Policy revised 1/2020 titled Documentation indicated all documentation is expected to be legible (if handwritten), accurate, understandable, timely, pertinent, and held in confidence. A review of the facility's Policy revised 6/2021 titled [CONDITION(S)] Medication Management indicated monitoring and accurate documentation of the resident's response to the medication and evaluation of the effectiveness of any non-pharmacological approaches.

Based on observation, interview, and record review, the facility failed to ensure residents were free of accidents and hazards for two of 16 sampled residents (Resident 42 and 1) when: 1. Resident 42 was not provided adequate supervision as indicated in her fall care plan and fall mats were not in place as ordered; 2. Resident 1's wandering alert system was not monitored. These failures had the potential to result in serious injury to the residents in the facility. Findings: 1. Review of Resident 42's clinical record indicated she was admitted on [DATE] and had diagnoses of [CONDITION(S)] ([CONDITION(S)], a group of lung diseases that block airflow and make it difficult to breathe), fracture of right femur neck, [CONDITION(S)] (a condition in which bones become weak), difficulty in walking, and dementia (a group of symptoms affecting thinking and social abilities interfering with daily functioning). Review of Resident 42's Minimum Data Set (MDS, an assessment tool) dated 4/06/22, indicated she had a brief interview of mental status (BIMS, a structured cognitive test) scoring 03 (severe impairment). Review of Resident 42's fall risk evaluation, dated 4/07/22, indicated, score: 22, at risk. Review of Resident 42's Physician order, dated 6/02/22, indicated, Special low bed with BIL floor mats to lessen the impact of injury in case of a fall. Review of Resident 42's care plan, titled, The resident is at high risk for unavoidable falls, date initiated 4/02/22, indicated one of the interventions was 1:1 sitter at all times. Do not leave unattended. During an observation on 10/19/22 at 9:50 a.m., Resident 42 was lying in bed. Certified nursing assistant H (CNA H) was caring for Resident 42's roommate. The curtain was drawn completely around Resident 42's roommate to provide privacy. There was no fall mat observed on the left side of Resident 42's bed. During a concurrent observation and interview on 10/19/22 at 9:50 a.m., certified nursing assistant H (CNA H) confirmed the observation. CNA H stated Resident 42 should have fall mats on both sides of her bed. CNA H further stated she could not provide 1:1 sitter care to Resident 42 while providing a care to Resident 42's roommate. During a concurrent observation and interview on 10/19/22 at 9:56 a.m., licensed vocational nurse D (LVN D) confirmed the observation. LVN D reviewed Resident 42's physician order and confirmed Resident 42 should have fall mats on both sides of her bed as ordered. LVN D confirmed CNA H was assigned to Resident 42 and her roommate. During an interview with CNA E on 10/21/22 at 8:23 a.m. in Resident 42's room, CNA E stated she was assigned to Resident 42 and Resident 42's roommate. During an interview with the assistant director of nursing (ADON) on 10/21/22 at 10:00 a.m., ADON stated the CNA would not be considered a 1:1 sitter if one CNA was assigned to care for two residents. ADON stated the CNA assigned for Resident 42 as a 1:1 sitter should not be assigned to care for another resident. During a concurrent interview and record review on 10/21/22 at 11:20 a.m., the director of staff development (DSD) reviewed CNA assignments from 10/01/22 to 10/20/22 and confirmed one CNA was assigned to Resident 42 and her roommate. The DSD stated 1:1 sitter was not provided as indicated in Resident 42's fall care plan. During a concurrent interview and record review on 10/21/22 at 11:54 a.m., the DSD reviewed Documentation Survey Report (CNA documentation of daily task, like bed mobility, dressing, personal hygiene, toilet use, and transferring) and confirmed one CNA provided all daily care to Resident 42 and her roommate. Review of facility's policy, Fall Reduction and Management Program revised 2/2021, indicated Care planning and implementation: Based on resident fall evaluation, an individualized care plan with the goal to prevent falls and/or minimize serious injury if fall occurs will be developed, implemented, monitored and modified as needed. Review of facility's policy, 1:1 Sitters provided by the DSD, indicated 1:1 CNA will provide all care for resident and monitor for risks and safety awareness issues. Review of the facility's policy Medication and Treatment Administration, revised 01/2020, indicated, Medications and treatments shall be administered as prescribed. 2. During an observation on 10/17/22 at 9:40 a.m., Resident 1 was in his wheelchair with a Wanderguard (a device that activates an alarm when a resident attempts to leave a safe area) on his right ankle. Resident 1 was going and up and down the hallway by self propelling his wheelchair with his legs. Review of Resident 1's clinical record indicated he was admitted on [DATE] with diagnoses of dementia (a decline in mental capacity affecting daily function), depression, weakness, unsteadiness on feet, and abnormalities of gait (manner of walking) and mobility. Review of Resident 1's Minimum Data Set (MDS, assessment tool), dated 7/10/22, indicated Resident 1 had severely impaired cognitive skills for daily decision making and for activities of daily living (ADL) he required extensive assistance on transfer, walking in room and corridor, and locomotion on and off unit. Review of Resident 1's Wandering Risk Assessment, dated 10/7/22, indicated Resident 1 was at moderate risk for wandering (wandering resident, actively and purposely looks to leave a facility or inadvertently attempts to leave a facility due to a cognitive impairment). Review of Resident 1's care plan Resident wanders/at risk for elopement dated 7/5/21, indicated to monitor Wanderguard alarm and document and trend resident's wandering behavior. During an interview with licensed vocational nurse A (LVN A) on 10/19/22 at 9:26 a.m., she stated Resident 1 had a Wanderguard device on his right ankle and if he went out of any exit door the device would alarm. When asked how staff ensures the device is functioning properly, LVN A stated she believed the ward clerk checks that. When asked if nurses monitored episodes of exit seeking behaviors of Resident 1, LVN A stated there was no shift monitoring by the licensed nurses for episodes of elopement. LVN A further stated there was no monitoring by the licensed nurses for the functioning of the Wanderguard in Resident 1's medical record. During an interview with the director of nursing (DON) on 10/19/22 at 9:48 a.m., she stated the expectation was for the nurses to test the function of the Wander Guard bracelet attached to Resident 1 every shift. The DON further stated there should be orders to monitor placement and function of the Wanderguard and documentation to reflect episodes of attempting to leave the facility. The DON confirmed there was no documentation in Resident 1's medical record by the licensed nurses that Resident 1's Wanderguard was being monitored every shift. The DON further confirmed the licensed nurses did not document episodes of Resident 1 attempting to leave the facility. Review of the facility's policy titled Wandering Resident Management: Wanderguard indicated facilities will provide devices to assist in monitoring the whereabouts of wandering residents and prevention of elopement from the facility. Staff will monitor the Wanderguard for proper placement and function every shift and will be documented on the medication administration record (MAR) or treatment administration record (TAR).

Based on observation, interview, and record review, the facility failed to ensure respect and dignity was maintained for two residents (Residents 12 and 42) when staff provided feeding assistance while standing. This failure had the potential to affect the emotional and psychosocial well-being of the residents. Findings: 1. Review of Resident 12's minimum data set (MDS, an assessment tool) dated 7/25/22 indicated her cognition was moderately impaired and she needed one-person physical assistance for eating. During a lunch meal observation on 10/17/22 at 12:18 p.m., Resident 12 was sitting in her wheelchair in her room. Certified nursing assistant B (CNA B) stood beside her while providing spoon-feeding assistance to Resident 12. During a concurrent interview with CNA B she confirmed she was standing while feeding Resident 12. She stated she should be sitting down when she feeds the residents. During an interview with the director of staff development (DSD) on 10/18/22 at 10:35 a.m., he stated he provides inservices to nursing staff and staff are trained to be at eye level when they are feeding residents. The DSD stated when residents are in the wheelchair, staff should be seated in a chair and at eye level with the resident. Review of an Inservice Lesson Plan dated 8/17/22, indicated Proper feeding to the residents was a topic covered in the inservice. A checklist for this skill included being positioned at eye level with the resident. CNA B had signed the attendance sign in sheet for the inservice on 8/17/22. 2. During a breakfast meal observation on 10/18/22 at 9:02 a.m., CNA E was observed standing over Resident 42 while feeding. During an interview with CNA E on 10/18/22 at 9:02 a.m., CNA E confirmed she was standing while feeding Resident 42 and stated she should sit down when feeding the residents. During an interview with the DSD on 10/18/22 at 10:33 a.m., the DSD confirmed staff should sit down and be at eye level with the residents. Review of facility's Caregiver/CNA Competency Checklist Skill: Dining Room included 11. Sit next to residents while assisting them to eat, rather standing over them.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when staff did not wash or sanitize her hands between changing gloves for one of four sampled residents (Resident 36). This failure could potentially result in infection transmission in the facility. Findings: During a medication administration observation with the Licensed Vocational Nurse (LVN) C on 10/18/2022 at 9:44 A.M., in Resident 36's room, The LVN C did not wash or sanitize her hands before putting on gloves to give eye drops and nasal spray. She also did not wash or sanitize her hands between glove changes. During a follow-up interview with LVN C on 10/18/2022 at 9:57 A.M., the LVN C stated she should wash or sanitize her hand during glove changes to prevent cross-contamination. During an interview with the Director of Nursing (DON) on 10/21/2022 at 9:30 A.M., the DON stated staff should wash or sanitize their hands between tasks and between changing gloves. A review of the facility's Policy revised 11/2017 indicated all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .in most situations, the preferred method of hand hygiene is with an alcohol-based hand rub, before donning gloves and after removing gloves .

Based on observation, interview and document review, the facility failed to ensure food was stored and prepared under sanitary conditions when kitchen staff used expired test strips to test the kitchen surface sanitizer and scooped ice from ice machine not using ice scooper. These failures had the potential to spread food-borne illness to 69 of 72 residents who received food from the kitchen. Findings: During an observation on [DATE] at 10:22 a.m., accompanied by the registered dietician (RD), one kitchen aide (KA) demonstrated kitchen surface sanitizer test with an expired test strips. The RD confirmed the Ecolab sanitizer 146 multi quart strip test strips had [DATE] expiration date. The RD disposed of the expired strips and brought an unopened strip dated [DATE]. Both staff stated expired strips should not be used because readings could be inaccurate. During an observation on [DATE] at 11:28 a.m., the nutritional aide (NA) used a big white pitcher to scoop ice from the ice machine, and her gloved right hand and bare arm touched the ice in the ice machine. The NA confirmed this observation when this was reported to the dietary supervisor (DS), Chef and RD. Both the DS and RD counseled the staff and stated staff should use the ice scooper at all times to prevent possible contamination.

Based on observation, interview and record review, the facility failed to identify and address potential complications related to indwelling catheter (flexible tube inserted and left in the bladder to drain urine) use for one of four residents (Resident 17). This failure had the potential to negatively affect the resident's health and well-being. Findings: Review of Resident 17's clinical record indicated he was admitted on [DATE] and had the [DIAGNOSES REDACTED]. Resident 17's record also indicated he had an indwelling catheter. Review of Resident 17's interdisciplinary (ID, staff from different disciplines who work together to plan and provide care) notes, dated 1/9/2020, indicated Resident 17 came back from a urology (branch of medicine concerned with the function and disorders of the urinary system) appointment where his indwelling catheter was replaced. The ID note further indicated Resident 17's indwelling catheter was draining clear, yellow urine at that time. During an observation on 2/5/2020 at 7:55 a.m., Resident 17 was lying in bed. The urine draining from Resident 17's indwelling catheter was yellow, but it was not clear and it had white sediments. During an interview with the clinical nurse manager (CNM) on 2/6/2020 at 8:13 a.m., she explained that for residents with an indwelling catheter, the urine should be yellow and clear. The CNM further explained that unclear urine with sediments could be an indication of infection. The CNM confirmed that licensed nurses should assess the characteristics of the urine every shift, report any abnormal findings to the resident's doctor, and initiating alert charting (licensed nurses on each shift monitor for specific conditions and document in the clinical record). During an observation and concurrent interview on 2/6/2020 at approximately 8:20 a.m., the CNM went into Resident 17's room and confirmed the urine draining from Resident 17's indwelling catheter was not clear and had white sediments. Certified nursing assistant F (CNA F) was also present in the room while the CNM assessed Resident 17's urine. CNA F stated Resident 17's urine was normally yellow and clear. During an interview and concurrent record review with the CNM on 2/6/2020 at approximately 8:25 a.m., the CNM reviewed Resident 17's clinical record and confirmed there was no documentation indicating the doctor was notified, there was no documentation of alert charting, and there was no other documentation indicating that Resident 17's unclear urine with white sediments had been identified and addressed. Review of Resident 17's indwelling catheter care plan, dated 2/6/2020, indicated to assess for adequate output, color, and odor of the urine. The care plan further indicated to notify the resident's doctor for abnormal urine clarity or consistency. Review of the facility's policy, Catheter: Use of Indwelling Urinary Catheter, revised 1/2020, indicated Assessment should also include ongoing monitoring for changes in condition related to potential CAUTI's (catheter-associated urinary tract infections), recognizing, reporting and addressing such changes.

Based on observation, interview and record review, the facility failed to implement their policy on medication self-administration (resident takes medication without staff assistance) for one of 18 residents (Resident 48) when: 1. The facility did not complete a medication self-administration assessment for Resident 48; 2. The facility did not obtain a physician's order for Resident 48 to self-administer medications; and 3. The facility did not ensure Resident 48's medication was kept in a locked container in his room. These failures had the potential to result in unsafe medication self-administration. Findings: Review of Resident 48's clinical record indicated he was admitted on [DATE] and had the [DIAGNOSES REDACTED]. Review of Resident 48's minimum data set (MDS, an assessment tool), dated 12/23/19, indicated he had a brief interview for mental status (BIMS) score of 13 (a score of 13 to 15 indicates the resident is cognitively intact). During an observation and concurrent interview on 2/4/2020 at 8:47 a.m., Resident 48 was in his room eating breakfast. There was a [MEDICATION NAME] HFA inhaler (a hand held device containing medication that is inhaled to treat wheezing and shortness of breath) on Resident 48's over bed table. Resident 48 stated that he had the medication with him pretty much all the time and that he had been taking the medication for a long time. During an observation on 2/5/2020 at 8:02 a.m., Resident 48 was sitting in his room and the [MEDICATION NAME] HFA inhaler was on his over bed table. During an observation and concurrent interview on 2/5/2020 at 8:39 a.m., Resident 48 was sitting in his room and the [MEDICATION NAME] HFA inhaler remained on his over bed table. Resident 48 stated he had the medication with him since his admission to the facility. Resident 48 further stated he had been using the medication maybe once or twice a week as needed. Resident 48's clinical record was reviewed. There was no assessment indicating Resident 48 was safe to self- administer medications. There was no physician's order for resident 48 to self-administer medications. Also, there was no physician's order for resident 48 to receive [MEDICATION NAME] HFA inhaler as needed. During an interview with the clinical nurse manager (CNM) on 2/5/2020 at 8:44 a.m., she explained that if a resident wanted to self-administer medications, the facility would need to do an assessment to determine that the resident was capable of self-administering the medications safely. The CNM also explained resident needed to have a physician's order to self-administer medications and the medications needed to be kept in a locked drawer in the resident's room. During the same interview, the CNM went to Resident 48's room and confirmed he had a [MEDICATION NAME] HFA inhaler that was not kept in a locked drawer. The CNM reviewed Resident 48's clinical record and confirmed the facility did not complete a medication self-administration assessment. The CNM also confirmed Resident 48 did not have a physician's order to self administer medications and did not have an order to receive [MEDICATION NAME] HFA inhaler as needed. Review of the facility's policy, Medication Administration: Self Administration Program, revised 3/2015, indicated a resident's competence must be established with a self-administration of medications assessment. The policy further indicated the resident must have a physician's order to self-administer medications and the medications must be kept secured in the resident's room in a locked container.

Based on interview and record review, the facility failed to consistently complete post [MEDICAL TREATMENT] (the clinical purification of blood as a substitute for the normal function of the kidney) assessments on the Nursing Facility/[MEDICAL TREATMENT] Center Communication Report for one resident (Resident 17) who received [MEDICAL TREATMENT] services. Failure to assess had the potential to compromise the facility's ability to identify and address potential complications after [MEDICAL TREATMENT]. Findings: Review of Resident 17's clinical record indicated he was admitted on [DATE] and had the [DIAGNOSES REDACTED]. The clinical record further indicated Resident 17 received [MEDICAL TREATMENT] on Mondays, Wednesdays and Fridays. Review of Resident 17's [MEDICAL TREATMENT] binder indicated the Nursing Facility/[MEDICAL TREATMENT] Center Communication Report was not completed consistently. The bottom portion that was to be completed by facility nurses upon Resident 17's return from [MEDICAL TREATMENT] was left blank. This portion was to be completed with information including the time the resident returned to the facility, his vital signs (temperature, heart rate, respirator rate and blood pressure) upon returning to the facility, assessment of the [MEDICAL TREATMENT], any changes in orders, and whether the doctor was notified of these changes. This portion of the Nursing Facility/[MEDICAL TREATMENT] Center Communication Report was left blank on 11/1/2019, 11/8/2019, 12/6/2019, 12/13/2019, 12/20/2019, 12/27/2019, 1/10/2020, 1/31/2020, 2/3/2020, and one other day in which the facility nurse did not fill out the date (total of ten days). During an interview and concurrent record review with the clinical nurse manager (CNM) on 2/6/2020 at 11:26 a.m., she reviewed Resident 17's [MEDICAL TREATMENT] binder and confirmed the facility nurses did not consistently complete the Nursing Facility/[MEDICAL TREATMENT] Center Communication Report. The CNM acknowledged the nurses should have completed the bottom section of the report when Resident 17 returned from [MEDICAL TREATMENT]. Review of the facility's policy, [MEDICAL TREATMENT] Services, revised 8/2013, indicated the plan of care shall include follow-up care, observation and monitoring.

Based on observation, interview and record review, the facility failed to ensure the necessary care and treatment was provided for one of one sampled resident (Resident 64) in accordance with professional standards when the registered nurse (RN) failed to use the proper technique of flushing the peripherally inserted central catheter (PICC, a long, slender, flexible tube inserted into a peripheral vein, typically in the upper arm, and advanced until the catheter tip terminates in a large vein in the chest near the heart to obtain intravenous access) line. The dynamic of the injection flow plays a pivotal role in adequate and correct flushing. Flushing using a so-called push-pause, pulsatile, or turbulent technique enhanced the rinsing effect in the catheter and helps prevent catheter occlusion. Findings: During an observation and concurrent interview on 2/4/2020 at 6:40 a.m. with registered nurse [NAME] (RN E), Resident 64's PICC line was flushed after completion of the intravenous [MEDICATION NAME] (medication for infection) dose. RN [NAME] flushed the PICC line using a continuous slow technique with 10 ml. (milliliter, unit of measurement) pre-filled syringe of normal saline solution. RN [NAME] confirmed she did not use the push, pause/stop turbulent technique when flushing Resident 64's PICC line. A review of the facility's undated policy and procedure, Catheter Insertion and Care, indicated flushing to maintain patency of catheter includes slowly administer appropriate amount of normal saline flush using the push-pause technique.

Based on observation, interview and record review, the facility failed to ensure controlled medications had been accurately accounted for one of four Controlled Drug Medication Carts, that were checked, when the licensed nurse did not timely document/log the [MEDICATION NAME] sulfate (MSO4- opioid pain medication) that was dispensed and administered to Resident 25. This failure had the potential to create problems related to accounting of controlled medications. Findings: During an inspection of Nursing Station 1's medication cart on 2/3/2020 at 1:37 p.m., with registered nurse C (RN C), RN C confirmed MSO4 solution indicated an amount of less than 21 ml. (milliliter, unit of measurement) remaining in the bottle. During the concurrent review and interview with RN C, the Narcotic Count Sheet # 045 for MSO4 indicated the amount should be 21.25 ml. RN C asked the licensed nurses who worked in Station 1 and confirmed/verified licensed vocational nurse D (LVN D) administered the medication to Resident 25. The Narcotic Count sheet #045 and the Medication Administration Record [REDACTED]. RN C stated, any controlled medication dispensed should be recorded as soon as medication was dispensed and documented in the MAR indicated [REDACTED] A review of the facility's revised 2/2015 policy and procedure, Medication Administration-Controlled Drugs, indicated when a controlled medication is administered, the person administering the medication must record on the narcotic record form or narcotic record book the date, time, the amount administered, the amount remaining, and sign the sheet.

Based on interview and record review, the facility failed to provide a monthly review of antipsychotics (drugs used to treat mental health disorders) and [MEDICAL CONDITION] (drugs that affect behavior, mood, thoughts or perception) by a licensed pharmacist for one of five residents (Resident 3) reviewed for unnecessary medications, which had the potential to result in the physician not acting upon the medication irregularities. Findings: During review of Resident 3 's clinical record, Resident 3 was admitted on [DATE] with [DIAGNOSES REDACTED]. During review of Resident 3 's physician order [REDACTED]. (1) [MEDICATION NAME] (antipsychotic) 20 milligram (mg, unit of dose) po (by mouth). Give 1 capsule (cap) po q (every) 12 hours for [MEDICAL CONDITION] with delusion due to known physiological condition. (2) [MEDICATION NAME] (drug to treat PBA) 20/10 mg - 1 cap by mouth for inappropriate uncontrollable laughing & screaming. (3) [MEDICATION NAME] SR ([MEDICATION NAME] HCl, [MEDICAL CONDITION]) 100 mg tablet sustained release for depression manifested by reduced social interaction. (4) [MEDICATION NAME] 20 mg tablet ([MEDICATION NAME] HCl, [MEDICAL CONDITION]) 1 tab by mouth for anxiety manifested by (m/b) inappropriate verbal sexual advances towards staff and resisting help with activities of daily living (ADLs). During review of Resident 3's monthly drug regimen review record for the period of 1/2019 to 12/2019 revealed no recommendations written by licensed pharmacist showed for Resident 3's use of [MEDICATION NAME] and [MEDICATION NAME]. During interview with the registered pharmacist (RPh) on 2/6/2020 at 11:07 a.m., RPh stated he did not conduct a monthly drug review of Resident 3's antipsychotics and [MEDICAL CONDITION] for the period of 1/2019 to 12/2019. RPh also stated that the physician who prescribed the medications did not respond to pharmacy note on 2/15/19. During review of the facility's policy and procedure (P&P), [MEDICAL CONDITION] Medication Management revised date 9/2018, indicated 6. Evaluation and Medication Review: .b. The Pharmacist will review each resident's medication regimen at least once a month. C. The pharmacy medication review recommendation will be acted upon in a timely manner .

Based on observation, interview and record review, the facility failed to ensure one of five residents reviewed was free from unnecessary [MEDICAL CONDITION], when: (1) There was no adequate indication for Resident 3's use of [MEDICATION NAME], Neudexta, [MEDICATION NAME] and [MEDICATION NAME], and (2) There was no GDR (gradual dose reduction) attempts in two separate quarter within the first year for [MEDICATION NAME] and [MEDICATION NAME]. These failures had the potential to cause medication adverse effects. Findings: 1. During review of Resident 3 's clinical record, Resident 3 was admitted on [DATE] with [DIAGNOSES REDACTED]. During review of Resident 3 's physician order [REDACTED]. Give 1 capsule po q (every) 12 hours for [MEDICAL CONDITION] with delusion due to known physiological condition. (Date started 11/06/18). (2) Neudexta 20/10 mg - 1 cap by mouth for pseudo bulbar affect (inappropriate uncontrollable laughing & screaming). (Date started 12/18/19). (3) [MEDICATION NAME] SR ([MEDICATION NAME] HCl) 100 mg tablet sustained release for depression manifested by reduced social interaction. (Date started 11/23/18). (4) [MEDICATION NAME] 20 mg tablet ([MEDICATION NAME] HCl) 1 tab by mouth for anxiety m/b inappropriate verbal sexual advances towards staff and resisting help with activities of daily living (ADLs). (Date started 10/31/18) During an observation with Resident 3 on 2/4/2020 at 1:20 pm, Resident 3, while lying on bed, was alert, oriented and with irregular periods of tongue movement. During review of Resident 3's behavioral monitoring record dated 11/2018 to 2/2019, indicated the following: (1) There was no targeted behavior for the use of [MEDICATION NAME]. Hence, behavior log for 11/18 revealed there was no documented indication for the initiation of or prescribing [MEDICATION NAME]. (2) [MEDICATION NAME] was indicated for uncontrollable laughing and screaming. However, behavior log for 12/18 revealed there was no documented indication for the initiation of or prescribing [MEDICATION NAME]. (3) [MEDICATION NAME] was indicated for depression as m/b reduced social interaction. However, behavior log for the month of 11/2018 revealed only one episode on 11/01/18, 11/18/18 and 11/19/18. (4) [MEDICATION NAME] was indicated for anxiety m/b inappropriate verbal sexual advances towards staff and resisting help with ADLS. However, behavior logs for 11/18 revealed staff were able to redirect the resident. During an interview with LVN G on 02/04/2020 at 4:25 pm, LVN G stated Resident 3 did not manifest any disruptive behaviors in the past. LVN G also stated Resident 3 did not have any uncontrollable laughing nor screaming during his encounters with him. During an interview with CNA H on 2/04/20 at 4:26 pm, CNA H stated there was only one incident she could recall with Resident 3 when he screamed but after he was redirected he kept quiet. During interview with the CNM (clinical nurse manager) on 02/05/2020 at 09:20 a.m., the CNM confirmed the behavior log had no documented clear indication for the initiation of or prescribing [MEDICATION NAME] and [MEDICATION NAME]. During an interview with the physician (MD) on 2/6/2020 at 10:30 a.m., the MD acknowledged the indications written for those [MEDICAL CONDITION] were off-label use. The MD stated his behaviors were a mess and behavior parameters for each medication should have been clarified. 2. During a review of Resident 3's clinical record, there was no evidence of physician justification related to GDR's clinical contraindications for use of [MEDICATION NAME] and [MEDICATION NAME], in two separate quarter within the first year. During an interview with the CNM on 2/05/2020, at 9:21 a.m., the CNM confirmed there was no evidence of physician justification related to GDR's clinical contraindications for use of [MEDICATION NAME] and [MEDICATION NAME]. During an interview with the RPh on 2/6/2020, at 11:07 a.m., RPh stated he was not able to write GDR recommendation for the [MEDICAL CONDITION]. RPh also stated the GDR should have started with [MEDICATION NAME] last 2/2019. During an interview with the MD on 2/6/20 at 10:30 a.m., the MD stated it would be hard to tell which of those medications to reduce first because there were no clear behavior parameters for each of the [MEDICAL CONDITION]. During a review of the facility's policy and procedure (P&P), [MEDICAL CONDITION] Medication Management, revised date 9/2018, indicated 4. Duration: a. Antipsychotic GDR/Tapering will be initiated and continued as follows: a.1. First year after admission or initiation: GDR/tapering in two separate quarters with at least one month in between, unless clinically contraindicated. a.2. After first year: GDR annually, unless clinically contraindicated.

Based on interview and record review, the facility failed to implement the activities of daily living (ADL's such bed mobility, toileting, transferring, and bathing) functional care plan for one of three sampled residents (Resident 1) when the intervention called for two person assist during bed mobility but Resident 1 was turned in bed with only one person. This failure resulted in Resident 1 sustaining a fall from her bed on [DATE] and sustaining a left femur (thighbone) fracture (breaking). Findings: Review of Resident 1's face sheet indicated she was admitted [DATE], with [DIAGNOSES REDACTED]. products) in the bloodstream). Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated [DATE], indicated the resident had impaired cognition (memory problem). Resident 1's MDS functional status in bed mobility, toileting, and transfer was coded for two persons on physical assist. During an interview with the director of staff development (DSD) on [DATE] at 3:15 p.m., the DSD stated Resident 1's functional status for bed mobility, transfer, toileting, and bathing required two person assist when giving care. Review of physical therapy evaluation and plan of treatment notes dated [DATE], indicated Resident 1's functional assessment was maximal assistance for bed mobility and total dependence for transfer. During an interview with the a physical therapist (PT) on [DATE] at 4 p.m., the PT stated Resident 1 was a total dependence (a full staff performance) in bed mobility and transfer which required two person assist during care. Review of Resident 1's fall risk assessment dated [DATE], indicated Resident 1 was at risk for fall due to intermittent confusion, a recent fall (Resident 1 claimed she fell in ,[DATE], complained of left hip pain, and X-ray (imaging creates pictures of the inside of your body) -revealed a left pubic rami (the bottom-most portion of the pelvis and comprises the bones we sit on) fracture), being chair bound, impaired balance during transition from bed to wheelchair, requirement to use an assistive device such as a wheelchair, and 3 or more combined medications for cardiovascular, diuretics (water pill), and medication which could cause lethargy (lack of energy) or confusion. Review of Resident 1's ADL Functional care plan dated [DATE], indicated the resident had impaired mobility related to dementia, gout, hypertension and left pubic rami fracture. The intervention started on [DATE] was two persons extensive assist for bed mobility and two persons dependent for transfers. Review of Resident 1's interdisciplinary notes dated [DATE], indicated the fall occurred on [DATE] at 5:30 a.m., when certified nursing assistant A (CNA A) went to Resident 1's room to provide ADL care while Resident 1 was in her bed asleep. CNA A was putting a new disposable brief on Resident 1, who was lying on her left side while CNA A held one hand on Resident 1's hip area. Resident 1 suddenly moved further to the side of the bed and fell on the floor on her left side. CNA A stated she was not able to hold Resident 1 because it happened so quickly. Resident 1 was asked by the charge nurse what happened and Resident 1 stated, All I remember I fell out of bed. Resident 1 complained of left hip pain and was transferred to an acute hospital. Review of Resident 1's ambulance report dated [DATE], indicated the ambulance was called at 6:04 a.m., and arrived at the facility at 6:11 a.m. Review of Resident 1's acute hospital emergency department note dated [DATE], indicated Resident 1 fell out of bed on the hard surface when being rolled on the left side, and sustained a left femur fracture. Review of Resident 1's discharge summary from the acute hospital dated [DATE], indicated Resident 1 sustained a fall from bed at the facility and had left hip pinning on [DATE] at the acute hospital. During an interview with CNA A on [DATE] at 1:58 p.m., CNA A stated she was the assigned CNA for Resident 1 on [DATE] when the incident happened. CNA A stated the resident was lying in her bed and by herself she provided care to Resident. CNA A stated she was pulling on the sheet to turn the resident on her left side, while she was holding the resident with one hand. CNA A stated she was changing a new disposable brief and suddenly the resident moved and fell on the floor. CNA A stated I was working with her before, she never moved a lot, there was no rails, and she was extensive assist. I'm by myself when I clean and change her, she was heavy, and a big lady turning to the side to change the brief. I only do her by one person. She moves and comes very fast. During an interview with registered nurse B (RN B) on [DATE] at 2:46 p.m., she stated on [DATE] at 5:30 a.m. she heard CNA A yelling and found Resident 1 on the floor. RN B stated she asked Resident 1 what happened and Resident 1 stated she fell from her bed. She stated CNA A was providing care when Resident 1 fell on the floor. RN B stated the fall could have been prevented if two persons had assisted the resident during ADL care. During an interview with the director of staff development (DSD) on [DATE] at 3:12 p.m., the DSD stated Resident 1's ADL care plan for bed mobility was not implemented for two persons extensive for bed mobility and two persons dependent for transfers. The DSD stated the fall could have been prevented if two people had assisted the resident. Review of Resident 1' acute hospital discharge summary dated [DATE], indicated Resident 1 was discharged from the acute hospital on [DATE] and returned to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 1's interdisciplinary notes dated [DATE], indicated Resident 1 expired seven days later on [DATE] at 1:40 p.m. Review of Resident 1's certificate of death issued on [DATE], indicated Resident 1 expired on [DATE] with cause of death of cardiorespiratory arrest (a sudden loss of blood flow resulting from the failure of the heart to effectively pump), septic shock (is a serious condition that occurs when a body-wide infection leads to dangerously low blood pressure), [MEDICAL CONDITION] ([MEDICAL CONDITION], a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues.), and hypertension (increase in blood pressure). Review of the facility's ,[DATE] policy, Fall Reduction and Management Program, indicated to develop an individualized care plan that addresses the risk factors identified, formulate goals that promote resident safety and prevention/reduction of falls and minimize serious injury if fall occurs. The policy states that the care plan is to be implemented in collaboration with the staff, resident or family and interdisciplinary team.

The facility's consultant pharmacist (CRPh) failed to identify the discrepancy between the attending physician's (AP) [DATE] visit notes stating Resident 1 was still on Eliquis, and the electronic Medication Administration Record [REDACTED]. Resident 1's order for medication Eliquis (a blood thinner, used to reduce the risk of stroke (interruption of blood flow to the brain) and blood clots) was discontinued indefinitely by registered nurse D (RN D) on [DATE] prior to a dental procedure, instead of putting it on hold for a day as per the attending physician's (AP) written order. The CRPh's failure to correct the discrepancy during the MRR on [DATE], resulted in Resident 1 continuing to miss her daily dose of Eliquis until [DATE], when she was sent to an acute hospital where she was diagnosed with [REDACTED]. Resident 1 died as a result of the stroke on [DATE]. Findings: Review of Resident 1's clinical record indicated she was admitted on [DATE] with [DIAGNOSES REDACTED]. She had been on Eliquis 5 milligram (mg, a unit of measure) tablet by mouth two times daily (BID) since [DATE] for AFIB. Resident 1's interdisciplinary (IDT) notes dated [DATE] 12:19 p.m., written by the social worker (SW) indicated Resident 1 went for dental x-rays, with recommendations to remove remaining jagged teeth. During an interview with registered nurse C (RN C) on [DATE], at 1:43 p.m., she stated on [DATE], she received the faxed dental order request (DOR) from the dentist (DDS) requesting the AP to fill out the section related to medications Resident 1 was currently taking. During an interview with RN C, on [DATE] at 2:20 p.m., she stated when she came back to work the following day, during the medication pass, she noticed Eliquis was not in Resident 1's electronic Medication Administration Record [REDACTED]. RN C further stated she did not check the physical chart and did not see the faxed DOR. Review of the faxed DOR to the DDS dated [DATE] indicated Resident 1 was on blood thinner and it can be put on hold only for one day prior to dental treatment. This DOR was signed by the AP on the same date, [DATE] and prior to the telephone order received by RN D at 4 p.m. During an interview with registered nurse D (RN D) on [DATE], at 3:10 p.m., she stated on [DATE], RN C reported Resident 1 was scheduled for tooth extraction with a pending DOR that the AP needed to fill out. RN D called the AP and received a telephone order to hold the Eliquis until further orders. The daily dose of Eliquis scheduled at 9:00a.m. and 5:00p.m. was held as ordered. RN D faxed the telephone order (TO) to pharmacy and marked to hold Eliquis on the EMAR until further orders. RN D stated Eliquis was discontinued on the computer so the next shift won't accidentally give it. She further stated she endorsed to the night shift Eliquis is on hold indefinitely. RN D also stated she did not see the faxed DOR with the order to hold Eliquis for one day signed by AP. Review of Resident 1's handwritten TO written by RN D, dated [DATE] 4:00 p.m. indicated HOLD ELIQUIS 5 mg . until further order. There was no documented reason why Eliquis was put on hold on the TO. Review of Resident 1's EMAR for (MONTH) and (MONTH) (YEAR) indicated on [DATE] at 5:00 p.m. -Eliquis was marked H (meaning Hold) as entered by RN D and no Eliquis was given from [DATE] through [DATE]. During an interview with the pharmacist (RPh), on [DATE], at 4:21 p.m., she stated the RPh had no access to medical decision why the Eliquis was discontinued, if it had the data to hold due to dental procedure, it would ask to clarify the order, in this case that information was not available. During an interview with Resident 1's attending physician (AP), on [DATE], at 3:05 p.m., he stated he wrote on the DOR to hold Eliquis for one day or more than 24 hours prior to the procedure and was supposed to be restarted after the procedure. He faxed the DOR back, but for some reason the nurse did not get it, so the nurse called him, he could not remember the exact conversation with the nurse, but he told the nurse Eliquis can be held, it was on hold and then supposed to be restarted. AP stated he assumed the nurse knows it can be held, usually it is held then restarted after the procedure, the nurse instead of holding it, it was never flagged to be restarted. The AP stated I assumed she is still taking it when he documented on his [DATE] visit notes that Resident 1 has [DIAGNOSES REDACTED]. AP also stated he did not review the TO, he only signed the TO in September, he should have reviewed the TO. AP stated he should have double checked that Eliquis was restarted. AP stated for any dental procedure, any anticoagulant is held before the procedure and restarted, this is something that happens frequently in nursing homes. AP further stated given the fact that Resident 1 was taken off anticoagulation, one can assume that the stroke was because of the AFIB and not being on anticoagulation. Review of Resident 1's AP's acute and follow-up visit notes dated [DATE] and [DATE], both indicated: Past Medical History included [MEDICAL CONDITION] Fibrillation and Current Medications included Eliquis 5 mg tablet 1 tab orally BID. During an interview with the director of nursing (DON), on [DATE], at 1:04 pm, she stated there were two medication regimen reviews (MRR) done, one on [DATE] (prior to [DATE] when the Eliquis was put on hold) and another on [DATE]. Both MRR indicated Resident 1's medications were reviewed and both said no recommendations. Review of a printout dated [DATE] and titled Consultant Pharmacist's Medication Regimen Review: Listing of Residents with No Recommendations . For Recommendation Created Between [DATE] and [DATE] indicated a MRR was conducted for Resident 1 between [DATE] and [DATE] and no recommendations were made. This MRR failed to identify a discrepancy between the AP's visit note dated [DATE] which indicated Resident 1's current medications still included Eliquis but it was put on indefinite hold on the EMAR. During an interview with the current consultant pharmacist (C-CRPh), on [DATE], at 9:48 a.m., she stated the MRR is a multidisciplinary review and is patient specific. She indicated when she does the MRR she looks at the [DIAGNOSES REDACTED]. The consultant pharmacists look at numerous documentation when they do the MRR. This includes looking at the AP visit notes and the EMAR. She stated the previous consultant pharmacist (P-CRPh) might have looked at the AP's notes and he may not have caught Eliquis was one missing medication. She acknowledged Resident 1 had been on Eliquis since (YEAR), she stated if she did the MRR and looked at the AP's visit notes and it is saying the resident is supposed to be on the Eliquis, but is not showing in the EMAR, she would have questioned that. She is not sure though if this was the process of the previous consultant pharmacist (P-CRPh). During an interview with the P-CRPh, on [DATE], at 3:44 p.m., he confirmed he did the MRR, he stated he cannot remember Resident 1; if he did not find anything to write then he has no recommendations for the resident for that month. He stated he generally does his MRR for two days, he was not in the facility on [DATE] so he did the MRR on [DATE] and [DATE] is the date when he printed the report. He cannot recollect seeing the AP's note dated [DATE]. He stated, if I did not question it, either I did not see the AP's note or there might have been a reason why it was discontinued. He stated, he did not see the discrepancy between the AP's visit note and the EMAR. The first time he looks at the chart, he checks what medications a resident is on, he looks to make sure there is a [DIAGNOSES REDACTED]. He does not go back to check the previous month's orders since he was there the previous month and had reviewed it. He stated if the Eliquis was discontinued in the EMAR, he would not have seen it. He also stated he checks the entire chart but did not see the telephonic order (TO) stating Eliquis was put on hold indefinitely, if he had seen the TO he would have asked the nurse why it was on hold. He stated it is hard for him to remember what happened two months ago. He stated I don't know how he could have missed the TO. Review of Resident 1's IDT notes on [DATE] 12:20 p.m. indicated at 11:30 a.m., Resident 1 was observed verbally unresponsive except to tactile stimuli, had a left side droop, cold clammy skin with right side arm noted stiff, 911 was called and she was sent via emergency transport to acute hospital. Review of Resident 1's emergency provider report from acute hospital dated [DATE] indicated resident was brought in by ambulance as a Code Brain Attack (Code STROKE, signifies a stroke is in progress and an emergency situation exists); emergency medical staff (EMS) noted Resident 1 with deviated gaze to the left side, right sided facial droop and right sided weakness in extremities. Review of Resident 1's acute hospital NEURO progress note dated [DATE] indicated the neurologist discussed the case with AP, who stated patient was taken off Eliquis in (MONTH) for a dental extraction, and for some reason (likely miscommunication) was not restarted on her Eliquis. AP was under impression that she was restarted on it, therefore in his (AP) notes he states that she is on Eliquis. Review of Resident 1's acute hospital discharge summary dated [DATE] indicated Resident 1 was admitted with acute left MCA embolic [MEDICAL CONDITIONS] with right-sided paralysis and left-sided gaze, was given tissue plasminogen activator (tPA , medication to dissolve the clot and improve blood flow to part of brain deprived of blood flow), and treated with [MEDICATION NAME] (an anticoagulant), her mental status improved but remained lethargic with severe dysphagia, failed multiple swallow evaluations, did not want feeding tube as per responsible party (RP), given overall poor prognosis in the setting of her advanced age and new embolic [MEDICAL CONDITION], patient discharged on hospice. Review of Resident 1's clinical record indicated she was readmitted to the facility on [DATE] on hospice care at 5:00 p.m. and passed away at 7:00 p.m. Review of Resident 1's death certificate issued on [DATE] indicated complications of [MEDICAL CONDITION] as the immediate cause of death with [MEDICAL CONDITION] and hypertension as the underlying causes. Review of facility's undated policy IA2: Provider Pharmacy Requirements includes screening each new medication order for appropriate indication or diagnosis . based on resident specific information and other pertinent variables. Review of facility's undated policy on Medication Regime Review indicated the consultant pharmacist performs a comprehensive medication regimen review of each resident at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy.

Based on interview and record review, the facility failed to ensure Resident 1's care was adequately supervised by a physician, when the attending physician (AP) inaccurately reviewed Resident 1's medications during a progress visit after a dental procedure, contrary to the facility's own policy on Physician Assessment and Visit Requirements. The AP's inaccurate review failed to note and reassess a recent medication change, resulting in a missed opportunity to correct an error regarding Resident 1's medication Eliquis (a blood thinner, used to reduce the risk of stroke (interruption of blood flow to the brain) and blood clots). Resident 1's Eliquis had been discontinued indefinitely on [DATE] prior to the dental procedure instead of being put on hold for a day due to conflicting orders that were not clarified. The AP's inaccurate medication review on [DATE] resulted in Resident 1's continuing to miss her daily dose of Eliquis until [DATE], when she was sent to an acute hospital where she was diagnosed with [REDACTED]. Resident 1 died as a result of the stroke on [DATE]. Findings: Review of Resident 1's clinical record indicated she was admitted on [DATE] with [DIAGNOSES REDACTED]. enough blood and oxygen to the body's tissues), [MEDICAL CONDITION] (loss of kidney function to filter wastes and excess fluids from the blood), and hypertension (HTN, high blood pressure). Review of Resident 1's care plan on cardiovascular disease (CVD) dated [DATE], indicated Resident 1 had potential for complications from [DIAGNOSES REDACTED]. Review of Resident 1's physician's order indicated she had been on Eliquis 5 milligram (mg, a unit of measure) tablet by mouth two times daily (BID) since [DATE] for AFIB. Review of Resident 1's interdisciplinary (IDT) notes by the social worker (SW) dated [DATE] 12:19 p.m., indicated Resident 1 went for dental x-rays, with recommendations to remove remaining jagged teeth. During an interview with registered nurse C (RN C) on [DATE], at 1:43 p.m., she stated on [DATE], she received the faxed dental order request (DOR) from the dentist (DDS) requesting the AP to fill out the section related to medications Resident 1 was currently taking. During an interview with RN C, on [DATE] at 2:20 p.m., she stated when she came back to work the following day, during the medication pass, she noticed Eliquis was not in Resident 1's electronic Medication Administration Record [REDACTED]. RN C further stated she did not check the physical chart and did not see the faxed DOR. Review of the faxed DOR to the DDS dated [DATE] indicated Resident 1 was on blood thinner and it can be put on hold only for one day prior to treatment. This DOR was signed by the AP. During an interview with registered nurse D (RN D) on [DATE], at 3:10 p.m., she stated on [DATE], RN C reported Resident 1 was scheduled for tooth extraction with a pending DOR that the AP needed to fill out. RN D called the AP and received a telephone order to hold the Eliquis until further orders. The daily dose of Eliquis scheduled at 9:00a.m. and 5:00p.m. was held as ordered. RN D faxed the telephone order (TO) to pharmacy and marked to hold Eliquis on the EMAR until further orders. RN D stated Eliquis was discontinued on the computer so the next shift won't accidentally give it. She further stated she endorsed to the night shift Eliquis is on hold indefinitely. RN D also stated she did not see the faxed DOR with the order to hold Eliquis for one day signed by AP. Review of Resident 1's handwritten TO written by RN D, dated [DATE] 4:00 p.m. indicated HOLD ELIQUIS 5 mg . until further order. There was no documented reason why Eliquis was put on hold on the TO. Review of Resident 1's EMAR for (MONTH) and (MONTH) (YEAR) indicated on [DATE] at 5:00 p.m. -Eliquis was marked H (meaning Hold) and no Eliquis was given from [DATE] through [DATE]. During an interview with the AP, on [DATE], at 3:05 p.m., he stated he wrote on the DOR to hold Eliquis for one day or more than 24 hours prior to the procedure and was supposed to be restarted after the procedure. He faxed the DOR back, but for some reason the nurse did not get it, so the nurse called him, he could not remember the exact conversation with the nurse, but he told the nurse Eliquis can be held, it was on hold and then supposed to be restarted. AP stated he assumed the nurse knows it can be held, usually it is held then restarted after the procedure, the nurse instead of holding it, it was never flagged to be restarted. The AP stated I assumed she is still taking it when he documented on his [DATE] visit notes that Resident 1 has [DIAGNOSES REDACTED]. AP also stated he did not review the TO, he only signed the TO in September, he should have reviewed the TO. AP stated he should have double checked that Eliquis was restarted. AP stated for any dental procedure, any anticoagulant is held before the procedure and restarted, this is something that happens frequently in nursing homes. AP further stated given the fact that Resident 1 was taken off anticoagulation, one can assume that the stroke was because of the AFIB and not being on anticoagulation. Review of AP's acute and follow-up visit notes dated [DATE] and [DATE], both indicated: Past Medical History included [MEDICAL CONDITION] Fibrillation and Current Medications included Eliquis 5 mg tablet 1 tab orally BID. Review of Resident 1's IDT notes on [DATE] 12:20 p.m. indicated at 11:30 a.m., Resident 1 was observed verbally unresponsive except to tactile stimuli, had a left side droop, cold clammy skin with right side arm noted stiff, 911 was called and she was sent via emergency transport to acute hospital. Review of Resident 1's emergency provider report from acute hospital dated [DATE] indicated resident was brought in by ambulance as a Code Brain Attack (Code STROKE, signifies a stroke is in progress and an emergency situation exists); emergency medical staff (EMS) noted Resident 1 with deviated gaze to the left side, right sided facial droop and right sided weakness in extremities. Review of Resident 1's acute hospital NEURO progress note dated [DATE] indicated the neurologist discussed the case with AP, who stated patient was taken off Eliquis in (MONTH) for a dental extraction, and for some reason (likely miscommunication) was not restarted on her Eliquis. AP was under impression that she was restarted on it, therefore in his (AP) notes he states that she is on Eliquis. Review of Resident 1's acute hospital discharge summary dated [DATE] indicated Resident 1 was admitted with acute left MCA embolic [MEDICAL CONDITIONS] with right-sided paralysis and left-sided gaze, was given tissue plasminogen activator (tPA , medication to dissolve the clot and improve blood flow to part of brain deprived of blood flow), and treated with [MEDICATION NAME] (an anticoagulant), her mental status improved but remained lethargic with severe dysphagia, failed multiple swallow evaluations, did not want feeding tube as per responsible party (RP), given overall poor prognosis in the setting of her advanced age and new embolic [MEDICAL CONDITION], patient discharged on hospice. Review of Resident 1's clinical record indicated she was readmitted to the facility on [DATE] on hospice care at 5:00 p.m. and passed away at 7:00 p.m. Review of Resident 1's death certificate issued on [DATE] indicated complications of [MEDICAL CONDITION] as the immediate cause of death with [MEDICAL CONDITION] and hypertension as the underlying causes. Review of the facility policy on Physician Assessment and Visit Requirements (approved ,[DATE]) indicated at each progress visit, the physician must review the resident's total program of care, including medications and treatments.