Every finding on record at South Marin Health & Wellness Center

Based on interviews and record reviews, the facility failed to send a notice of discharge to the Office of the State Long-Term Care Ombudsman (an independent, impartial official that mediates complaints in the long-term care setting) at the same time the notice was given to one resident (Resident 1) of three sampled residents.This failure decreased the facility's potential to ensure Resident 1 was not unsafely discharged .Findings:A review of Resident 1's Notice of Transfer or Discharge dated 10/21/25, indicated Resident 1's spouse received a notice of Resident 1's discharge from the facility on the same day Resident 1 was expected to leave on 10/21/25. Further review of this document indicated, The facility must send a copy of this notice to a representative of the Office of the Long-Term Care Ombudsman.A review of a facility fax transmission report indicated a copy of Resident 1's notice of discharge was sent to the Office of the State Long-term Care Ombudsman on 11/11/25 at 10:01 a.m., which was 22 days after Resident 1 was discharged from the facility. During an interview on 1/26/26 at 1:46 p.m., the SSD (Social Services Director) acknowledged she was responsible for sending notices of transfers or discharges to the Ombudsman in October 2025. The SSD director stated Resident 1's discharge was a facility-initiated discharge. The SSD stated she understood that the Ombudsman advocated for residents and the notice should have been sent before Resident 1's discharge from the facility.During an interview on 2/3/26, at 2:25 p.m., Resident 1's family member stated Resident 1's family did not request Resident 1's discharge home. Resident 1's family member stated the family wanted Resident 1 to stay at the facility. A review of the facility's policy and procedure (P&P) titled, Transfer or Discharge Notice, dated December 2016 indicated, Our facility shall provide a resident and/or a resident's representative (sponsor) with a thirty (30)- day written notice of an impending transfer or discharge.Under the following circumstances, the notice will be given as soon as practicable but before the transfer or discharge.A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman.

Based on interviews and record reviews, the facility failed to ensure licensed nurses administered significant medication (a medication that increased the risk of harm when not taken) to one resident (Resident 1) of three sampled residents on 10/15/25 because they did not reorder the medication prior to it running out.This failure decreased the facility's potential to ensure Resident 1 received medication as ordered and decreased Resident 1's risk of developing a blood clot.Findings:A review of Resident 1's admission record indicated admission to the facility on 9/27/25 with diagnoses which included wedge compression fracture (occurs when the front part of one of the bones in the spine collapses and forms a wedge shape and causes back pain), chronic pulmonary embolism (a blockage in a lung artery), atrial fibrillation (an irregular and often rapid heart rhythm that can lead to blood clot formation and an increase in the risk of stroke and heart disease), and muscle weakness.A review of Resident 1's Order Summary Report, dated October 2025 indicated, Rivaroxaban [a medication that thins blood] Oral Tablet 15 mg [milligram, a unit of measure], give 1 tablet by mouth one time a day for thromboembolism [a condition in which a blood clot breaks off from its original site and travels through the bloodstream to obstruct a blood vessel, causing tissue and organ damage] for chronic atrial fibrillation.During a concurrent interview and record review with Licensed Nurse 1 (LN 1) and LN 2 on 1/23/26, at 1:55 p.m., both nurses reviewed Resident 1's Medication Administration Record (MAR) dated October 2025. Both LN 1 and LN 2 stated the number 8 was documented on Resident 1's MAR which meant the rivaroxaban was not available on 10/15/25 to be administered.During an interview on 1/26/26 at 4:03 p.m., LN 3 stated that on 10/15/25, she did not administer Resident 1's rivaroxaban because the supply ran out. LN 3 stated if the rivaroxaban was not available in the emergency medication supply kit (E-Kit), Resident 1 had to wait until the following day when the supply of the medication would be delivered by the pharmacy. LN 3 stated the medication bubble pack's (a specialized, organized packing system used in a long-term care facility) background turned blue to signal to the nurse that the medication supply was getting low.During an interview on 2/2/26 at 9:33 a.m., the Director of Nursing (DON) stated that if medication was not available the nurse should check the E-Kit, follow-up with the pharmacy, and notify the doctor through a secure message system or via phone call. The DON stated the medication bubble pack had a blue background at medication number 4 which indicated the supply was low and needed to be reordered by the nurse. The DON stated the nurses were responsible for reordering the medication when the supply became low.A review of the facility's pharmacy policy and procedure (P&P) titled, Medication Ordering and Receiving from Pharmacy, dated January 2022, indicated, .If not automatically refilled by the pharmacy.Reorder medication five days in advance of need to assure an adequate supply is on hand. The refill order is called in, faxed, or otherwise transmitted to the pharmacy. A review of the facility's P&P titled, Medication Administration (General), dated 8/18/22, indicated, To be able to safely administer in a timely manner, and as prescribed, in accordance to nursing scope and practices.

Based on observation, interview and record review the facility failed to ensure the dignity of three sampled residents (Resident 27, Resident 76 and Resident 52), when the residents reported missing clothing and personal items to the facility and the facility did not respond according to their Facility Policy and Procedure for Theft and Loss.This failure to follow their Policy and Procedure for theft and loss resulted in a loss of dignity and respect for the residents when they did not have access to clothing from home that felt familiar as well as personal item that were important to their day-to-day life in the facility. During an observation at the nurses' station, on 12/3/25 at 12:42 p.m., a binder titled THEFT /LOSS / GRIEVANCE, not dated, indicated there were no completed documents or forms for any residents.During an observation and interview with Resident 76 on 12/3/25 at 9:08 a.m., he stated he was missing a grey sweater and a red polo shirt. He stated when he was admitted to the facility staff did not label his clothing. He stated staff labeled his remaining clothing after he told Unlicensed Staff G his grey sweater and the red polo shirt were missing. He stated that no staff had followed up with him about the missing items.During an interview on 12/3/25 at 9:20 a.m., Resident 76 stated he had informed Unlicensed Staff G about his missing clothing this morning. He stated the facility did his laundry and when it came back his red shirt and grey sweater were missing and that was when staff wrote his name in whatever clothing he had left. He stated staff had not written his name on his clothing until then. Resident 27 stated the facility had lost his clothing and personal items and had offered to replace them. He stated they never followed up and then told him to go ahead and replace the items himself and give them receipt and they would repay him. He stated the facility had lost Everything. Resident 27 stated the facility had lost so much clothing it was ridiculous. He stated he had informed staff and felt the facility made it difficult to replace them. He stated the facility had not replaced anything and his relatives had stopped purchasing clothing and gifts for him because it got lost. Resident 76 and Resident 27 had stated they did not recall hearing from the facility about how to report the theft or loss of personal items.During an interview on 12/3/25 at 11:53 a.m., Resident 52 stated she had lost two black hoodies and two sweatpants (one green and one eggplant color). She stated she had informed Unlicensed Staff I they were missing from today's personal laundry delivery. Resident 52 stated she had multiple items got lost, had informed staff but nothing had been replaced.During an interview and record review on 12/3/25 at 12:15 p.m., Social Services stated the process if a resident reported a lost or stolen item was the staff were supposed to fill out a grievance form, she would review it with the resident and then resolve it as soon as possible. She stated for lost clothing she would look in the laundry lost and found. She stated if the item was not located anywhere she would attempt to replace or reimburse the resident She stated she would document the resolution of the resolution form and then place the documentation in the theft / loss binder. She reviewed the binder where documented theft / loss forms were stored and there was no documentation of reported loss of laundry or personal items for Resident 27, Resident 76 or Resident 52. She stated there was supposed to be a report for each report of a resident loss of laundry or personal items and there was no documentation. She stated the facility did not follow the P&P and it would make the resident's feel like their stuff was not safe.During an interview on12/03/2025 at 12:50 p.m., Laundry Staff stated she picked up Resident clothing that was contained in a labeled bag. She stated the resident clothing would remain in the bag during washing and drying and was removed to be folded and returned to the resident. She stated each resident was supposed to have all their clothing labeled by the unlicensed staff when a resident was admitted . She stated sometimes the laundry is not labeled but she washed it anyway.During an interview on 12/3/25 at 12:58 p.m., Unlicensed Staff J stated when a resident was admitted she was supposed to document all personal items on the inventory form and have the resident or the family sign it. She stated all items were supposed to be labeled and then put away. She stated if a resident reported a lost item of clothing, she would look in the laundry lost and found and then report it to the nurse who was supposed to document on a form and report it to someone.During an interview with Unlicensed Staff I on 12/3/25 at 1:02 p.m., she stated when a resident was admitted she would fill out the inventory sheet, sign it, have the resident sign and put the items away. She stated if the resident was having laundry done by the facility, we would label the clothing items. She stated if something was reported lost, she would check the closets and drawers of the resident and their roommate and then check in the laundry lost and found. She stated the facility P&P for lost items was to tell the nurse.During an interview on 12/3/25 at 2:54 p.m., the Director of Nursing stated she did not know that missing resident items were documented on and given to social services. She stated the Social Services person handled all lost items and grievances. She stated she was unaware of any lost items, lost item complaints from residents or any grievances.During an interview on 12/03/2025 at 3:00 p.m., Licensed Nurse K stated she did not know what the facility P&P for loss or theft was. She stated she would ask the Director of Nursing or Social Services if a resident stated they had lost personal items.During an interview with Unlicensed Staff G on 12/03/2025 at 3:08 p.m. he stated if a resident informed him of a lost item of clothing he would go look in the laundry department in the lost and found basked. He was unable to state the facility Policy and Procedure (P&P) for lost items and required prompting to state a lost form needed to be filled out and provided to the nurse. He stated he did not recall the last time he filled out a lost item form. He stated he did not remember Resident 6 telling him about lost grey sweater and lost red polo shirt. Unlicensed Staff G stated resident clothing was supposed to be labelled upon admission and to fill out a resident inventory list.During an observation, interview and record review on 12/4/25 at 1:50 p.m., Unlicensed Staff I reviewed Resident 52's clothing in the closet and drawers and compared it to the document titled INVENTORY OF PERSONAL EFFECTS, for Resident 52, date 8/22/25 and 9/2/25. Unlicensed Staff I stated she observed 12 pieces of clothing. She stated none of them matched Resident 52's description of her two missing sweatpants and two hoodies. She stated the items in the closet and the drawers did not match the inventory list.During a review of a facility Policy and Procedure titled Safeguarding Personal Property / Theft-and-Loss Policy, revised 10/25, it indicated Facility will exercise reasonable care to protect and promote the safety and security of personal belongings, while upholding residents' rights to personal choice and possession. 7. Personal property is required to be clearly marked with the resident's name and must be listed on Resident's inventory form. The name can be sewn on the garment or written with a permanent ink marker. Personal property such as TVs, radios, dentures, glasses, prosthetics etc. must be clearly marked (preferably inscribed or engraved) and identifiable. Staff shall assist Residents to properly label items as indicated. When personal property is reported missing, staff should immediately begin a search for the missing property. If the property is not readily found, a Theft and Loss report shall be completed and routed to Social Services Department for processing and resolution. Individual Theft and Loss reports shall include but not be limited to the following information: A description of the missing item(s); an estimated value of the item; date and time the theft or loss was discovered; the date and time theft or loss occurred (if determined); and action(s) taken. (theft/robbery) shall be immediately reported to facility Administrator and others in accordance with state and federal laws. Social Services will coordinate additional search, investigate circumstances, and work with Resident, family, &/or facility Administrator to determine how the loss will be resolved in accordance with policy.A review of Resident 76's medical record document titled admission RECORD, indicated Resident 76 was admitted to the facility 11/25/25 with diagnoses that included CELLULITIS of Left Lower Limb,(A severe infection of the skin and tissue), SEPSIS, (A severe infection), and MULSTPLE SCLEROSIS (A progressive disease of the nerves and spinal cord). A document titled Brief Interview for Mental Status (BIMS) indicated a score of 12, indicating mild cognitive impairment. A review of a medical record document for Resident 76 titled INVENTORY OF PERSONAL EFFECTS, dated 11/25/25 indicated one sweater and one shirt.A review of a medical record document for Resident 27 titled admission RECORD, indicated was admitted [DATE], with diagnoses that included INTERVETEGRAL DISC DISORDERS WITH MYELOPATHY, THORACIC REGION, (A condition where the spine degenerated causing severe chronic pain in the back, neck and arms), PARAPLEGIA (Inability to move lower extremities.), among others. An electronic medical record titled Brief Interview for Mental Status indicated a score of 15, indicating intact cognition. A review of a medical record document for Resident 27 titled INVENTORY OF PERSONAL EFFECTS, dated 10/30/25 indicated upon entry 40 personal items. An area of the document titled ACQUIRED AFTER ENTRY, dated 10/30/25 indicated 35 personal items. A review of a medical record document titled admission RECORD, for resident 52, indicated she admitted [DATE] with diagnoses that included NONDISPLACED COMMINUTED FRACTURE OF LEFT PATELLA SUBSEQUENT ENCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALTING, (A fracture of the kneecap that had not moved out of place.), ATAXIA, (A dysfunction of the brain that can result in involuntary muscle movement, resulting in unstable walking, standing, eye rolling.), CHRONIC PAIN.An electronic medical record titled Brief Interview for Mental Status indicated a score of 12.

Based on observation, interviews and record reviews, the facility failed to follow the physician's orders for three out of three sampled residents (Residents 11, 63 and 68) when: 1. Residents 11 and 63 did not received their insulin before meals as ordered. 2. Resident 68 received pain medication that was ordered to relieve mild pain only when Resident 68 was complaining of severe pain.This failure could result in:1. Inappropriate Diabetes management, which could result in blood sugar spike (hyperglycemia) followed by a potential delayed low blood sugar (hypoglycemia) several hours later. 2. increased pain and suffering. Findings:1.A review of Resident 11s face sheet (resident demographics) indicated an admission date of 11/2025 with a diagnosis of Diabetes Mellitus (DM, disorder characterized by difficulty in blood sugar control and poor wound healing) and Stage 3 chronic kidney disease (kidneys have mild to moderate damage and are less able to filter waste and fluid out of your blood).A review of Resident 11s EMAR (Electronic Medication Administration Record) for 12/2025 indicated an order for Insulin Aspart injection 100 unit/ml (milliliter) inject 8 unit subcutaneously (under the skin) before meals at 7:00 AM, 12:00 PM and 5:00. The EMAR documentation indicated Resident 11 received 8 units of insulin on 12/2/25 at 5:00 PM.A review of Resident 63s face sheet indicated an admission date of 9/2025 with a diagnosis of DM and Stage 3B chronic kidney disease (more severe half of Stage 3, where kidneys struggle to filter waste, leading to potential buildup and complications). A review of Resident 63s EMAR for 12/2025 indicated an order for Humalog solution 100 unit/ml (insulin lispro human) inject as per sliding scale: 0-69 0 follow hypoglycemic protocol, 70-150 0, 151-200 2, 201-250 4 unit, 251-300 6, 301-350 8, 351-400 10, 401+ call prescriber subcutaneously before meals. The EMAR documentation indicated that on 12/2/25 at 5:00 PM, with a blood sugar of 190, Resident 63 received 2 units of Humalog insulin.During a concurrent observation and interview on 12/02/2025 at 5:58, LN M verified Resident 63s order for Humalog solution 100 unit/ml (insulin lispro human) inject as per sliding scale was to be administered before meals. LN M was present when Resident 63 stated he was done with dinner and was now eating dessert. LN M proceeded to check Resident 63s blood sugar level and administered the insulin while Resident 63 was eating his dessert. During a concurrent observation and interview on 12/02/2025 at 6:22 PM, Licensed Nurse (LN) M verified the physician order for Insulin Aspart injection 100 unit/ml, inject 8 unit subcutaneously before meals at 7:00 AM, 12:00 PM and 5:00 PM. With LN M present, Resident 11 verified he had eaten his dinner. LN M checked Resident 11s blood sugar level and proceeded to draw the insulin. When asked why the order for aspart injection before meals on the EMAR was highlighted red, LN M stated she was already late checking Resident 11s blood sugar and administering the insulin. LN M verified blood sugar level was supposed to be checked prior meals and insulin was to be given prior to meals per physician's order.During an interview on 12/03/2025 at 3:39 PM, LN P stated the physician's order should always be followed. LN P stated blood sugar level should be checked before meals to ensure accurate reading and insulin should be administered per physician's order. LN P stated if insulin was administered after a meal and the order was to administer the insulin before meals then it was a medication error. LN P stated not following the physician order on when to check the blood sugar and when to administer the insulin was a safety risk to the resident.During an interview on 12/03/2025 at 3:45 PM, LN M stated she did not follow the physician's order when LN M checked Residents 11 and 63s blood sugar level after meals and had given their insulin after meals as well. LN M stated these were both medication errors. LN M stated the orders for Residents 11 and 63s were to check their blood sugar level and give insulin before meals. LN M stated checking the blood sugar level after meals yields inaccurate high blood sugar level result which could lead to over medicating the resident with insulin which was a safety risk for the resident.During an interview on 12/03/2025 at 3:53 PM, the Infection Preventionist (IP) stated physician's order should always be followed. The IP stated that giving the insulin after meals when the physician ordered the insulin to be given before meals was a medication error. The IP stated it was also an error to check a resident's blood sugar level after meals as this would result in inaccurately high blood sugar result. The IP stated not following the physician's order to check the blood sugar level before meals and instead checking it after a resident had their meals could result to high blood sugar level reading which could lead to giving the resident an increased amount of insulin. The IP stated this inaccuracy was a medication error and a safety issue that could lead to hypoglycemic episodes.2. A review of Resident 68 face sheet (resident demographics) indicated an admission date of 5/2025 with a diagnosis of polyneuropathy (condition where multiple nerves in the body are damaged, leading to symptoms like pain, numbness, tingling, and weakness) and chronic pain (ongoing pain lasting longer than 3-6 months).A review of Resident 68 BIMS dated 11/4/25 resulted in a score of 15 out of 15 indicating intact cognition.A review of Resident 68s EMAR for 12/2025 indicated an order for Tylenol (acetaminophen) 325 mg 2 tablets by mouth every 6 hours for mild pain (pain level 1 to 3) (Reference range: mild pain at 1 to 3 level, moderate pain at 4 to 6 level, and severe pain at 7 to 10 level) The EMAR indicated Resident 68 received this medication on 12/3/25 at 6:00 PM for a pain level of 6 out of 10 (moderate pain).During a concurrent interview and EMAR record review on 12/03/2025 at 6:20 PM, with LN N present, Resident 68 stated acetaminophen did not help with his pain, and he preferred narcotic pill. LN N verified acetaminophen was ordered for mild pain only and Resident 68 was currently in severe pain. LN N administered acetaminophen to address Resident 68s severe pain. When asked if LN N was following the physicians order when he administered Resident 68 the acetaminophen which was ordered for mild pain when Resident 68 was complaining of severe pain, LN N was silent. LN N stated the physician's order must always be followed.During an interview on 12/04/2025 at 10:18 AM, the Minimum Data Set coordinator (MDSC 1) stated administering acetaminophen to address moderate or severe pain was inappropriate when an order was to administer acetaminophen for mild pain only. She stated this was considered a medication error. MDSC1 stated the physician's order should always be followed.During an interview on 2/04/2025 at 12:13 PM, the Director of Nursing (DON) stated the facility defined mild pain at 1 to 3 level, moderate pain at 4 to 6 level and severe pain at 7 to 10 level. The DON stated it was not appropriate for staff to give acetaminophen for a complaint of moderate or severe pain when the physician order was to give acetaminophen for mild pain only. The DON stated the physician's order must be followed for resident's safety.A review of the facility's P&P titled Administering Medications, revised 4/2019, the P&P indicated.medications are administered in accordance with the prescribers order.

Based on observations, interviews and record reviews, the facility:A. did not implement Enhanced Barrier Protection (EBP, an infection control intervention, primarily used in nursing homes, that involve the use of gowns and gloves during high-contact resident care activities to reduce the transmission of Multidrug-Resistant Organisms (MDROs, microorganisms, primarily bacteria, that are resistant to one or more classes of antimicrobial agents) ) for one out of three sampled residents (Resident 53) when Resident 53s surgical thoracic wound was treated using Negative Pressure Wound Therapy (NPWT/wound vac, a treatment that uses a sealed dressing, connected to a vacuum pump to apply continuous or intermittent suction to a wound).B. did not follow the manufacturers recommendation on the appropriate contact time when sanitizing the glucometer (small, portable medical device used to measure the amount of sugar (glucose) in a drop of blood) before using it to check three out of three sampled residents blood sugar.C. failed to ensure staff observed hand hygiene (hand washing) prior to performing task and prior to donning new gloves when providing care for one out of four sampled residents (Resident 30).D. failed to ensure adequate monitoring for Legionella bacteria (naturally found in water but become a health risk in man-made systems like hot tubs, cooling towers, and water heaters when inhaled as mist or vapor from contaminated water) in the facility's water system.These failures could result in cross contamination and higher infection risk, germs to spread rapidly and residents getting sick with infection and put the residents at risk for serious diseases like Legionnaire's disease. Findings: A.A review of Resident 53's face sheet indicated an admission date of 11/2025 with a diagnosis of infection and inflammatory infection due to internal device of spine. A review of Resident 53's physician order summary (POS,a healthcare professional's written instruction specifying the care, services, treatment and medications a patient should receive) indicated that on 11/19/25, the physician ordered the wound vac to treat Resident 53's thoracic surgical wound. During a concurrent observation and interview on 12/01/2025 at 11:20 AM, Resident 53 stated she had a surgical wound on her back and nurses did the treatment. It was noted there was no EBP signage noted by the door to alert staff to practice EBP following high contact resident care activities. Resident 53 stated staff did not wear gown when they did her wound treatment, while changing her briefs, during dressing or transferring. During an interview on 12/02/2025 at 3:11 PM, Licensed Nurse (LN) P verified Resident 53 had a surgical wound on her back currently being treated using a wound vac. LN P verified Resident 53 was not placed on EBP. LN P stated he did not wear gown when he was treating Resident 53's surgical back wound. LN P stated residents on wound vac should be placed on EBP for residents and staff safety. LN P stated EBP should be in place for residents on wound vac to prevent wound infection and to prevent cross contamination. During an interview on 12/02/2025 at 3:19 PM, the Infection Preventionist (IP) verified Resident 53 had a wound vac but was not placed on EBP which she should have been. The IP stated it was an oversight on her part. The IP stated it was important for residents with open wound requiring dressing and residents with wound vac to be placed on EBP to ensure residents safety and to prevent risk of spreading infections. During an interview on 12/02/2025 at 3:30 PM, the Director of Nursing (DON) verified residents with wound vac should be placed on EBP per facility policy. The DON verified Resident 53 should be on EBP and stated since Resident 53 was not initially placed on EBP, then the facility policy was not followed. The DON stated it was important for a resident to be placed on EBP if treated with wound vac to prevent cross contamination and prevent the spread of infection. A review of the CDC poster titled Enhanced Barrier Precaution which the facility currently used, it indicated.enhanced barrier precaution providers and staff must also wear gloves and gowns for the following high contact resident care activities: device care or use.wound care: any skin opening requiring a dressing. A review of the facility's policy and procedure (P&P) titled Enhanced Barrier Precaution, dated 8/2022, the P&P indicated.EBPs were indicated for residents with wounds and or indwelling medical devices regardless of their MDRO colonization. B.A review of Resident 4 face sheet indicated an admission date of 10/2025 with a diagnosis of Diabetes Mellitus (DM, disorder characterized by difficulty in blood sugar control and poor wound healing) and Stage 5 chronic kidney disease (severe kidney damage) A review of Resident 11's face sheet indicated an admission date of 11/2025 with a diagnosis of DM and Stage 3 chronic kidney disease (kidneys have mild to moderate damage and are less able to filter waste and fluid out of your blood). A review of Resident 63s face sheet indicated an admission date of 9/2025 with a diagnosis of DM and Stage 3B chronic kidney disease (more severe half of Stage 3, where kidneys struggle to filter waste, leading to potential buildup and complications). During an observation on 12/02/2025 at 5:35 PM, Licensed Nurse (LN) M used the super sani cloth purple top germicidal wipe to sanitize the glucometer. LN M did not observe the recommended 2 minutes contact time to sanitize the glucometer. LN M used the glucometer to check Resident 4's blood sugar level 70 seconds after sanitizing the glucometer. During an observation on 12/02/2025 at 5:58 PM, LN M super sani cloth purple top germicidal wipe to sanitize the glucometer. LN M inserted the glucose test strip while the glucometer was still wet. LN M did not follow the 2 minutes recommended contact time to sanitize the glucometer prior to checking Resident 11's blood sugar level. During a concurrent observation and interview on 12/02/2025 at 6:12 PM, LN M used the super sani cloth purple top germicidal wipe to sanitize the glucometer. LN M verified the glucometer was still wet when LN M inserted the glucose test strip and LN M verified not waiting for the 2 minutes contact time to sanitize the glucometer prior to checking Resident 11's blood sugar level. During an interview on 12/03/2025 at 3:39 PM, LN P verified the facility used the super sani cloth purple top germicidal wipe to sanitize the glucometer. LN P thought glucometer should have a 5 minutes contact time with the sanitizing wipe solution prior to using the glucometer to check a residents' blood sugar level. LN P stated if the contact time to sanitize the glucometer using the super cloth purple top germicidal wipe was under 2 minutes, then it would not be effective in getting rid of the bacteria or germs in the glucometer and could result in cross contamination. LN P stated residents could end up getting sick or infected. During an interview on 12/03/2025 at 3:45 PM, LN M verified the facility used the super sani cloth purple top germicidal wipe to sanitize the glucometer and would only wait between 1 to 3 seconds before using the glucometer. When shown the super sani cloth purple top germicidal wipe, LN M verified the contact time to kill bacteria and viruses was 2 minutes. LN M confirmed she was not following the recommended contact time whenever she was disinfecting the glucometer. LN M stated it was important to follow the recommended contact time when sanitizing the glucometer to ensure bacteria and viruses were killed. LN M stated not following the recommended contact time when sanitizing the glucometer could result in spread of infection. During an interview on 12/03/2025 at 3:53 PM, the Infection Preventionist (IP) verified the facility used the super sani cloth purple top germicidal wipe to sanitize the glucometer. The IP verified the glucometer needs to have a 2-minute contact time with the wipe's solution prior to use. The IP stated not ensuring there was 2 minutes contact time could result to infection and could result to not killing all the bacteria present in the glucometer. A review of the super sani cloth germicidal disposable wipe description indicated.the disinfecting wipe was.effective against 34 microorganisms in 2 minutes.fast contact time allows for a quick room turnover. ideal for daily use in fast-paced environments that require short contact times and broad coverage of microorganisms. C. During an observation on 12/3/25 at 9:25 AM, Certified Nursing Assistant (CNA) B was observed providing care for Resident 30. CNA B loosened and opened Resident 30's brief (undergarment), wiped clean her perineal area, disposed of the brief into the waste bin, adjusted the plastic lining of the waste bin and proceeded to apply a clean brief on the resident. CNA B was not observed to change her gloves from the time she opened the resident's brief to the time she applied the clean brief. During an interview on 12/3/25 at 9:50 AM, CNA B stated said should have changed her gloves between changing soiled to clean brief. During an observation on 12/3/25 at 11:32 AM, Licensed Nurse (LN) D was observed providing wound care to Resident 30. LN D removed the dressing covering the wound on the lower back above the tailbone of Resident 30. LN D cleansed the wound with normal saline then removed his gloves and disposed of it. LN D then put on new gloves without performing hand hygiene, applied medication and covered the wound with foam dressing. During an interview on 12/3/25 at 11:43 AM, LN D sadly confirmed he had not performed hand hygiene prior to donning a new pair of gloves. During an interview on 12/4/25 at 9:59 AM with the Director of Nursing (DON), the DON stated staff should perform hand hygiene before tasks and before putting on new gloves. When performing wound care, staff should wash hands before and after the procedure. DON stated after removing wound dressing, staff should remove gloves, perform hand hygiene and put on new gloves. The DON confirmed they follow CDC standards of practice. A review of the Centers for Disease Control (CDC) webpage on Clinical safety: Hand hygiene for healthcare workers dated 2/27/24 (https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html) indicated, if tasks require gloves, perform hand hygiene before putting on gloves and touching the patient or the patient's surroundings, and always clean hands after removing gloves. Change gloves and clean hands when gloves become soiled with blood or body fluids after a task, and when moving from a soiled body site to a clean body site on the same patient. D. During an interview on 12/04/2025 at 1:00 PM, the Infection Preventionist (IP) stated they call to inform the local health department if they suspect the presence of Legionella. The Local health department does the testing for the presence of Legionella. During an interview with the facility Administrator on 12/4/25 at 2:27 PM, the Administrator stated they do not do tests for the presence of Legionella in the water system. The Administrator stated that when they suspect growth or presence of Legionella, they notify the local health department, and they test. During an interview with the Maintenance Director on 12/4/25 at 2:42 PM, he stated he had been monitoring water temperature but when his logs were reviewed, he confirmed he was monitoring water temperatures in residents' rooms and bathrooms to ensure safety of temperature for residents use. A review of the facility's policy titled Legionella water management program dated effective 6/12/24 indicated its purpose is to identify areas in the water system where Legionella bacteria can grow and spread and to reduce the risk of Legionnaire's disease. The elements of the program include specific measures used to control the introduction and or spread of Legionella, and control limits or parameters that are acceptable and that are monitored. Further review of the water flow diagram did not indicate markers in the water system where Legionella bacteria can grow and spread and where parameters may be monitored.

Based on interview and record review, the facility failed to develop an antibiotic use protocol in addition to a system to effectively monitor the use of antibiotics.This failure can result in inappropriate use of antibiotics that can lead to the development of antibiotic-resistant organisms, difficulty treating infections and severe health complications. Findings:During an interview on 12/04/2025 at 1:00 PM, the facility Infection Preventionist (IP) stated the facility use the McGeer criteria ( an evidence-based guideline for defining infections in long-term care facilities (LTCFs), focusing on specific group of symptoms and laboratory results for respiratory, gastrointestinal, and urinary infections) to guide treatment. On further interview the IP stated aside from the McGeer criteria they have no other protocol they use for antibiotic stewardship (a coordinated effort in healthcare to ensure antibiotics are used appropriately-only when needed, with the right drug, dose, and duration-to improve patient outcomes, combat the serious threat of antimicrobial resistance, and preserve the effectiveness of antibiotics). The Agency for Healthcare Research and Quality (AHRQ) home page on Nursing home antimicrobial stewardship guide, last reviewed on 9/2017, indicating a Minimum criteria for antibiotic tool a decision support tool for use of prescribers to determine whether it is necessary to treat a potential infection with antibiotics was shown to the IP. The IP stated she is not aware of the protocol and have not used this kind of tool. During an interview on 12/4/25 at 2:56 PM with the Medical Director, the Medical Director stated she is not aware of a protocol to use before antibiotic is considered for a suspected infection. The Medical Director stated she was not familiar with the decision support tool from the AHRQ homepage before it was described to her. A review of the facility's policy titled, Antibiotic stewardship program revised 6/2021, indicated the program was to promote appropriate use of antibiotics, limiting antibiotic resistance, treatment efficacy and resident safety.

Based on interviews and record review, the facility failed to ensure the resident's code status (defines what life-sustaining treatments (like CPR (cardiopulmonary resuscitation), intubation, shocks) a medical team should provide if a patient's heart stops or they stop breathing, guiding emergency care to match the patient's wishes) was accurately clarified, consistently documented, and incorporated into the resident's goals of care for one of six residents sampled for Advance Directives (Resident #5). This failure resulted in conflicting information regarding Resident #5's code status and had the potential to result in the resuscitation of a resident who wished to have a natural death.Review of Resident #5's physician's order dated [DATE] indicated the resident was designated Full Code (patient wants all possible life-sustaining treatments used if their heart stops or they stop breathing).Review of Resident #5's advance health care directive signed on [DATE] indicated both Full Code and DNR (a medical order instructing healthcare providers not to perform CPR if a patient's heart or breathing stops) were initialed by Resident #5, creating a conflicting determination.Review of Resident #5's POLST (Physician Orders for Life-Sustaining Treatment, a medical form that allows patients to clearly indicate their decision to have a Full Code or a DNR status) dated [DATE] indicated the resident elected DNR status.During an interview and concurrent record review on [DATE] at 10:40 a.m., Admissions Nurse stated he was responsible for entering the code status for residents in the facility's electronic medical records (eMR) system. Admissions Nurse reviewed the code status for Resident #5 in the eMR and verified Resident #5's code status was entered as Full Code. Admissions Nurse opened Resident #5's advance directive in the eMR and verified Resident #5 had initialed both places indicating she wished for prolonging her life and she did not wish to prolong her life. Admissions Nurse stated he was not aware she had initialed in both places and verified it should be clear on the advance directive which status Resident #5 was choosing. Admissions Nurse pulled out Resident #5's chart and reviewed her POLST. Admissions Nurse verified the advance directive was completed [DATE] and the POLST was completed [DATE]. Admissions Nurse verified Resident #5 had chosen DNR on the POLST. Admissions Nurse stated the advance directive and the POLST did not match and he needed to discuss this with Resident #5. Admissions Nurse stated that as a result of the discrepancy, the staff could potentially do CPR on a resident who wished to be a DNR. Admissions Nurse stated he would go talk to Resident #5 and her family.During an interview and concurrent record review on [DATE] at 11:32 a.m., Social Services Director (SSD) stated she recalled discussing the advance directive with Resident #5. SSD stated she gave the form to Resident #5 and when it was completed, she uploaded it to the eMR. SSD stated she reviewed advance directives when she uploaded them, but usually only looked to see if the healthcare power of attorney sections were completed. SSD opened Resident #5's advance directive in the eMR and verified Resident #5 had initialed both places indicating that she wanted Full Code status and DNR status. Referring to Resident #5's initials in both places, SSD stated, I missed that. SSD stated that Resident #5 may have been confused, but we should catch that if that's the case. During an interview on [DATE] at 12:33 p.m., Director of Nursing (DON) stated Admissions Nurse asked residents if they had an advance directive. DON stated it was her expectation that Admissions Nurse clarify the advance directive if it was unclear. DON stated she expected the physician order in the eMR, the advance directive, and the POLST to all be consistent. DON stated that if the POLST was signed by the resident and the physician on [DATE] it should have been updated in the eMR at that time. DON stated the medical records director was responsible for ensuring the physician's order and the POLST matched, and she expected the medical records director to come tell her if they were not consistent. Review of facility policy Resident Rights, last revised 2/2021, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: be informed of, and participate in, his or her care planning and treatment.

Based on interview and records review, the facility failed to provide a copy of the notice of discharge to the Office of the State Long-Term Care Ombudsman for one (Resident 74) of three sampled discharged residents.This failure had the potential for inappropriate and unsafe discharge and deprived Resident 74 of access to an advocate who can provide information of her options and rights.Findings: A review of Resident 74's electronic medical record indicated she was admitted on [DATE] with a diagnosis of stroke, Parkinson's disease, dementia, diabetes, atrial fibrillation and malnutrition. Resident 74 was discharged on 9/22/25. A review of Resident 74's discharge records did not indicate a copy of the notice of discharge was provided to the Ombudsman's office. During a concurrent interview and review of records with the Social Services Director (SSD) on 12/4/25 at 3:52 PM, the SSD confirmed Resident 74 was discharged on 9/22/25. The SSD verified the Notice of discharge was opened on 9/22/25 but was not completed nor sent to the Ombudsman. The SSD stated this should have been completed and sent to the ombudsman. The SSD also stated it was important the Ombudsman was notified of the resident discharge to ensure the resident's safety, to ensure the discharge plan was appropriate and for reference in case the resident wants to appeal the decision to discharge.A review of the facility's policy titled: Interdisciplinary team (IDT) discharge (DC) planning revised 1/1/17, indicated the purpose of discharge planning was to ensure a plan is in place to meet the resident/patient's continuing healthcare needs following discharge form the facility.

Based on interview and records review, the facility failed to develop a plan of care to prevent the development of a pressure ulcer on one (Resident 24) of 19 sampled residents when Resident 24 developed pressure ulceration under the oxygen tubing over his left ear. This failure led to staff not having an individualized plan to follow to regularly monitor and ensure the oxygen tubing with ear protector is kept in place to prevent skin ulceration. Findings:During an initial observation and interview on 12/2/25 at 8:58 AM, Resident 24 was in bed, on oxygen therapy at a rate of 2 liters per minute supplied via nasal cannula (oxygen fed through transparent tiny tubing that splits into left and right tubes commonly applied at the back of the head and run over the ears and over the cheekbone to the nose). Resident 24's skin behind the ears under the oxygen tubing was very red. The cannula ear protector was over the left cheekbone instead of over the back of the ear. During an interview inside the room of Resident 24, Certified Nursing Assistant (CNA) E did not have a response when asked how the facility could prevent the development of pressure ulcer for a patient using a nasal cannula. During a follow-up visit on 12/3/25 at 9:55 AM, the skin under the oxygen tubing behind Resident 24's left ear was still very red, the canula ear protector was lying over the left cheekbone. During an interview on 12/3/25 at 10:05 AM, Licensed Nurse C was requested to check the skin under the nasal cannula tubing behind the ears of Resident 24. Licensed Nurse C confirmed Resident 24 has a broken skin behind the left ear. Licensed Nurse C stated the cannula ear protector was not effective. During a review of Resident 24's care plans focusing on: 1) the risk for skin breakdown related to impaired cognition, fragile skin, and impaired ability to move freely initiated on 11/15/25 and, 2) the need for special care related to oxygen use, initiated 11/26/25, both care plans did not include interventions to monitor skin integrity or ensure proper placement of the canula ear protector over the ears to prevent skin breakdown. During a concurrent interview and review of records on 12/4/25 at 10:10 AM with the Director of Nursing (DON), the DON stated staff should check skin integrity before and after application of oxygen. The DON stated, during medication pass, nurses should check for placement of the oxygen cannula and the ear protector. The DON reviewed Resident 24's care plans for risk of skin breakdown and special care for oxygen administration. The DON was unable to show interventions to monitor and prevent pressure ulceration related to use of nasal cannula tubing. A review of the facility's policy titled: Care plans, comprehensive person-centered. indicate the comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being.

Based on observation, interview and records review, the facility failed to monitor and ensure proper placement of oxygen tubing and ear protector to prevent the development of pressure ulcer on one (Resident 24) of 19 sampled residents.This failure led to Resident 24 developing a pressure ulcer behind his left ear from oxygen cannula tubing pressure.Findings:During an initial observation on 12/2/25 at 8:58 AM, Resident 24 was in bed, on oxygen therapy at a rate of 2 liters per minute supplied via nasal cannula (oxygen fed through transparent tubing that splits into left and right tubes passed at the back of the head and run over the ears, and over the cheekbone to the nose). The skin behind the resident's ears under the oxygen tubing was very red especially the left ear with the tubing pressed against the skin creating an indentation. The cannula ear protector was over the left cheekbone. During a follow-up visit on 12/3/25 at 9:55 AM, the skin under the oxygen tubing behind Resident 24's left ear was very red with some dried blood, the canula ear protector was lying over the left cheekbone. During an interview on 12/3/25 at 10:05 AM, Licensed Nurse C was requested to check the skin under the nasal cannula tubing behind the ears of Resident 24. Licensed Nurse C confirmed the skin behind the left ear of Resident 24 is broken. Licensed Nurse C stated the cannula ear protector was not effective. A review of Resident 24's face sheet indicated he was admitted to the facility on [DATE] with a diagnosis of life-threatening blood infection, progressive decline in mental abilities, and a disorder that makes it difficult to speak.A review of Resident 24's admission assessment dated [DATE], and Braden scale for predicting pressure sore risk dated 6/9/25, indicated he was at risk for developing pressure ulcer and had a bedsore on admission. A review of the following Nursing Progress Notes did not indicate the pressure injury on Resident 24's left ear was noted or documented: Order Administration Noted dated 12/2/25 at 3:58 PM and 12/2/25 at 10:40PM during oxygen saturation monitoring Skilled Services Documentation by Nursing dated 12/2/25 at 11:12 PM indicated there was no pressure or skin-related issues on skin assessment Order Administration dated 12/3/25 at 7:15 AM and 12/3/25 at 2:50 PM during oxygen saturation monitoring.On 12/3/25 at 3:10 PM, a Change in condition for skin wound or ulcer was documented. During an interview on 12/4/25 at 10:10 AM with the Director of Nursing (DON), the DON stated staff should check skin integrity before and after application of oxygen. During medication pass, nurses should check for placement of the oxygen cannula and cannula ear protector. The DON located on her computer Resident 24's care plans for risk of skin breakdown and special care for oxygen administration. The DON was unable to find intervention in the care plan to monitor and prevent pressure ulceration related to nasal cannula tubing. A review of the facility's policy titled: Prevention of pressure ulcers/injuries taken from the (C)2001 MED-PASS, Inc, revised 7/2017, indicated under Risk assessment - inspect the skin on a daily basis when performing or assisting with personal are or activities of daily living (ADL), identify any signs of developing pressure injuries and inspect pressure points.

Based on observation, interview, and record review, the facility failed to properly administer tube feeding to one of one resident sampled for tube feeding (Resident #8) when Resident #8 was found laying flat during tube feeding administration. This failure had the potential to result in aspiration (inhaling foreign substances like food, liquids, saliva, or stomach contents into the lungs, which can lead to pneumonia, a lung infection) of the tube feeding formula, difficulty breathing, aspiration pneumonia, and hospitalization. Review of Resident #8's face sheet (demographics) indicated an admission date of 5/28/24 and multiple medical diagnoses including but not limited to cerebral infarction (stroke caused by a blockage in the brain), dysphagia (difficulty swallowing), and gastrostomy (a surgically inserted tube that brings nutritional formula through the abdomen directly into the stomach).Review of Resident #8's physician orders indicated an order, dated 10/30/25, for tube feeding 20 hours per day from 2 p.m. to 10 a.m.Review of Resident #8's care plan, dated 7/23/24, indicated a focus area of Risk for Aspiration related to tube feeding with an intervention to keep head of bed 30 degrees during and for 60 minutes after tube feed. During a phone interview on 12/1/25 at 3:39 p.m., Resident #8's family member stated she had found Resident #8's head of bed and feet at different elevations while the tube feeding was running. She stated she had to inform staff of the importance of the head of the bed being up when she found Resident #8 with the head of her bed down and having trouble breathing. During an observation on 12/3/25 at 9:12 a.m., Resident #8 was in bed with with her tube feeding being administered by a tube feeding pump. The head of the bed was raised but Resident #8 had slid down in the bed and was laying flat. During an observation and concurrent interview on 12/3/25 at 9:20 a.m., Licensed Nurse A verified she was Resident #8's nurse. Licensed Nurse A observed Resident #8's position in her bed. Licensed Nurse A stated Resident #8 was a little low in the bed and that she was not positioned at 30 degrees. Licensed Nurse A verified Resident #8's tube feeding was currently running. Licensed Nurse A stated she would get someone to help to reposition Resident #8. When queried, Licensed Nurse A stated she monitored for Resident #8's position during her tube feeding by coming to check on her every hour. Licensed Nurse A stated the CNAs (certified nursing assistants) knew as well that Resident #8 needed to be at 30 degrees, there was a sign above the bed so everyone knew that her head of bed needed to be up at 30 degrees. During an interview on 12/4/25 at 12:33 p.m., Director of Nursing (DON) stated it was her expectation for residents during tube feeding to be positioned with their head of bed at 30 degrees elevated. DON stated the nurse was responsible for monitoring for the resident's position while the tube feeding was running. Review of facility policy and procedure Enteral Feedings - Safety Precautions, last revised 11/2018, indicated, Preventing aspiration: . 3. Elevate the head of the bed (HOB) at least 30 [degrees] during tube feeding and at least 1 hour after feeding.

Based on observations, interviews and record reviews, the facility failed to ensure two out of four sampled residents' (Residents 5 and 68) pain was adequately and timely addressed. These failures left Resident 5 distressed, tearful, feeling like she was dying and experiencing 12/10 (Twelve out of Ten), severe pain for 30 minutes before receiving her narcotic (strong but addictive pain medicine) pain medication and Resident 68 feeling frustrated and enduring pain while having to wait for over an hour to receive his routine narcotic medication.Findings:A review of Resident 5's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission date of 6/2025, with a diagnosis of pathological fracture of left femur (broken bone in the thigh caused by disease) and malignant neoplasm (cancerous tumor) of the bone.A review of Resident 5s Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident), dated 8/28/25, resulted in a score of 12 out of 15, indicating moderately impaired cognition (MCI, some memory issues, confusion, or difficulty with daily tasks, requiring potential assistance). A review of Resident 5s EMAR (Electronic Medical Administration Record) for 12/2025, indicated an order for Oxycodone Hydrochloride (narcotic) 5 milligram (mg, unit of measurement) two tablets every six hours for pain management; hold for sedation or respiratory rate of less than 12. It indicated Resident 5 received this medication on 12/2/25, routinely ordered to be administered at 6:00 PM. A review of Resident 68s face sheet indicated an admission date of 5/2025, with a diagnosis of polyneuropathy (condition where multiple nerves in the body are damaged, leading to symptoms like pain, numbness, tingling, and weakness) and chronic pain (ongoing pain lasting longer than 3-6 months). A review of Resident 68 BIMS, dated 11/4/25, resulted in a score of 15 out of 15, indicating intact cognition. A review of Resident 68's EMAR for 12/2025, indicated an order for Tylenol (acetaminophen) 325 mg two tablets by mouth every six hours for mild pain (pain level (PL) 1 to 3), routinely scheduled to be administered at 6:00 PM. Resident 68's 12/2025, EMAR indicated he received this medication on 12/3/25, scheduled at 6:00 PM, for a PL of 6 out of 10 (moderate pain). A review of the facility medication administration schedule indicated every six hours meant a medication should be administered routinely at 6:00 AM, 12:00 PM, 6:00 PM and 12:00 AM. During a concurrent observation and interview on 12/02/2025 at 4:48 PM, Licensed Nurse (LN M) verified Resident 5 was complaining of (c/o) severe pain on her left hip all the way to the groin with a pain level (PL) of 12/10. LN M stated Resident 5 could not receive the oxycodone during this time as it was not due yet. Resident 5 was on the verge of crying and could be seen grimacing, and Resident 5 stated it was due to the extreme pain she was experiencing at the moment. LN M verified Resident 5 had an order for Oxycodone Hydrochloride (narcotic) 5mg two tablets every six hours for pain management; hold for sedation or respiratory rate of less than 12. LN M stated this narcotic was scheduled to be given at 6:00 PM, and the earliest LN M could give it to Resident 5 was 5:00 PM. LN M stated, although Resident 5 was in severe pain, LN M still needed to follow the physician's order. LN M was observed to be pacing back and forth multiple times from the medication cart into Resident 5s room while interviewing Resident 5 repeatedly about her pain. Meanwhile, Resident 5 was noted with furrowed brows and appeared to be guarding her left thigh. LN M verified Oxycodone was finally administered at 5:22 PM. When asked if there was anything LN M could have done so that Resident 5 could receive the Oxycodone the moment Resident 5 was c/o severe pain and thus alleviate her hip and groin severe pain faster, the LN M did not respond. During a concurrent interview and EMAR record review, dated 12/3/2025, on 12/04/2025 at 10:39 AM, the Minimum Data Set Coordinator (MDSC) 1 stated the facility defined mild pain at 1 to 3 level, moderate pain at 4 to 6 level, and severe pain at 7 to 10 level. MDSC 1 verified, based on Resident 5s 12/3/2025, EMAR, she did c/o severe pain on the PM shift. MDSC 1 stated residents should not be left in severe pain for a long period of time. When asked what staff should do when a resident was c/o of 12/10 PL and a narcotic was not due yet, MDSC 1 stated the nurse should have called the physician to notify of the need to address Resident 5s c/o severe pain and request a narcotic to relieve the pain if the narcotic was not due yet. MDSC 1 stated 12/10, was really severe pain and should be addressed immediately. MDSC 1 stated Resident 5 should not endure 12/10 PL and stated it was not appropriate for Resident 5 to be left in severe pain for over 30 minutes while waiting for a narcotic to be administered. MDSC 1 stated, leaving Resident 5 in severe pain, could result in anger and frustration. During an interview on 12/04/2025 at 10:56 AM, Resident 5 stated she was really distressed when she experienced a PL 12/10 about two days ago, and the nurse could not give her the narcotic pill at that time. Resident 5 stated she felt it was unnecessary to wait for half an hour before being able to take her narcotic pill. Resident 5 stated it was frustrating and distressing on her part to be in such severe pain and thought she would die from pain at that time. Resident 5 stated she understood the nurses were busy but Resident 5 wished she was not left to be in severe pain for half an hour. Resident 5 stated she hoped this incident would never occur again and wished the facility could do better on ensuring Resident 5s c/o of pain was managed timely. During an interview on 12/03/2025 at 6:11 PM, LN N, Resident 68's primary nurse at that time, stated Resident 68 was c/o 7 out of 10, pain on his right leg. LN N stated Resident 68 was in severe pain. LN N stated leaving Resident 68 in severe pain could affect his quality of life. During a concurrent observation and interview on 12/03/2025 6:20 PM, with LN N present, Resident 68 stated acetaminophen did not help with his severe pain and preferred the narcotic pill. LN N stated acetaminophen was scheduled routinely at 6:00 PM, and Resident 68 could not be administered the narcotic until 8:00 PM. LN N verified the order for the acetaminophen was to give it for mild pain. LN N stated, although Resident 68 was c/o severe pain, LN N would still administer the acetaminophen since this was a routine order from the physician. When asked if administering acetaminophen was appropriate and could adequately alleviate Resident 68 c/o severe pain since acetaminophen was ordered for mild pain only, and Resident 68 was c/o 7 out of 10 pain, LN N stated acetaminophen was not adequate enough to alleviate Resident 68s c/o severe pain, but was unsure of what to do and decided to just follow the physician order. LN N stated, if a resident was left in pain, they could feel upset, angry and frustrated. During an interview on 12/04/2025 at 10:03 AM, Resident 68 stated he always experienced right leg pain. Resident 68 stated last night he experienced 7 out of 10 pain level in his right leg and was given acetaminophen which did not help at all with his pain. Resident 68 stated he talked to the staff about it, but they were insistent to give acetaminophen despite his c/o severe pain and acetaminophen being ineffective, but the staff still administer this medication because, it was the doctor's order. Resident 68 stated, although he was experiencing severe pain, he had to wait until it was time for him to receive the narcotic pill. Resident 68 stated it was a waste of his time, and also frustrating to be receiving acetaminophen as he knew, and the nurses knew it would not help with his pain. Resident 68 stated he wished the facility could better control his pain because at this time, the facility was poor in taking care of his pain. During a concurrent interview and EMAR record review, dated 12/3/2025, on 12/04/2025 at 10:18 AM, MDSC 1 verified staff had administered acetaminophen for Resident 68s c/o severe pain on 12/3/25 PM, shift and verified acetaminophen was ordered for mild pain only. MDSC 1 stated it was not appropriate to administer acetaminophen for moderate or severe pain. MDSC 1 stated, although it was not time for Resident 68 to receive the narcotic pill yet, the nurse should have called the physician at that time to request it be given at the time when Resident 68 needed it to immediately address Resident 68s severe pain. MDSC 1 stated, if left in severe pain, a ripple effect could occur and could negatively affect residents. During an interview on 12/04/2025 at 12:13 PM, the Director of Nursing (DON) stated the facility defined mild pain at 1 to 3 level, moderate pain at 4 to 6 level and severe pain at 7 to 10 level. The DON stated it was not appropriate for staff to give acetaminophen for c/o moderate or severe pain when the physician order was to give acetaminophen for mild pain only. During an interview on 12/04/2025 at 12:13 PM, the DON stated staff should have called the doctor to request a stronger pain medication to address a resident's pain if a resident was not due for a narcotic yet. The DON stated it was not acceptable to leave residents in severe pain for a long time. The DON stated it was also important to address residents' pain as soon as possible and not to keep residents in a state of severe pain. The DON stated leaving a resident in pain could lead to that resident experiencing increased pain and agitation. A review of the facility's policy and procedure (P&P) titled, Administering Pain Medications, revised 10/2010, the P&P indicated, .pain management program is based on a facility wide commitment to resident comfort.Pain Management is defined as the process of alleviating the residents pain to a level that is acceptable to the resident. A review of the facility's P&P titled, Administering Medications, revised 4/2019, the P&P indicated, .medications are administered in accordance with the prescribers order. A review of the Numeric Pain Rating Scale (NPRS, a widely used, unidimensional measure of pain intensity that provides a simple, quick, and reliable assessment of pain), it indicated 1-3 as mild pain, 4 to 6 as moderate pain and 7 to 10 as severe pain.

Based on observations, interviews and record reviews, the facility failed to ensure:only medications that were prescribed by the physician were administered for two out of four sampled residents (Residents 2 and 45). 2. two out of four sampled residents (Residents 2 and 45) were allowed to keep medications at bedside without safe administration assessment and physician order.These failures had the potential to put residents at high risk for masking of serious medical condition and adverse drug reactions.Findings:A review of Resident 2s face sheet (resident demographics) indicated an admission date of 7/2025 with a diagnosis of Hypertension (high blood pressure) and hyperlipidemia (high cholesterol)A review of Resident 45s face sheet indicated an admission date of 11/2025 with a diagnosis of muscle weakness and cellulitis (a skin infection that causes swelling and redness) of right and left lower limb.During a concurrent observation and interview on 12/01/2025 at 10:44 AM, Resident 45 was noted with refresh eye drops at bedside. Resident 45 stated she had the eye drops there since last month and had been administering them herself. Resident 45 stated staff had seen the eye drop at her bedside but had not said anything about it.During a concurrent interview and physician order summary (healthcare professional's written instruction specifying the care, services, treatment and medications a patient should receive) (POS) record review dated 2/01/2025 at 10:48 AM, Licensed Nurse (LN) O stated Resident 45 had no order for refresh eye drops as far as she could recall. After checking the POS, LN O verified Resident 45 had no physician's order for refresh eye drops, no physician order that Resident 45 may keep the refresh eye drops at bedside or that Resident 45 could self-administer the refresh eye drops. LN O stated in order for Resident 45 to self-administer refresh eye drops and keep them at bedside, it had to be ordered by the physician. LN O stated she suspected the family member snuck in the refresh eye drops and did not tell the staff. During a concurrent observation and interview on 12/01/2025 at 12:30 PM, Resident 2 was noted with hydrogen peroxide on top of her bedside drawer. Resident 2 stated she had it there since admission and was bought from home. Resident 2 stated staff knew about the hydrogen peroxide and she uses it herself for her tooth issue and some wounds. Resident 2 stated the hydrogen peroxide had no physician order and staff did not check whether she was safe to self-administer the hydrogen peroxide.During a concurrent observation, interview and POS record review on 12/02/2025 at 2:56 PM, LN O verified Resident 2 had hydrogen peroxide on top of bedside drawer. LN O verified the physician did not order the hydrogen peroxide. LN O stated hydrogen peroxide was a medication and thus need a valid physician order prior to administration. LN O stated at the moment, Resident 2 should not be allowed to use, keep at bedside nor self-administer the hydrogen peroxide since Resident 2 did not have a self-administration assessment and the hydrogen peroxide had no physician order yet.During an interview on 12/02/2025 at 3:07 PM, LN O stated keeping medications at bedside, self-administering medication without proper assessment and administering medication without a physician order was a safety risk to the residents.During an interview on 12/02/2025 at 3:30 PM, the Director of Nursing (DON) verified hydrogen peroxide and refresh eye drops needed to have a physician's order prior to administration. The DON stated residents who wished to self-administer medications or needed to keep medications at bedside needed to have a completed self-administration assessment first per facility policy. The DON stated if these were not done, then the facility policy was not followed. The DON stated it was important to have physicians order for these medications although these were considered over the counter medications. The DON stated residents needed to complete a self-administration assessment to determine whether they were safe to self-administer medications or keep medications at bedside. The DON stated it was a safety issue to allow resident to self-administer a medication, allow a resident to keep medication at bedside and administer medication without a physician order and proper assessment. The DON stated the potential harm to the residents includes over or under medication and accidental ingestion by other residents resulting in adverse drug reaction.A review of the facility's policy and procedure (P&P) titled Self Administering Medication:, revised 12/2016, the P&P indicated.as part of their overall evaluation, staff and practitioner will assess each residents mental and physical abilities to determine whether self-administration is clinically appropriate for the resident.self-administered medication must be stored in a safe and secure place which is not accessible by other residents.A review of the facility's P&P titled Administering Medications, revised 4/2019, the P&P indicated.medications are administered in accordance with the prescriber's order.

Based on observation, interview and record review, the facility failed to ensure two of three medication carts (Medication cart for Station 2 and medication cart for Station 3), in addition to the medication room, were free of expired and outdated medications and medical supplies for residents. This failure had the potential to result in inadvertently using these products on residents, which could have caused them harm and infections. Findings: During a medication storage observation and interview on 11/18/24 at 10:55 a.m., with Licensed Nurse (LN) F, the medication Latanoprost 0.005% (A medication to treat increased pressure in the eye) was observed stored inside the medication cart for Station 2 with other active medications. This medication had an expiration date of 11/15/24 and belonged to Resident 47. LN F confirmed the finding and stated the Infection Preventionist (IP) and Director of Staff Development (DSD) were responsible for checking the medication carts every week to check for expired medications. LN F confirmed this expired medication should not be stored in the medication cart with other active medications. During a concurrent observation and interview with the Director of Nursing (DON) on 11/18/24 at 3:36 p.m., inside the medication room of the facility, more than 10 syringes were found with an expiration date of 11/10/2024 in a storage container, stored with unexpired medical supplies. In addition, more than 10 syringe caps with an expiration date of 5/01/24 were found stored with unexpired supplies. An insulin syringe with an expiration date of 3/16/23 was found stored with unexpired medical supplies. Several COVID-19 tests with an expiration date of 12/19/23 were found stored in the medication room with unexpired medical supplies. The DON confirmed these findings and stated expired medical supplies may not be good to use after their expiration date. Photographs were taken as evidence. During a medication storage observation and interview on 11/19/24 at 11:05 a.m., with Licensed Nurse (LN) R, a bottle containing 30 collagen tablets was found inside a mailing package stored inside the medication cart of Station 3, with other active medications. LN R stated this medication belonged to a resident who had been discharged about a week prior, and the packet had arrived to the facility after the resident had been discharged . During an interview on 11/21/24 at 3:10 p.m., the DSD stated Licensed Nurses were assigned to check the medication carts assigned to them to ensure there were no expired or outdated medications. The DSD stated the medication room was assigned to be checked by the central supply department once a month to ensure there were no expired supplies in place for use. The DSD stated expired items could malfunction after their expiration date. Record review of the facility policy titled, MEDICATION STORAGE IN THE FACILITY, last revised in April of 2008 indicated, Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists.

Based on observation, interviews and record reviews, the facility failed to follow the recipe for pureed rice. This failure could lead to potential food safety issues, inconsistent quality of meals for residents, and nutritional deficiencies. Findings: A review of [NAME] Puree Recipe Book, recipe name Pureed Potatoes, Pasta, Rice and Other grains, the recipe indicated an ingredients of potatoes, pasta, rice cooked and drained, broth hot or hot 2 percent milk, margarine and thickener. A review of [NAME] Puree Recipe Book, recipe name Pureed Salad-Potato, Pasta and Other Grains the recipe indicated an ingredients of salads, potato and pasta type and thickener. During an observation on 11/20/24 at 11:40 a.m., [NAME] 1 did not follow the pureed recipe for rice when she did not add margarine and thickener when she prepared the pureed rice. During an interview on 11/20/24 at 10:12 a.m., the Registered Dietician (RD) stated it was expected cooks were following the recipes to ensure consistent quality food was served to the resident and to prevent potential health risks for the residents. During a concurrent observation and interview on 11/20/24 at 11:40 a.m., [NAME] E was observed looking at the recipe binder and stated she was looking for the recipe for pureed rice. [NAME] E verified she followed the Pureed Salads-Potato, Pasta and Other Grains recipe. [NAME] E verified using 10 scoops of rice and 1 and a half (1 1/2) cup of broth. [NAME] E verified she did not add anything else. [NAME] E stated it was the facility's policy to ensure they follow the recipes when cooking to make sure residents were receiving the right amount of nutrients with food they were preparing. [NAME] E stated not following the recipes could lead to food not having the same flavor, residents may not eat the food and weight loss. During an interview on 11/20/24 at 3:20 p.m., the Dietary Manager (DM) stated staff should be following the recipes. The DM stated the facility should not use pureed salad recipe when making pureed rice. The DM stated it was important staff follow the correct recipe to provide residents with consistent quality food and proper portion control and to ensure food served for the residents were meeting their dietary needs. A review of the facility policy and procedure (P&P) titled Food Preparation, RDs for Healthcare 2018, the P&P indicated the facility will use approved recipes, standardized to meet the residents census .recipes are specific as to portion yield, method of preparation, amounts of ingredients .

Based on observation, interviews and record reviews, the facility failed to ensure residents were served with food that was palatable, attractive and at an appetizing temperature. These failures could put the residents at risk for illness, injury, malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things), and poor nutritional status. Findings: A review of Resident 18's face sheet (demographics) indicated he was admitted on [DATE] with a diagnosis of Essential Hypertension (HTN, high blood pressure) and Muscle weakness. Resident 18's Brief Interview for Mental Status (BIMS, used to get a quick snapshot of how well you are functioning cognitively -mental process involved in comprehension and gaining knowledge) dated 11/12/24 score was 15 indicating intact cognition. A review of Resident 22's face sheet indicated she was admitted on [DATE] with a diagnoses of Essential Hypertension and Atelectasis (partial or complete collapse of the lung). Resident 22's BIMS dated 11/8/24 score was 15 indicating intact cognition. During an observation on 11/20/24 at 1:00 p.m. [NAME] E did not sample the food she prepared. During an observation on 11/20/24 at 1:27 p.m., the food served did not have a pleasant presentation and looked unappealing and unappetizing. The dietary manager (DM) took the temperature of the food items on the test tray: temperature was as follow: rice at 130 degrees, chicken with lemon and thyme at 130 degrees and the burger patty was at 118 degrees. Per facility policy, hot foods should be held prior to service (the process of storing prepared food at a safe temperature before it is served) at 140 degrees or above. Upon sampling the chicken with lemon and thyme, it was dry, had a bland taste and was not able to taste the lemon. The rice and chicken with lemon and thyme when sampled was lukewarm. During an interview on 11/22/24 at 9:30 a.m. Resident 18 stated there was not a taste of lemon on the chicken. Resident 18 stated he recalled the chicken being dry and not having a lot of taste. Resident 18 stated he wished the chicken was not dry and hoped the food would have more flavor. During an interview on 11/22/24 at 3:07 p.m., Resident 22 stated the chicken was dry as a straw and was very bland and did not have a taste at all. Resident 22 stated she did not taste lemon in the chicken at all. Resident 22 stated the food was already lukewarm when she received it. During an interview on 11/22/24 at 9:52 a.m., the DM stated the temperatures taken on the food on test tray on 11/20/22 were not at a level where it was appetizing. The DM verified the food served did not appear appetizing at all. The DM stated if the food did not have flavor, was not served in an appealing manner and at a temperature that residents will enjoy, residents would be at risk of weight loss and residents not receiving the appropriate nutrients they need to stay healthy or get better. A review of the facility policy and procedure (P&P) titled Food Preparation, RDs for Healthcare 2018, the P&P indicated the food shall be prepared by methods that conserve nutritive value, flavor and appearance .prepared food will be sampled. The food and nutrition services employee who prepares the food will sample it to be sure the food has a satisfactory flavor and consistency .hot foods should be held prior to service at 140 degrees or above .

Based on observations, interviews and record reviews, the facility failed to ensure: 1A. two food items in the freezer were clearly labeled to identify what it was, when it was opened and when to discard the food item. 1B. one pitcher of tea was discarded by the use by date of 11/16/24. 2. one dented can (might contain bacteria that can make you sick, or even produce a toxin that can be deadly) was not separated from intact cans. These failures could put the residents at risk for: 1A. allergic reactions, health complications and food poisoning (infection or irritation of your digestive tract that spreads through foods). 1B.consuming tea that might contain bacteria which can cause abdominal pain, vomiting, diarrhea (three or more loose stools per day), and fever. 2. consuming food that was contaminated with molds, bacteria or the toxin produced by the bacteria Clostridium botulinum (causes Botulism, a rare but serious condition caused by a toxin that attacks the body's nerves and may cause life-threatening symptoms such as paralysis-loss of the ability to move and difficulty breathing). Findings: 1A and 1B. During a concurrent observation and interview on 11/18/24 at 9:38 a.m., the dietary Manager (DM) verified refrigerator number (#) 1 had a pitcher of tea, with a label indicating it was made on 11/9/24 and a discard date by 11/16/24. The DM verified this tea should have been discarded on 11/16/24 to ensure only items safe for residents' consumption were stored in the refrigerator. The DM stated not discarding the tea on the discard date could result to staff accidentally serving this tea to the residents. The DM stated this was a quality and safety issue. During a concurrent observation and interview on 11/18/24 at 9:48 a.m., there was a blue plastic bag containing brownish colored nuggets inside the freezer #6 which was unlabeled and undated. The dietary Manager (DM) verified the blue plastic bag with brownish colored nuggets was undated and had no label to identify what the content was. The DM stated he knew it was vegan chicken nuggets. The DM stated all items in the kitchen should be labeled so it should be easily distinguished from other food items. The DM stated the reason for this was to ensure correct items were being served to the residents. The DM stated that not clearly labeling what the food item was could put the residents at risk for being served a food item that they were allergic to or being fed with food item that was not appropriate for their diet. The DM stated this could be a safety risk for the residents. The DM stated food items should also be open dated with discard date. The DM stated it was important to ensure there was a discard date on food items to ensure quality control and to ensure residents were not fed food that were spoiled. The DM stated not discard dating a food item could put the residents at risk for eating food that were spoiled which could make them sick with gastrointestinal illness (GI, pertains to stomach and intestines) and diarrhea (loose stools). During an interview on 11/20/24 at 10:12 a.m., the Registered Dietician (RD) stated all food items in the kitchen should be labeled so staff would know what it was. The RD stated not properly labeling the food could result to staff mistaking it for something that it was not. The RD stated this was a safety issue for the residents as well. The RD stated the facility would not want to serve residents food that was not in accordance with their diet preference. During a concurrent observation and interview on 11/20/24 at 10:18 a.m., the RD pulled a bag of white sticks out of the refrigerator. The RD and DM both verified the bag of white sticks in the refrigerator was not labeled on what it was. The RD stated that should have been labeled so staff could easily identify the food item. The DM verified it was hash brown. The RD stated she thought it was cheese. During an interview on 11/20/24 at 10:30 a.m., [NAME] 1 stated the food items should be labeled to identify what it was and should be open and discard dated to ensure staff were serving the right food for the residents and to ensure staff were only serving food items to the residents that was not past due to prevent them from getting sick. A review of the facility's policy and procedure (P&P) titled Storage of Food and Supplies RD's for Healthcare, Inc. 2017, it indicated it was the policy the food and supplies will be stored properly in a safe manner .labels should be visible, should be dated- month, date and year. A review of the facility's P&P titled General Receiving of Delivery of Food and Supplies RD's for Healthcare, Inc. 2018, it indicated to label all items with delivery date or use by date. 2. During a concurrent observation and interview on 11/18/24 at 10:04 a.m., the DM verified a large can of dented vanilla pudding was stored along with the intact cans where staff could access it and serve to the residents. The DM stated this can should have been removed from that shelf and should have been placed in a shelf dedicated for dented cans. The DM stated not removing the dented can in the shelf where staff could access it and serve to the residents put their safety at risk. The DM stated dented can might be chipped and might had allowed bacteria to enter the can. During an interview on 11/20/24 at 10:12 a.m., the RD stated dented cans should be separated from the intact cans and should not be placed with items that was going to be used for residents' consumption. The RD stated dented cans should be placed away from cans that would be used for residents' consumption. The RD stated using a dented can for resident consumption was unacceptable because bacteria could potentially get into a dented can. The RD stated this was a safety risk for the residents. During an interview on 11/20/24 at 10:30 a.m., [NAME] A stated dented cans should be separated from the ones to be used for residents' consumption. [NAME] A stated not separating the dented can from cans that were not dented could lead to staff accidentally using the dented can for residents' consumption. [NAME] A stated if that happened and a dented can was served to the resident, it could make the residents sick. A review of the facility's policy and procedure (P&P) titled Storage of Food and Supplies RD's for Healthcare, Inc. 2017, it indicated it was the policy the food and supplies will be stored properly in a safe manner . have a separate area for dented cans and damaged food items

Based on observation, interviews and record reviews, the facility failed to follow their policy on foods brought by family/ visitors when the food stored in resident's refrigerator by the nursing station did not have a use by date per their policy. This failure could lead to residents potentially consuming food that has gone past its safe consumption window, increasing the risk of foodborne illness due to bacteria growth, as well as potential issues with food quality and taste deterioration, which could impact resident nutrition and well-being. Findings: A review of Resident 225's face sheet (demographics) indicated an admitted [DATE] with a diagnoses of Essential Hypertension (HTN, high blood pressure) and Hyperlipidemia (HLP, abnormally high concentration of fats or lipids in the blood). During an observation on 11/19/24 at 3:48 p.m., Resident 225 had 6 food containers in the resident's refrigerator by the nursing station as follows, 2 containers of chilis, 1 container of meatloaf, 1 container of cage free egg salad, and 2 container of potato salads. All these containers did not have a use by date. During a concurrent observation and interview on 11/19/24 at 3:48 p.m., Licensed Nurse (LN) H and LN F verified Resident 225 food items did not have a use by date. During a concurrent observation, interview and Foods brought by Family/Visitors policy and procedure record review on 11/19/24 at 4:24 p.m., LN G verified Resident 225's food items had no use by date. LN G read the facility's policy and procedure (P&P) titled Foods brought by Family/Visitors. LN G verified the P&P indicated containers will be labeled with the resident's name, the item, and the use by date. LN G verified the P&P was not followed when Resident 225's food containers did not have a use by date. LN G stated not putting the use by date could result in serving a food item that was spoiled which could make the resident sick. During a concurrent interview and Foods brought by Family/Visitors P&P record review on 11/19/24 at 4:28 p.m., LN F stated the P&P was not followed when Resident 225's food items did not have a use by date. LN F stated it was important to make sure food items brought by family/visitor's had use by date to make sure residents were served food that was not spoiled and was still safe for residents to eat. During a concurrent interview and Foods brought by Family/Visitors P&P record review on 11/21/24 at 11:31 a.m., the Infection Preventionist verified the P&P indicated the containers should be labeled with the residents name, the item and the use by date. When shown a photograph of Resident 225's food items found in residents' refrigerator by the nursing station on 11/19/24, the Infection Preventionist (IP) stated Resident 225's food containers did not have a use by date. The IP verified the policy was not followed when there was no use by date indicated on Resident 225's food items. The IP stated it was important to make sure the use by date was indicated on the food stored in the resident's refrigerator by the nursing station to ensure residents would not be served food that was past use by date and to ensure food was still safe for consumption. The IP stated putting a use by date on food items lessen the risk of residents getting sick with food borne illness. During a concurrent interview and Foods brought by Family/Visitors P&P record review on 11/22/24 at 10:28 a.m., the Director of Nursing (DON) verified the policy was not followed when Resident 225's food items did not have a use by date. The DON stated it was important to put the use by date to prevent staff from serving food items that were spoiled for residents' safety. When shown a photograph of Resident 225's food items found in residents refrigerator on 11/19/24, the DON verified Resident 225's food containers did not have a use by date. A review of the facility's P&P titled Foods Brought by Family/Visitors, revised 2013, the P&P indicated the containers will be labeled with the resident's name, the item and the use by date.

Based on observations, interviews, and record reviews, the facility failed to: 1. Process soiled linens to prevent the spread on infection. 2 A. Offer hand hygiene (HH) to eight of nine residents (Resident 59, Resident 225, Resident 61, Resident 121, Resident 40, Resident 5, Resident 49, and Resident 120) before meals. 2 B. Perform HH prior to donning new gloves by one dietary staff , [NAME] E. 3. Use enhanced barrier precautions (A set of infection control measures that reduce the spread of multidrug-resistant organisms (MDROs) in nursing homes) when two nursing assistants working with Resident 33 who had a history of Methicillin-resistant Staphylococcus aureus (MRSA-A type of bacteria resistant to a certain type of antibiotics), did not follow the precautions. 4. Air dry kitchen utensils prior to storing in the kitchen drawers. These failures had the potential to result in the transmission of infections to the residents of the facility. Findings: 1. During a concurrent observation and interview on 11/21/24, at 10:07 a.m., with Laundry Staff D, it was observed that the facility's washing machine equipment was in use, but the temperature gauge was at 0 degrees Fahrenheit. Laundry Staff D stated that she observed earlier that day that the temperature gauge of the washing machine was at 160 degrees Fahrenheit. (Per CDC (Centers for Disease Control and Prevention) in nursing homes, the washing machine temperature should be at least 160 degrees Fahrenheit to kill bacteria and viruses). This surveyor took pictures and videos while doing the observation to indicate that the facility's washing machine equipment had a malfunction. During a concurrent observation and interview on 11/21/24, at 10:51 a.m., with the facility Administrator and Licensed Staff D, the Administrator stated there was another temperature gauge that was now missing. The Administrator stated that the temperature gauge, which was showing that it was at 0 degrees Fahrenheit, seemed newly installed, but he did not know who installed it. This surveyor did not feel any heat after touching the sides of the washing machine equipment. When the Administrator and Licensed Staff D were asked if the laundry kept a log of washing machine temperatures to determine previous temperature readings, both stated that the laundry did not keep temperature logs of their washing machine equipment. A review of a facility policy and procedure (P&P) titled, Departmental (Environmental Services)- Laundry and Linens, dated January 2014, indicated under, Purpose, the P&P indicated, The purpose of this procedure is to provide a process for the safe and aseptic (free from contamination caused by harmful bacteria, viruses, or other microorganisms) handling, washing, and storage of linen. Under Washing and other Soiled Linens, the P&P indicated, 1. Laundry may be processed in either low-temperature or high temperature cycles. For high-temperature processing, wash linen in water that is at least 160 degrees Fahrenheit, for a minimum of twenty (25) minutes. For low-temperature processing, wash linen in water that is at least 71-77 degrees Fahrenheit and use a 125 part-per-million (ppm) chlorine bleach rinse if the material being washed can withstand leach and remain intact. A review of a CDC infection control laundry and bedding guidelines from the Guidelines for Environmental Infection Control in Healthcare Facilities (2003), indicated, .A temperature of at least 160 F (71 C) for a minimum of 25 minutes is commonly recommended for hot water washing. Water of this temperature can be provided by steam jet or separate booster heater. The use of chlorine bleach assures an extra margin of safety . 2A. During observation on 11/18/24, the following were observed: at 12:51 p.m., CNA (Certified Nursing Assistant) A served Resident 59's lunch tray but was not heard or seen to encourage or offer hand hygiene to the resident and did not use the alcohol-based hand rub (ABHR) found at the door of the room. at 12:53 p.m., CNA A served Resident 225's lunch tray, but after moving the resident to an upright position, was not heard or seen offering or reminding hand hygiene to the resident. at 12:57 p.m., CNA A served Resident 61's lunch in the presence of another CNA in the room but was not heard to remind or offer HH to the resident. at 1:03 p.m., CNA B served Resident 121's lunch tray but was not heard or observed to offer HH to the resident. CNA B was not observed to use the AHR by the door of the room. at 1:07 p.m., CNA C served Resident 40's lunch tray but was not heard or seen to offer or remind HH to the resident. at 1:09 p.m., CNA C served Resident 5's lunch tray but was not heard or seen to offer HH to the resident. at 1:11 p.m., CNA B served Resident 49's lunch tray but was not heard of seen to offer HH to the resident. CNA B was not seen performing HH coming out the room. During an interview on 11/18/24, at 1:13 p.m., Resident 120's wife was asked if the CNA who served her husband's lunch tray offered, reminded, or encouraged HH to her husband, stated: no, he was not offered nor reminded HH before eating. During an interview on 11/18/24, at 4:27 p.m., CNA B stated she was not aware she had to remind residents to use the wet wipes in their meal trays when serving residents in their rooms. CNA B stated she knew in the dining room they encouraged the resident to use the wet hand wipes. CNA B stated she had to return the tray covers outside, but she did her HH after that. A review of the facility's policy and procedure (P&P) titled Handwashing/Hand Hygiene, revised 6/2021, the P&P indicated to use an alcohol based hand rub containing at least 62 percent alcohol; or alternatively, soap (antimicrobial- contains chemicals that kill or stop the growth of bacteria or non-antimicrobial) and water for the following situations: before or after eating food .before donning gloves .after removing gloves 2 B. During a concurrent observation and interview on 11/20/24 at 11:15 am., [NAME] E verified she did not perform HH when she removed her gloves and donned a new glove. [NAME] E stated the facility policy was to ensure staff perform HH after removing gloves and prior to donning new gloves. [NAME] E stated it was for infection control measure. During an interview on 11/21/24 at 9:10 a.m., the Infection Preventionist (IP) stated it was the facility's policy to ensure staff were performing HH after removing gloves and prior to donning gloves. The IP stated performing HH prior to donning new gloves prevents contamination of gloves and the spread of bacteria. The IP stated, if the staff removed the gloves and donned new gloves without performing HH first, it meant the policy was not followed and it could be a safety risk for the residents. During an interview on 11/21/24 at 10:03 a.m., CNA L stated it was the facility's policy for staff to perform HH after removing gloves and prior to donning new gloves to prevent transmission of infection and to prevent cross commination so that residents were protected from infection. A review of the facility's policy and procedure (P&P) titled Handwashing/Hand Hygiene, revised 6/2021, the P&P indicated to use an alcohol based hand rub containing at least 62 percent alcohol; or alternatively, soap (antimicrobial- contains chemicals that kill or stop the growth of bacteria or non-antimicrobial) and water for the following situations: before or after eating food .before donning gloves .after removing gloves 3. Record review of Resident 33's Face sheet (Facility demographic) indicated she was admitted to the facility on [DATE] with medical diagnoses including Chronic Obstructive Pulmonary Disease (A lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible). Record review of a General Acute Care Hospital discharge summary for Resident 33 dated 10/07/24 at 10:18 a.m., indicated, recent admission in 6/24 for MRSA (Methicillin Resistant Staphylococcus Aureus-A type of bacteria resistant to a certain type of antibiotics) PNA (Pneumonia), which specified Resident 33 had a history of MRSA. Record review of a document titled, Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, published by Centers for Disease Control and Prevention (National public health agency of the United States) on 6/28/24, indicated, Residents colonized with a novel or targeted MDRO (Multidrug-resistant organisms (MDROs) are bacteria that are resistant to more than one antibiotic and can be difficult to treat) are intended to remain on Enhanced Barrier Precautions (A set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms) for the duration of their stay in a facility. During an observation on 11/18/24 at 1:13 p.m., CNA P was observed working directly with Resident 33 in her room in close proximity, cutting her meat for lunch. CNA P's clothing was observed brushing against Resident 33's clothing. CNA P was not wearing a gown or gloves. Outside of Resident 33's room, a posting was taped to the wall indicating residents in Resident 33's room were on enhanced barrier precautions. During an interview with CNA P on 11/18/24 at 1:15 p.m., she confirmed not wearing a gown or gloves while working with Resident 33. CNA P stated she was unaware Resident 33 was on enhanced barrier precautions, as she was from a registry agency, and this was her first time assigned to Resident 33. During an observation on 11/19/24 at 9:46 a.m., CNA Q was observed working with Resident 33. CNA Q was observed wearing gloves but no gown while brushing Resident 33's hair. Some of Resident 33's hair was observed to be touching CNA Q's exposed arms, and CNA Q's clothing was observed brushing against Resident 33's clothing. During an interview on 11/19/24 at 9:50 a.m., CNA Q confirmed he was required to wear a gown while in close contact with Resident 33, but stated he forgot to wear it. During an interview with the Infection Preventionist (IP) on 11/18/24 at 1:23 p.m., she stated staff performing high contact activities with Resident 33 were required to wear a gown and gloves because Resident 33 had a history of MRSA. Record review of the facility policy titled, Enhanced Barrier Precautions, dated 6/20/24, indicated, Enhanced Barrier Precautions (EBP)-used in conjunction with the standard precautions and expand the use of PPE (Personal protective equipment) to donning of gown and gloves during high-contact resident care activities and in situations of expected exposure to blood, body fluids, skin breakdown, or mucous membranes that provide opportunities for transfer of MDROs to staff hands and clothing to reduce transmission. 4. During a concurrent observation and interview on 11/20/24 at 11:51 a.m. [NAME] E checked the 2 drawers on the preparation table by the kitchen window and verified utensils were still wet when it was stored in the drawers. [NAME] E stated this was unacceptable because moisture attracts germs and bacteria. [NAME] E stated this could put residents at risk for getting sick if you used a utensil that had germs. During a concurrent observation and interview on 11/20/24 at 11:54 a.m., [NAME] M checked the 2 drawers on the preparation table by the kitchen window and verified utensils were still wet when it was kept in the drawers. [NAME] M stated these utensils should be air dried and completely dried prior to storage. [NAME] M stated keeping the utensils in the drawer while it's still wet could result to cross contamination which could result to residents getting sick. During a concurrent observation and interview on 11/20/24 at 12:04 p.m., the Dietary Manager (DM) opened the 2 drawers on the preparation table by the kitchen window and verified utensils were still wet when it was kept in the drawers. The DM stated this was not acceptable. The DM stated storing the utensils in the drawers while it was still wet was a risk for cross contamination and breeding ground for bacteria. The DM stated utensils should be air dried prior to storing it in the drawer. The DM stated moisture attracts germs. The DM stated keeping the utensils inside the drawer while still wet was an infection control issue. The DM stated it was a safety concern as well because it put residents at risk for getting sick. During an interview on 11/21/24 at 11:31 a.m., the Infection Preventionist (IP) stated all utensils should be air dried prior to storing in the drawers. The IP stated moisture attracts bacteria or germs. The IP stated using utensils that had germs and bacteria could result to residents getting sick with food borne illness (an illness caused by contamination of food and occur at any stage of the food production, delivery and consumption chain). A policy and procedure for utensils storage was requested but not provided. A review of the ServSafe blog titled NFSM 2021- Week 3- Cleaning and Sanitizing Dishes dated 9/2021, it indicated to Air-dry all items. NEVER use a towel to dry items. Doing this could contaminate the items.? Make sure they are completely dry before stacking or storing them. 39621 46132

Based on observation, interviews and record reviews, the facility failed to ensure hot water was available for use to the shared bathrooms in rooms (rms) 26-28 and 27-29 when the hot water temperature in these rooms were below 105 degrees. This failure resulted in Resident 48 who was in rm 26 complaining of inconvenience and unpleasantness of using cold water to wash her hands for over a week. This failure also put the residents at risk for not washing their hand due to discomfort, residents could then get sick and spread infection (invasion and growth of germs in the body) to others. Findings: A review of Resident 48's face sheet (demographics) indicated an admitted [DATE]. Resident 48's diagnoses included Essential Hypertension (HTN, high blood pressure), Muscle Weakness and Anxiety disorder (AD, a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation). Resident 48's Minimum Data Set assessment (MDS, a federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) dated 11/12/24 indicated staff provided set up assistance with Resident 48's daily care. Resident 48's Brief Interview for Mental Status (BIMS, a mandatory assessment used to identify cognitive (anything related to thinking, learning, and understanding) impairment in long-term care facilities) dated 11/12/24 score was 15 indicating intact cognition. Resident 48 was continent (ability to control) of both bowel and bladder function. Resident 48 uses the shared bathroom in rms 26-28. During an interview on 11/18/24 at 11:30 a.m., Resident 48 stated the hot water on her bathroom sink had been broken for over a week now. Resident 48 stated the Maintenance Director was supposed to fix it but had left. Resident 48 stated it was inconvenient and unpleasant to use cold water when washing her hands. Resident 48 stated she uses the shared bathroom in rms 26-28 and washes her hand after using the bathroom so not having a hot water to use for hand washing was inconvenient. Resident 48 stated not having a hot water available for use was a safety hazard. Resident 48 stated they needed hot water and wished the problem with the unavailability of hot water to use would be fixed soon. During an interview on 11/19/24 at 1:48 p.m., Certified Nursing Assistant (CNA) J stated having hot water for resident to wash their hand was important. CNA J stated not having hot water readily available for use to wash hands put the residents at risk for getting sick and infections. During an interview on 11/19/24 at 1:52 p.m., Licensed Nurse (LN) F verified there was no hot water coming out of Resident 48's bathroom faucet for over a week now. LN F stated she might have verbally reported this issue to the maintenance. LN F stated it was important to have hot water available for use as residents would not want to wash their hand with cold water. LN F stated not washing hands could put the residents at risk for diarrhea (3 or more loose stool per day). LN F stated a lot of infection could be transferred via hands. LN F verified Resident 48 uses the bathroom and washes her hand in the bathroom sink. During a concurrent observation and interview on 11/19/24 at 2:02 p.m., the Director of Nursing (DON) verified there was no hot water coming out of the faucet in the shared bathroom in rms 26-28. The DON stated she was not aware there was no hot water coming out of Resident 48's bathroom faucet for over a week now. The DON stated it was important to make sure there was hot water available for resident's use. The DON stated older residents were prone to cold and not having hot water available could deter residents from washing their hands. The DON stated not washing hands could lead to sickness and diseases and was a big infection control issue. The DON stated not washing hands would put residents at risk for Clostridium Difficile (C.Diff, infection of the colon, the longest part of the large intestine) and diarrhea. During a concurrent observation and interview on 11/20/24 at 3:00 p.m., the surveyor tested the water temperature coming off the faucet by allowing the water to run for 20 seconds before taking the temperature of running water for about 20 seconds. CNA K verified the water temperature coming out of the faucet in the bathroom in rms 26-28 was 84.8 degrees and the shared bathroom in rms 27 and 29 was 87 degrees. CNA K verified the hot water was not hot enough in the shared bathroom in rms 6-28 and 27-29 faucet. CNA K stated the water coming out of the shared bathroom in rms 6-28 and 27-29 faucet was not hot enough and residents may not be comfortable on washing their hands if it was not hot enough. CNA K stated not washing hands could result to cross contamination and residents could get sick. During a concurrent observation and interview on 11/21/24 at 3:26 p.m., the Administrator (ADM) tested the water temperature in the shared bathroom in rms 26-28 and 27-29 faucet using the facility thermometer. The water was allowed to run for 35 seconds prior to ADM taking the temperature. The ADM kept the thermometer in running water for 25 seconds. The ADM verified the hot water temperature in the shared bathroom in rms 26-28 was 84 degrees and the water temperature in the shared bathrooms in rms 27-29 was 86 degrees. The ADM verified the water temperature was not meeting the hot water temperature. The ADM stated the policy was for hot water to be at least 105 degrees. A review of the facility's policy and procedure (P&P) titled Water Temperatures, Safety of revised 12/2009, the P&P indicated water heaters that service residents rooms, bathrooms, common areas shall be set to temperatures of no more than 120 degrees .

Based on observation, interview and record review, the facility failed to follow up on a missing monthly weight resulting in a severe weight loss of 14% within two months for one (Resident 38) of 16 sampled residents. This failure resulted in harm from delayed care and treatment to address the severe weight loss. Findings: During an observation on 5/21/19 at 9:13 a.m., Resident 38 was observed to be lying in his bed and was unable to carry on a conversation by staring blankly in response to questions or answering yes or no only. During a review of the Admission Record dated 9/24/18, indicated Resident 38 was admitted to the facility on [DATE] with a history of [MEDICAL CONDITION] (a group of lung diseases that block airflow and make it difficult to breathe), diabetes (the body's inability to regulate blood sugar levels) and traumatic ischemia of muscle (Resident 38 suffered a crushing injury to his right arm which permanently effected the use of his right hand and arm). The plan was for Resident 38 to remain at the facility for long term care. A review of Resident 38's Admission MDS (Minimum Data Set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems) dated 10/1/18, indicated Resident 38 had a BIMS (Brief Interview of Mental Status) which was evaluated as moderate cognitive impairment and needed physical staff assistance with eating. During a review of the clinical record for Resident 38, the: Plan of Care dated 9/25/18 indicated he was admitted to the facility with impaired nutritional status related to his injury of his right arm. The goal was set for his plan of care indicating the facility wanted Resident 38 to maintain his nutritional status and not have a significant weight loss through to the next review cycle which was 4/1/19. A review of the clinical record for Resident 38, the: Plan of Care dated 10/4/18 indicated he had impaired cognitive function and thought processes's and the plan was for staff to document changes in declining cognitive function like decision making ability, memory recall and general awareness. A review of Resident 38's Quarterly MDS (Minimum Data Set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems) dated 1/1/19, indicated Resident 38 had a BIMS (Brief Interview of Mental Status) which was evaluated as minimal cognitive impairment and needed physical staff assistance with eating. A review of the clinical record for Resident 38,: The Weights and Vitals Summary indicated he weighed 231.3 lbs on 3/5/19. There was no weight measured for the month of (MONTH) and on 5/10/19, Resident 38's weight was 198.8 lbs. A review of the clinical record for Resident 38,: Dietary Progress Note dated 5/17/19 at 12:45 p.m., indicated he had a 12.9 % weight loss over a three month period which was indicated to be classified as significant. Registered Dietician F (RD F) indicated Resident 38 had an approximate 65% average intake of meals and Resident 38 had not been aware that he had been losing weight. RD F progress note indicated Glycerna (dietary supplement specifically designed for diabetic persons) would be added to be given by nursing daily, weekly weights for the next 4 weeks, consider additional laboratory blood tests, consider a speech or swallow evaluation and a psychiatric evaluation for poor appetite. During a concurrent interview with Registered Dietician (RD G) and Director of Food Services (DFS) on 5/23/19 at 2:53 p.m., RD G indicated she had just started at the facility on 5/21/19 and this was her second day getting to know the residents. DFS indicated the previous registered dietician (RD F) had ceased to carry out the registered dietician duties the facility on 5/17/19. RD G was asked how she would prioritize which residents to see first and she indicated the new admissions were her first priority and then weight loss residents would be her second priority. RD G did not indicate she had not begun working with the weight loss residents and was not aware of Resident 38's significant weight loss nor of the notes left by the previous registered dietician (RD F). RD G reviewed the electronic medical record for the last note by the RD on 5/17/19 and was not aware of the most recent weight of 197.7 lbs measured on 5/21/19, which was down from the weight taken on 5/10/19 of 198.8 lbs. RD G indicated she was not aware of the interventions suggested by the previous RD or if those interventions had been ordered by either nursing or a physician. DFS stated he had not met with Resident 38 regarding meal choices since the progress note from RD F on 5/17/19 indicated Resident 38 was not aware of the weight loss or that Resident 38 was unhappy with his menu choices. DFS was not aware of the Resident 38's cognitive challenges or how to present meal choices to a resident with cognitive challenges; as an example Resident 38 would often answer questions with a yes or no response and it was unclear if he understood what was being asked. During an interview with Resident 38's family member (RF 500) on 5/23/19 at 4:36 p.m., he indicated Resident 38 looked like he had lost weight but was not aware of how much weight Resident 38 has lost. RF 500 stated the staff had not informed him of Resident 38's weight loss. RF 500 asked Resident 38's current weight and let out a gasp when he was informed that it was 197.7 lbs. RF 500 was aware of Resident 38's previous weight range of 230 lbs. RF 500 indicated he was very concerned regarding the significant weight loss and wondered if Resident 38 was shutting down and starting to decline in overall health. During an interview with Director of Rehabilitation on 5/24/19 at 9:19 a.m., she indicated Resident 38 had not had a speech/swallow screen because she did not see an order for [REDACTED].>During an interview with the Director of Nursing (DON) on 5/24/19 at 9:35 a.m., she indicated a swallow screen request which was recommended by a registered dietician would be communicated to her through a request on paper or through an email. DON looked through the electronic medical record during the interview and could not locate a swallow screen request. DON indicated the time to process the swallow screen request to the therapy department would usually take about 48 hours to complete and since the previous registered dietician had vacated her position on 5/17/19, the swallow screen request had not been processed because the request from the registered dietician had not been sent to the nursing department.

Based on observation, interview and record review, the facility failed to maintain the safety of Resident 1 when they did not monitor and maintain the wander guard system used to alert staff if a resident wearing a wander guard transmitter exited the facility. This failure resulted in Resident 1, who was wearing the wander guard transmitter; leaving the building unnoticed, walking down the street, falling to the ground and suffering a broken arm. Findings: The facility admitted Resident 1, a [AGE] year-old female, to the facility on [DATE] for long-term care due to an unspecified dementia. Resident 1 ambulated independently. The facility identified Resident 1 as an elopement risk as she would seek to leave the facility in the mornings wanting to go to church. The Facility Reported Event, dated [DATE], documented that on [DATE] at about 9:10 am the facility received a phone call to notify the facility of finding Resident 1 down the street by herself and on the ground. During an observation on [DATE] at 9:10 a.m., the road between 1220 and 833 S Elisero Drive, where Resident 1 walked was, a 2-lane road marked with a double yellow line and without any designated crosswalk. This stretch of road passed some businesses and apartment buildings with many cars parked on both sides of the street. During on observation on [DATE] at 9:20 a.m., a city park with a creek behind the park was across the street from the driveway of the facility. During an interview on [DATE] at 9:45 a.m., DON stated that on Sunday [DATE] at around 9:10 a.m. her staff received a call from a bystander who reported finding the resident after she had fallen. DON stated that Paramedics treated Resident 1 at the scene and transported her to the hospital. The Facilities Unusual Occurrence report form dated [DATE] at 5:00 p.m., documented that the CNA last saw Resident 1 between 7:30 and 8:00 a.m., when she was served breakfast. During an interview on [DATE] at 1:00 p.m., LN A stated that on Sunday [DATE] one of the other nurses received a phone call alerting the facility to the fact that a resident was down the road from the facility. LN A stated the staff went out in small groups to find Resident 1. LN A stated that paramedics were attending to Resident 1 when they found her. LN A stated that Resident 1 was dressed appropriately and her ID band and Wander Guard transmitter were on her. The emergency departments report on [DATE] indicated Resident 1 wandered away from her nursing home today and suffered an unwitnessed fall. The discharge [DIAGNOSES REDACTED]. The emergency department report on [DATE] documented, Resident 1 transferred here from her nursing home for a right wrist fracture. Patient was seen here yesterday following a fall at her nursing home. This refers to the event on [DATE]. The discharge [DIAGNOSES REDACTED].) During an interview on [DATE] at 9:45 a.m., DON stated the facility staff tested Resident 1's wander guard transmitter by having the resident stand near the door. DON stated the transmitter worked intermittently and stated that it did not work when covered by clothing or hand. The facility staff placed a new wander guard transmitter on Resident 1. During an interview on [DATE] at 12:20 p.m., Maintenance stated that on Mondays he tests the sensors at the doorways making sure the alarm for the wander guard system sounds. During an interview on [DATE] at 1:00 p.m., LN A stated that a resident's wander guard transmitter is checked every day to ensure it is on the resident. On Saturdays, they use an electronic testing device on the residents wander guard transmitter to ensure the alarm is working. Resident 1's Medication Administration Record [REDACTED].: Functioning. Therefore, a day shift nurse was to check the functioning of the wander guard transmitter every Saturday. Resident 1's MAR for ,[DATE], ,[DATE] and ,[DATE] had documentation that these checks were done. The facilities Wandering Resident Bracelet Testing Record was used to document the expiration date of the Wander guard transmitters. The facility had records for the check of expiration dates, dated [DATE], [DATE], and ,[DATE] to [DATE]. Documentation for the expiration dates before the elopement on [DATE] were from [DATE] to [DATE]. The Wander Guard User Guide describes weekly testing as follows: The following testing is required weekly for transmitters in use on residents. All steps are mandatory. 1. Test the operation of transmitters using the transmitter tester. 2. Visually inspect transmitters for damage or loose parts. 3. Verify that the warranty expiration date stamped on the transmitter has not expired. If the warranty period has expired, discard and replace the transmitter immediately. 4. Your facility must keep records of test and transmitter inspection.

Based on interview and record review, the facility failed to ensure residents remained free of unnecessary drugs when: 1) Resident 21 received an incorrect and excessive dose of narcotic medication, and required transfer to an acute care hospital for treatment of [REDACTED]. 2) Resident 15 received an excessive dose of pain medication without indications for its use, or monitoring of the effectiveness and side effects of the medication; and 3) Staff did not monitor vital signs consistent with best practice for one resident (Resident 2) receiving [MEDICATION NAME] (a heart medication). This failure resulted in narcotic overdose resulting in hospitalization for Resident 21, and the potential for respiratory depression or changes in heart rhythm leading to death for Residents 21, 15 and 2. Findings: 1) Review of Resident 21's medical record revealed a nursing progress note dated [DATE] at 11:05 a.m. that indicated the facility called 911 to transfer Resident 21 to the hospital at 10:30 a.m. The nursing note indicated a nursing assistant was unable to arouse the resident at 9:30 a.m. and his blood pressure had dropped to ,[DATE] (average blood pressure is ,[DATE]). The nursing note indicated Resident 21 received 45 mg. (milligrams) of [MEDICATION NAME] (narcotic/opioid pain medication) twice the day before ([DATE]) when the physician order [REDACTED]. The nurse's note revealed the facility wrote a medication error incident report related to Resident 21. Review of Resident 21's hospital physician admission note, dated [DATE] at 2:08 p.m., indicated Resident 21 was receiving [MEDICATION NAME] 15 mg. BID (twice a day), and the dose was increased to 30 mg. on [DATE]. The physician note indicated Resident 21 received 45 mg. of [MEDICATION NAME] on [DATE], instead of 30 mg. The physician note indicated the Emergency Department (ED) doctor reported Resident 21 was difficult to arouse in the ED and received intravenous [MEDICATION NAME] (an opioid antagonist used in acute opioid overdose). The note indicated Resident 21 became alert and oriented after the [MEDICATION NAME], but later became more difficult to arouse. His oxygen level dropped to 87% (normal is 95%-100%) which necessitated delivery of supplemental oxygen. The physician note indicated Resident 21 presented with somnolence (excess sleepiness/drowsiness) that improved with [MEDICATION NAME] and the presentation was consistent with narcotic over-ingestion. Review of Resident 21's hospital physician discharge note, dated [DATE] at 1:18 p.m., indicated Resident 21 received continuous intravenous [MEDICATION NAME] overnight while in the hospital, and he was now awake, alert and oriented. The physician note indicated Resident 21 had acute [MEDICAL CONDITION] (disease of the brain that altered brain function and mental state) due to accidental overdose of opioids. ([MEDICATION NAME] is an opioid.) Review of Resident 21's physician orders [REDACTED]. (sustained release or extend release - slow release of medication/long acting) every twelve hours (twice a day). Review of Resident 21's MAR (medication administration record) revealed a new physician order [REDACTED]. The MAR also contained the old order for [MEDICATION NAME] (15 mg. every twelve hours). The old [MEDICATION NAME] order was not discontinued when the new order was written. Review of Resident 21's Controlled Drug Record (sign out sheet for narcotic medication) indicated one [MEDICATION NAME] ER (extend release) 15 mg. tablet and one [MEDICATION NAME] ER 30 mg. tablet were signed out (taken from the package) on [DATE] at 9:00 a.m. Review of Resident 21's MAR indicated staff administered both tablets (totaling 45 mg, not 30 mg as ordered) to him at 9:00 a.m. Review of Resident 21's Controlled Drug Record indicated one [MEDICATION NAME] ER 15 mg. tablet and one [MEDICATION NAME] ER 30 mg. tablet were signed out on [DATE] at 9:00 p.m. Review of Resident 21's MAR indicated staff administered the 15 mg. tablet to him at 9:00 p.m. The [MEDICATION NAME] ER 30 mg. was not documented as given (although it was signed out of the package). Review of facility document titled, Resident Event Report Worksheet dated [DATE] indicated a medication error occurred with Resident 21's [MEDICATION NAME] that may have, contributed to or resulted in temporary harm to the resident and required initial or prolonged hospitalization . The document further indicated the medication error caused a change in level of consciousness and a significant change in vital signs. The document indicated two of the possible causes for the medication error were 1) a failure to check medication with the MAR and 2) a transcription error (a specific type of medication error due to inaccurate data entry, such as incorrectly copying a physician order [REDACTED]. Review of facility policy titled, 6.0 General Dose Preparation and Medication Administration (revised [DATE]) indicated prior to medication administration, facility staff should, 4.1.1 Verify each time a medication is administered that it is the correct dose and, 4.1.2 confirm that the MAR reflects the most recent medication order. 2) Record review for Resident 15 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A Patient Nursing Evaluation, dated [DATE] at 4:30 p.m., included a pain assessment: Resident 15 was breathing normally, not moan/groan or call out, had a smiling or inexpressive facial expression and relaxed body language, and had no need for consolation. Review of physician orders [REDACTED]. Oral [MEDICATION NAME] 20 milligrams per milliliter (mg./ml.) solution, 0.25 ml. (5 mg.) every hour for mild pain (1-,[DATE]) or shortness of breath/grimacing, 0.5 ml. (10 mg.) for moderate pain (4-,[DATE]) or shortness of breath/grimacing, and 1.0 ml (20 mg.) hourly for severe pain (8-,[DATE]) or shortness of breath/grimacing. Review of the Medication Record (MAR) revealed Resident 15 received an initial dose of [MEDICATION NAME] on [DATE] at 9 p.m. Notes on the back of the Medication Record indicated 10 mg. was given for pain ,[DATE] and was effective. The nurse gave a second dose of 10 mg. on [DATE] at 10 p.m. for generalized pain with no numerical value charted. A nurses' narrative Health Status Note indicated, pt (patient) is alert and responsive. Maintain comfortable (sic) care .[MEDICATION NAME] 0.5 ml given (by mouth) at (p.m. and 10 p.m.) with good effective (sic). The nurse medicated Resident 15 on [DATE] with 0.5 ml. (10 mg.) at 12:30 a.m., 1:30 a.m., and 2:30 a.m., and with 1 ml. (20 mg) at 3:30 a.m., 4:30 a.m., 5:30 a.m. and 6:30 a.m. The nurse dose documented each dose on the back of the Medication Record as given for generalized pain and with help, but contained no information regarding Resident 15's degree of pain before or after the medication. A Health Status note for that night shift, dated [DATE] at 7:18 a.m., revealed Opens eyes to voice .medicated with [MEDICATION NAME] (sublingual) for comfort. There is no documentation of verbal or nonverbal indicators of pain or respiratory distress. A Health Status Note by Administrative Staff R, dated [DATE] at 10:56 a.m., revealed; MD anticipates increasing (sic) [MEDICATION NAME] to greater frequency. The note contained no documentation indicating the need for increasing frequency of the [MEDICATION NAME]. Resident 15's MAR revealed on [DATE] during the day shift he received 5 mg. of oral [MEDICATION NAME] at 8:20 a.m., 9:40 a.m., and 10:40 a.m. and 20 mg. at 11:40 a.m. The note on back of the MAR indicated these doses were for generalized pain with relief. The notes failed to contain an assessment for pain or discomfort. A physician's orders [REDACTED]. comfort care. Routine [MEDICATION NAME] solution 1 ml. (20 mg.) hourly for [DATE] (sic), increased to 1.5 ml. (30 mg.) hourly for [DATE] (sic), and 2.0 ml. (40 mg.) hourly for [DATE] (sic). A second order dated [DATE], untimed, revealed [MEDICATION NAME] solution 20 mg. /1 ml. give 1.5 ml. (30 mg.) hourly for [DATE] and discontinue the order for 1 ml. (20 mg) hourly. The orders contained no parameters for when licensed staff should hold the medication. Resident 15 received 20 mg. hourly through 7:40 p.m. The nurses Health Status Note for evening shift, dated [DATE] at 10:35 p.m., indicates, Pt. is alert and responsive. maintain comfortable (sic) care. [MEDICATION NAME] 1 ml. (sublingual, under the tongue) given (every hour) until 8:40 p.m., then changed to 1.5 ml. orally or sublingually every hour. The MAR contains no documentation of pain assessment for evening shift on [DATE]. Resident 15 received 30 mg. of [MEDICATION NAME] hourly from [DATE] at 8:40 p.m. through [DATE] at 11:40 p.m., totaling 840 mgs. over 27 hours. The MAR reflected documentation of zero pain for the night and day shifts of [DATE] and [DATE]; there is no documentation on the MAR at all for pain assessment during evening shifts on [DATE] and [DATE]. A Health Status Note for night shift, dated [DATE] at 6:08 a.m., revealed, Pt .obtunded .faint carotid pulse, Cheyne-stoke respiration 12 (respiratory rate), on (oral [MEDICATION NAME] solution) every (one) hour .no manifestation of discomfort (A normal respiratory rate is 12 to 20 breaths per minute.) The MAR reflected documentation of zero pain for the shift. A Health Status Note for day shift, dated [DATE] at 3:40 p.m., indicated Resident asleep throughout the shift, did not open eyes Hourly [MEDICATION NAME] (1.5 ml.) given .seen by MD this shift .Weak carotid pulse .respiration 12 The MAR revealed documentation of zero pain for the shift. A Health Status Note for evening shift, dated [DATE] at 10:30 p.m., revealed, pt is slow responsive. his brething (sic) slow and shallow. ,[DATE]/min. (oral) [MEDICATION NAME] 1.5 ml. given (under the tongue every 1) hour as needed . Documentation indicated [MEDICATION NAME] given hourly as needed, however; nurses give [MEDICATION NAME] hourly throughout the shift. The MAR contains no documentation of pain assessment for the shift or reasons for as needed administration. Documentation did not indicate notification to the physician of the slow respiratory rate, a well-known side effect of narcotic medications. A Health Status Note for night shift, dated [DATE] at 5:30 a.m., revealed, Patient was on [MEDICATION NAME] solution 1.5 ml. (by mouth/under tongue every hour) for comfort care. Unresponsive but biting down on syringe during med pass. Family members in room. Family member agitated and requesting more medication for patient. Family member called (physician) and request was made. MD called back and gave new orders for increased [MEDICATION NAME] to 3 ml. every 1 hour and orders were noted at (2:45 a.m.). Cheyenne(sic)-Stokes breathing noted for 5 minutes and patient started making gurling sounds .Continue to monitor respirations. Patient still breathing slowly but noisy at time of this report. Resident 15 received hourly doses of oral [MEDICATION NAME] 3 ml. (60 mg) from 3 a.m. through 7 a.m. The MAR contains documentation of zero pain for the night shift. A telephone order received by Licensed Staff BB from Physician AA, dated [DATE] at 7:50 a.m., indicated, Increase [MEDICATION NAME] oral solution 20 mg./ml. Give 4 ml. (80 mg.) (orally or under the tongue) every one hour. Resident 15 received oral [MEDICATION NAME] 80 mg. at 8 a.m. and 9 a.m. No dose indicated for 10 a.m. An untimed order written by Physician AA on [DATE], and noted by Licensed Staff BB on [DATE] at 10:55 a.m., indicated Increase [MEDICATION NAME] solution 20 mg./1 ml. to 8 ml (every) one hour, start now, then increase [MEDICATION NAME] 20 mg./1 ml. to 12 ml. (every one hour), start at (3 p.m.). This reflected doubling the dose from 40 mg. per hour to 80 mg. per hour at 7:50 a.m., doubling it again from 80 mg. per hour to 160 mg. per hour at 10:55 a.m., and increasing it from 160 mg. per hour to 240 mg. per hour at 3 p.m., without documentation of persistent, recurrent, or increasing pain. Resident 15 received 160 mg. of [MEDICATION NAME] at 11 a.m. on [DATE] and 60 mg. (or 30 ml.) of a 10 mg./5 ml. concentration at 12 noon on [DATE], pending delivery of a more concentrated solution (20 mg./1 ml.). The chart lacked documentation why Resident 15 did not receive the full 160 mg. at noon as ordered. The MAR contained no documentation of pain assessment for day shift on [DATE]. There was no Health Status Note written for day shift on [DATE]. A document titled Record of Death reveals Resident 15 died on [DATE] at 12:55 p.m. During an interview on [DATE] at 11:30 a.m., Physician AA stated she could use intravenous medications in the hospital, but was limited to oral [MEDICATION NAME] solution in the skilled nursing facility. When asked about the lack of indication that Resident 15 was in pain, Physician AA stated, The family perceived he was in pain. Physician AA stated she recalled Resident 15 had a very high tolerance to [MEDICATION NAME]. Review of Resident 15's chart reveal no physician progress notes [REDACTED]. Left blank was The Initial Physician Comprehensive Assessment section titled Past Medical/Surgical History, and the admission respiratory rate omitted with Resident 15's vital signs. Resident 15's Care Plan included Potential for Alteration in Comfort Pain (due to) Immobility, initiated [DATE]. Interventions included Administer medications as ordered. See medication record. monitor for effectiveness and side effects .Evaluate pain level (every) shift using ,[DATE] scale. Record results and interventions taken. Review of a facility policy titled Pain Management, dated [DATE], revealed Pain is assessed at least every shift, when a patient complains of pain and after an [MEDICATION NAME] is given to determine effectiveness of the [MEDICATION NAME]. During an interview on [DATE] at 9:30 a.m., Consultant I stated the contracted pharmacy could not find a record of Resident 15 as a patient, and thus no documentation of dispensing the oral [MEDICATION NAME] solution, but she would check with my supervisor. No subsequent documentation provided. Review of a professional resource, LexiComp Online, indicated, All [MEDICATION NAME] sulfate formulations are capable of causing respiratory depression; risk increased in elderly patients, debilitated patients, and patients with conditions associated with [MEDICAL CONDITION] or hypercapnia. Monitor for respiratory depression especially during initiation and titration. (http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/ 28#f_warnings-and-precautions, retrieved [DATE]) 3) Review of Resident 2's clinical record revealed an admission date of [DATE] from an acute care hospital. [DIAGNOSES REDACTED]. Resident 2's discharge orders from the acute care hospital included [MEDICATION NAME] ([MEDICATION NAME]) 125 mcg. (microgram) by mouth daily. Handwritten additions to the discharge orders reflected hold for SBP<65, indicating the medication should not be given if Resident 2's systolic blood pressure was less than 65 mm. (millimeters of mercury). Review of printed orders generated by the pharmacy for the months of [DATE] through [DATE] revealed continuation of the order with the same parameter. [MEDICATION NAME] is a medication that increases the force and decreases the rate of heart contraction, thereby improving circulation. Review of a professional resource, Lexicomp Online, indicated nursing assessment includes Monitor apical pulse before administering any dose. (http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/6745#mst, retrieved [DATE]) During an interview on[DATE] at 9:30 a.m., Consultant I was asked about using a systolic blood pressure of 65 as the parameter by which [MEDICATION NAME] should be held. Consultant I stated, I would question the parameter. That is wrong. That systolic blood pressure is wrong and should not have passed by me. Review of policy and procedure 4.4 titled New Orders for Non-Controlled Substances, developed by the contracted pharmacy and used as facility policy and procedure, indicated A new order should include .pertinent ancillary instructions; and, reason for use.