Every finding on record at St. Catherine Healthcare

Based on interview, facility document review, and facility P&P review, the facility failed to ensure the safety of the residents when one of two volunteer staff (the Activity Volunteer) with a prior history of conviction was recruited to work with the residents. * The Activity Volunteer was a current sex offender registrant who was volunteering in the facility. This failure had the potential to put the residents at risk of harm or negative outcomes.Findings: Review of the facility's P&P titled Abuse: Prevention and Prohibition Against revised December 2023 showed the following:- The P&P applies to all facility staff including but not limited to employees, consultants, volunteers, students, and other caregivers who provide care and services to residents on behalf of the facility; and- All employees, temporary staff, prospective consultants, contractors, volunteers, caregivers, and students will be properly screened prior to working at the Facility. Review of the Activity Volunteer's facility volunteer application dated 8/2/24, showed a hand written response of yes to the section asking if the applicant had been convicted of a criminal offense by any court. The volunteer application showed the Activity Volunteer disclosed he was currently a sex offender registrant. The volunteer application further showed the facility initiated a background check, which came back with no criminal findings. On 3/11/26 at 1625 hours, an interview and concurrent facility document review was conducted with the Administrator. The Administrator stated all the employees and volunteers have background checks conducted. The Administrator stated he was not aware Activity Volunteer wrote their sex offender status on the application. On 3/12/26 at 0932 hours, a telephone interview was conducted with the Activity Volunteer. The Activity Volunteer stated he had been on the sex offender registry since before the early 2000's. On 3/12/26 at 1105 hours, an interview was conducted with the HR. The HR stated she did not see the Activity Volunteer's application showing he was a registered sex offender. The HR stated she ran a background check done on him and the results did not show any criminal history. The HR stated she missed where he wrote he was a registered offender on the application. The HR stated had she seen it, she would have contacted him to get more information. The HR stated she first reached out to the Activity Volunteer about his application's sex offender response yesterday (3/11/26), and he refused to give her any information other than it went back 20 years.

Based on interview, medical record review, facility document review and facility P&P review, the facility failed to implement their antibiotic stewardship program to show timely physician notification for two final sampled residents (Residents 17 and 49) and three nonsampled residents (Residents 16, 47, and 93) who received antibiotics for infections that did not meet McGeer's criteria. * The facility failed to ensure Resident 47's symptoms met the criteria for a UTI, notify the physician the infection did not meet the criteria, and reassess the need for continued antibiotic therapy. * Resident 16's physician was notified the UTI infection did not meet the criteria, however there was no indication as to when the physician was notified. Additionally, the form was completed by the IP who was out of the facility at the time and returned in March 2026. * Resident 17's physician was notified the UTI infection did not meet the criteria, however there was no indication as to when the physician was notified. * Resident 49's physician was notified the UTI infection did not meet the criteria, however there was no indication as to when the physician was notified. * Resident 93's physician was notified the UTI infection did not meet the criteria, however there was no indication as to when the physician was notified. These failures had the potential for the residents' being on unnecessary antibiotic therapy potentially resulting in MDRO's. Findings: Review of the facility's P&P titled Antibiotic Stewardship revised January 2022 showed the Antibiotic Stewardship Program will promote appropriate use of antibiotics while reducing possible adverse events associated with antibiotics use with the potential to limit antibiotic resistance. The World Health Organization has reported that antibiotic resistance is one of the major threats to human health, especially because some bacteria have developed resistance to all known classes of antibiotics. Diseases caused by these bacteria are increasing in long-term care facilities and contributing to higher rates of morbidity and mortality. 1. Medical record review for Resident 47 was initiated on 3/13/26. Resident 47 was admitted to the facility on [DATE]. Review of Resident 47's UTI Surveillance Data Collection Form for symptoms that started on 1/4/26, showed the data met criteria for a true infection. However, review of Resident 47's medical record failed to show the resident's symptoms met criteria for a UTI. Review of Resident 47's MAR for January 2026 showed the resident received ciprofloxacin (an antibiotic) 500 mg medication from 1/7/26 through 1/17/26. Review of Resident 47's medical record and the Surveillance Data records failed to show the resident's physician was notified the infection did not meet criteria, and to reassess the need for continued antibiotic therapy. On 3/13/26 at 1305 hours, an interview, medical record review, and concurrent facility document review for Resident 47 was conducted with the IP and DSD. The DSD stated she assisted the IP with IP duties. The IP and DSD verified Resident 47's Surveillance Data Collection Form incorrectly showed the UTI met criteria, and therefore the physician was not followed-up with to re-assess the need for continued antibiotic therapy. 2. Medical record review for Resident 16 was initiated on 3/13/26. Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's UTI Surveillance Data Collection Form for UTIs for symptoms that started on 2/19/26, showed the infection did not meet McGeer's criteria for infection. The form showed the physician was notified the infection did not meet criteria and instructed to continue the antibiotics, however the form failed to show when the physician was notified. In addition, the form was completed by the IP, who was out of the facility at the time, and returned in March 2026. Review of Resident 16's MAR for February 2026 showed the resident received cephalexin (an antibiotic) 500 mg medication from 2/20/26 to 2/24/26. On 3/13/26 at 1305 hours, an interview, medical record review for Resident 16 and concurrent facility document review was conducted with the IP. The IP stated she completed the Surveillance Data Collection Form after returning to the facility on 3/1/26, which was after the resident completed the antibiotic therapy, and verified the physician was not notified timely regarding the resident's infection did not meet criteria. 3. Medical record review for Resident 17 was initiated on 3/11/26. Resident 17 was admitted to the facility on [DATE]. Review of Resident 17's Surveillance Data Collection Form for UTIs showed the resident's symptoms started on 1/18/26, showed the infection did not meet McGeer's criteria for infection. The form showed the physician was notified the infection did not meet criteria and instructed to continue the antibiotics, however the form failed to show when the physician was notified. Review of Resident 17's MAR for January 2026 showed the resident received ciprofloxacin 500 mg medication from 1/22/26 through 1/29/26. On 3/13/26 at 1305 hours, an interview, medical record review, and concurrent facility document review for Resident 17 was conducted with the IP and DSD. The DSD stated she assisted the IP with IP duties. The IP and DSD verified Resident 17's Surveillance Data Collection Form failed to show when the physician was notified the infection failed to meet criteria, and re-assessed the need for continued antibiotic therapy. 4. Medical record review for Resident 49 was initiated on 3/11/26. Resident 49 was initially admitted to the facility on [DATE]. Review of Resident 49's Surveillance Data Collection Form for Other Infections for symptoms which started on 1/30/26, showed the infection did not meet McGeer's criteria for infection. The form showed the physician was notified the infection did not meet criteria and instructed to continue the antibiotics, however the form failed to show when the physician was notified. Review of Resident 49's MAR for February 2026, showed the resident had an order dated 1/30/26, for amoxicillin-potassium clavulanate (an antibiotic) 875-125 mg. The antibiotic was administered through 2/5/26. On 3/13/26 at 1305 hours, an interview, medical record review for Resident 49 and concurrent facility document review was conducted with the IP and the DSD. The DSD stated she assisted the IP with IP duties. The IP and the DSD verified Resident 49's Surveillance Data Collection Form failed to show when the physician was notified the infection failed to meet criteria, and reassessed the need for continued antibiotic therapy. 5. Medical record review for Resident 93 was initiated on 3/13/26. Resident 93 was re-admitted to the facility on [DATE]. Review of Resident 93's UTI Surveillance Data Collection Form initiated for symptoms which started on 2/2/26, showed the infection did not meet McGeer's criteria for infection. The form showed the physician was notified the infection did not meet criteria and instructed to continue the antibiotics, however the form failed to show when the physician was notified. Review of Resident 93's MAR for February 2026 showed the resident received cephalexin 500 mg medication from 2/4/26 to 2/11/26. On 3/13/26 at 1305 hours, an interview, medical record review, and concurrent facility document review for Resident 49 was conducted with the IP and DSD. The DSD stated she assisted the IP with IP duties. The IP and DSD verified Resident 93's Surveillance Data Collection Form failed to show when the physician was notified the infection failed to meet criteria, and reassessed the need for continued antibiotic therapy.

Based on observation, interview, medical record review and facility P&P review, the facility failed to ensure one of 19 final sampled residents (Resident 6) and one nonsampled resident (Resident 41) were assessed to self-administer medications. * Resident 6's bedside table was observed with a bottle of Mylanta (antacid and anti-gas medication) on top of bedside table. There was no physician's order for the Mylanta medication and no self-administration assessment for Resident 6. * Resident 41's bedside table was observed with a Biofreeze Cool the Pain (topical analgesic) medication on top of bedside table. There was no physician's order for the Biofreeze Cool the Pain and no self-administration assessment for Resident 41. These failures had the potential for the residents to administer the medications inaccurately and negatively impact the residents' well-being.Findings: Review of the facility's P&P titled Self Administration of Medications dated February 2021 showed it is the policy of this facility to respect the wishes of alert, competent residents to self-administer prescribed as allowable under state regulations. The Procedure section showed if a resident desires to participate in self-administration, the interdisciplinary team will assess and periodically re-evaluate the resident based on change in the resident's status. 1. On 3/11/26 at 0956 hours, during the initial tour of the facility, an observation and concurrent interview was conducted with Resident 6 in Resident 6's room. Resident 6's bedside table was observed with a bottle of Mylanta medication on top of the bedside table. Resident 6 stated he forgot who brought the medication for him. Resident 6 stated he took the medication about a week ago or maybe more. Medical record review for Resident 6 was initiated on 3/11/26. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's MDS assessment dated [DATE], showed the resident was cognitively intact. Review of Resident 6's Order Summary Report for March 2026 failed to show there was a physician's order for the Mylanta medication and for self-administration of medications. On 3/11/26 at 1018 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified there was a bottle of Mylanta medication on top of Resident 6's bedside table. LVN 1 stated the Mylanta medication should not be on Resident 6's bedside and every medication would need a physician's order. LVN 1 stated Resident 6 had no consent for self-administration. On 3/13/26 at 0933 hours, an interview and concurrent medical record review for Resident 6 was conducted with RN 2. RN 2 verified there was no physician's order for the Mylanta medication and no documented evidence an assessment of self-administration of the medication was conducted for Resident 6. RN 2 stated the licensed nurse should have explained to Resident 6 the medication he had needed to have a physician's order. 2. During the initial tour of the facility on 3/11/26 at 1039 hours, an observation and concurrent interview was conducted with Resident 41 in Resident 41's room. Resident 41's bedside table was observed with a Biofreeze Cool the Pain medication. Resident 41 stated he brought Biofreeze Cool the Pain medication when he came to the facility. Resident 41 further stated he applies the Biofreeze Cool the Pain medication on his hand when it hurts. Resident 41 stated he only used Biofreeze Cool the Pain medication when the pain was really bad. Medical record review for Resident 41 was initiated on 3/11/26. Resident 41 was admitted to the facility on [DATE]. Review of Resident 41's MDS assessment dated [DATE], showed the resident was cognitively intact. Review of Resident 41's Order Summary Report for March 2026 failed to show there was a physician's order for the Biofreeze Cool the Pain medication and for self-administration of medications. On 3/11/26 at 1048 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified the Biofreeze Cool the Pain medication was on top of right bedside table. LVN 1 acknowledged the Biofreeze Cool the Pain medication was open and not sealed. LVN 1 stated Resident 41's belongings should have been searched better. LVN 1 stated the staff should make sure there was nothing at the bedside that could harm Resident 41 and the Biofreeze Cool the Pain medication should have been accounted for. On 3/13/26 at 0918 hours, an interview and concurrent medical record review for Resident 41 was conducted with RN 2. RN 2 verified Resident 41 did not have a physician's order and self-administration assessment for the Biofreeze Cool the Pain medication. RN 2 stated usually the licensed nurse would ask the resident if they wanted to use a medication that was not on their medication list. RN 2 further stated the licensed nurse would let the physician know and ask if the resident could use the medication. RN 2 stated if the resident wanted to self-administer the medication, the licensed nurse would notify the physician again. RN 2 stated if the resident was capable of self-administration of the medication, the licensed nurse would do the self-administration assessment. On 3/17/26 at 1036 hours, the Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the Advance Directive and POLST were complete for one of 19 final sampled residents (Resident 32). * Resident 32's Advanced Directive did not show who the resident selected as his health care agent. In addition, the facility failed to ensure the POLST completed with Family Member 1 matched the resident's wishes for life sustaining treatment as detailed in Resident 32's Advanced Directive. This failure had the potential for the resident's end of life wishes not being followed.Findings: Review of the facility's P&P titled Advance Directives revised [DATE] showed the following:- Should the resident indicate that he or she has issued Advance Directives about his/her care and treatment, the facility will require that a copy of such directives be included in the medical record;- The facility will notify the attending physician of Advance Directives so that appropriate orders can be documented in the resident's medical records and plan of care; and- Inquiries concerning Advance Directives should be referred to social services, and/or to the director of nursing services. Medical record review for Resident 32 was initiated on [DATE]. Resident 32 was admitted to the facility on [DATE], and transferred to another facility on [DATE]. Review of Resident 32's Advanced Directive Durable Power of Attorney for Health Care and Living Will dated [DATE], showed the following specific scenarios and the residents request if life-sustaining treatment (CPR, a breathing machine, kidney dialysis, feeding tubes/artificial nutrition and hydration) should be provided:- If the resident is unconscious, in a coma, or a vegetative state and there is little or no chance of recovery: the resident selected no, he would not want life-sustaining treatments; - If the resident is in need of a breathing machine and will be in bed for the rest of his life: the resident selected no, he would not want life-sustaining treatment;- The Advance Directive also showed the resident selected he wanted his preferences, as expressed in this Living Will, to be followed strictly, even if the person making the decisions for him thinks it isn't in the resident's best interests; and- The Advance Directive was missing page number two, and failed to show who the resident selected as his healthcare agent. The form was labeled acute care hospital form 10-0137 [DATE] in the lower left corner. Review of the acute care hospital's form 10-0137 [DATE] template showed page two was where the option to select a health care agent, and an alternate health care agent. Review of Resident 32's POLST dated [DATE], signed by Family Member 1 showed the resident had an Advance Directive dated 2024 and the legally recognized decision maker was Family Member 1. The POLST showed to attempt resuscitation/CPR, full treatment with the primary goal of prolonging life, and long term artificial nutrition including feeding tubes. The back side of the POLST's directions for health care provider showed: A POLST does not replace the Advanced Directive. When available, review the Advance Directive and POLST form to ensure consistency, and update form appropriately to resolve any conflicts. Review of Resident 32's H&P examination dated [DATE], showed the resident had no capacity to understand and make decisions. Review of Resident 32's Social Services Assessment/Evaluation - V 3 dated [DATE], showed a copy of the acute care hospital's Healthcare Directive was in the resident's medical record, and the POLST was completed with Family Member 1. Review of Resident 32's Social Services note dated [DATE], showed the resident's acute care hospital's Advance Healthcare Directive contradicts with the POLST, and the SSD discussed it with Family Member 1, who wants to continue with the current POLST. On [DATE] at 1611 hours, an interview and concurrent medical record review for Resident 32 was conducted with the SSD. The SSD stated Family Member 1 was Resident 32's health care agent. The SSD stated she noticed the resident's POLST and Advance Directive did not match and discussed it with Family Member 1 on [DATE]. The SSD verified the resident's Advance Directive failed to show Family Member 1 was listed as the health care agent. The SSD stated she would reach out to the acute care hospital and see if they have a copy of the resident's Advance Directive. On [DATE] at 0936 hours, the facility provided a copy of a prior, now void, Advance Directive that was on file at the acute care hospital. The Advanced Healthcare Directive was dated [DATE], and listed Family Member 2 as the designated healthcare agent and Family Member 1 as the alternate.

Based on interview and medical record review, the facility failed to ensure two of seven final sampled residents (Residents 7 and 8) reviewed for unnecessary medications were free from unnecessary psychotropic drugs. * The facility failed to document the nonpharmacological interventions to be attempted when Resident 7 had an episodes of angry outbursts. * The facility failed to ensure the episodes of anxiety were monitored for Resident 8. In addition, the facility failed to provide interventions to address Resident 8's behavior when the resident exhibited agitation and angry outbursts. These failures had the potential for adverse effects from the psychotropic medications and the potential for not providing the correct data to the prescriber to adjust the dosage of the psychotropic medications.Findings: 1. Medical record review for Resident 7 was initiated on 3/11/26. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's H&P examination dated 1/24/26, showed Resident 7 had no capacity to understand and make decisions. Review of Resident 7's Order Summary Report showed the following physician's orders: - dated 6/16/25, to monitor and document number of psychotic behaviors as evidence by angry outburst every shift; and -dated 2/17/26, to administer quetiapine (anti-psychotic medication) 25 mg by mouth, at bedtime for schizoaffective disorder manifested by angry outburst. Review of Resident 7's care plan for potential behavior problem related to angry outbursts dated 6/16/25, showed interventions including document behaviors and resident response to interventions. Review of Resident 7's MAR for September to December 2025 showed to monitor and document the number of psychotic behaviors as evidenced by angry outburst. The MAR from September 2025 to December 2025 showed the following: - dated 9/23 at night shift - one episode; - dated 10/21 at evening shift – two episodes; - dated 12/20 at day shift – one episode; and - dated 12/28 at night shift – one episode. Further review of Resident 7's MAR failed to show documented evidence of nonpharmacological interventions when Resident 7 had episodes of angry outbursts. On 3/12/26 at 1446 hours, an interview and medical record review for Resident 7 was conducted with the MDS Coordinator. The MDS Coordinator verified the above findings. The MDS Coordinator stated there was no documentation related on which nonpharmacological interventions would be attempted if the resident had an episode of angry outburst. On 3/17/26 at 0909 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. Medical record review for Resident 8 was initiated on 3/12/26. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's Order Summary Report showed the following physician's orders: - dated 2/19/26, to monitor for episodes of anxiety as evidenced by agitation and angry outbursts every shift; - dated 2/19/26, to administer Ativan (antianxiety medication) 1 mg one tablet by mouth every eight hours as needed for anxiety with manifested behavior of agitation and angry outbursts for 14 days (2/19 to 3/5/26); and -dated 3/5/26, to administer Ativan 1 mg one tablet by mouth every eight hours as needed for anxiety with manifested behavior of agitation and angry outbursts for 30 days (3/5 to 4/4/26). a. Review of Resident 8's MAR for March 2026 showed Resident 8 received Ativan 1 mg on the following dates and times: - dated 3/1 at 0300 hours; - dated 3/11 at 0721 hours; - dated 3/12 at 0636 hours; and - dated 3/15 at 1208 hours. Review of Resident 8's medical record failed to show the episodes of anxiety were monitored and documented when the Ativan medication was given on the above listed dates. b. Review of Resident 8's care plan for Ativan for anxiety dated 1/13/26, showed interventions including to give antianxiety medication ordered by physician, monitor/record occurrence of target behavior symptoms, and nonpharmacological interventions (back rub, redirection, speak to/approach in a calm manner, reposition, offer snacks or fluid/milk, assess for pain, provide a quiet environment, encourage to express feelings, take to activities, and provide reassurance). Review of Resident 8's MAR for March 2026 showed Resident 8 was monitored and documented with episodes of anxiety as evidenced by agitation and angry outbursts on the following dates and shifts: - dated 3/2 at night shift – one episode; - dated 3/4 at evening shift – one episode; - dated 3/4 at night shift – one episode; - dated 3/6 at day shift – one episode; - dated 3/7 at day shift – one episode; - dated 3/7 at night shift – one episode; - dated 3/8 at day shift – one episode; and - dated 3/10 at day shift – one episode; Review of Resident 8's medical record failed to show the manifested behaviors were addressed by either providing nonpharmacological interventions or administering the Ativan medication as prescribed. On 3/16/26 at 1344 hours, an interview and concurrent medical record review for Resident 8 was conducted with RN 1. RN 1 verified the above findings. RN 1 stated the manifested behaviors should be accurately documented to determine if the resident was getting better or worse and it would also assist in determining whether the medication should be continued or not. RN 1 further stated the manifested behavior should be addressed by providing nonpharmacological interventions and if not effective, administer the prescribed medication for anxiety. On 3/16/26 at 1455 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings for Resident 8.

Based on interview, medical record review and facility P&P review, the facility failed to ensure the comprehensive plan of care was revised to reflect the resident's current care needs and interventions for one of 19 final sampled residents (Resident 5). * The facility failed to revise Resident 5's care plan to address the interventions for the left arm AV fistula. This failure posed the risk of not providing the resident with individualized and person-centered care.Findings: Review of the facility's P&P titled Care plan and care plan update revised 3/2020 showed it is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well being in accordance with the interdisciplinary comprehensive assessment and plan of care. Care plan will be initiated based on identified problems and medical change of condition. On 3/11/26 at 0808 hours, during the initial tour of the facility, Resident 5 was observed with the upper right chest perma-catheter. Resident 5 stated that she goes to dialysis and use the perma-catheter for dialysis. Resident 5 further stated she has a new left upper arm fistula. Medical record review for Resident 5 was initiated on 3/11/26. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's Care Plan Report showed a care plan problem dated 10/29/24, addressing needs for dialysis related to renal failure. Review of Resident 5's H&P examination dated 10/10/25, showed the resident could make needs known and make medical decisions. Review of Resident 5's Arteriovenous Access Creation/Surgery Discharge Instructions dated 2/10/26, showed left arm AV fistula creation with a discharge instruction to not lift anything or strain your access arm. Review of Resident 5's care plans failed to show the care plan interventions for dialysis related to renal failure was updated to include addressing precautions to be taken on the new left arm AV fistula. On 3/16/26 at 1017 hours, an interview and concurrent medical record review for Resident 5 was conducted with RN 1. RN 1 verified there were no interventions developed to address the left arm AV fistula and verified the findings. On 3/17/26 at 0902 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. Cross reference to F842

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure two licensed nurses reviewed for competency had specific competencies and standard of practice skill sets needed to provide safe and efficient nursing care. * The facility failed to ensure LVN 3 was able to demonstrate competency in the calibration of a glucometer accucheck machine (a device used to measure the concentration of glucose in the blood). * The facility failed to ensure RN 2 was able to competently administer the correct intravenous medication dosage to Resident 101. These failures had the potential to put the residents at risks for the care not provided in a safe and competent manner.Findings: Review of the facility's document titled Registered Nurse Supervisor Job Description dated 12/17/21, showed the RN must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulation and guidelines that pertain to long-term care. Review of the facility's document titled Licensed Vocational Nurse/Licensed Practical Nurse Job Description dated 12/17/21, showed the LVN must be knowledgeable of the nursing and medical practices and procedures, as well as laws, regulation and guidelines that pertain to long-term care. Review of the blood glucose meter manufacturer's information sheet titled Quality Assurance/ Quality Control Reference Manual (undated) showed the following:- under Quality Control Test section showed to perform a control test to ensure the meter is working properly:a. Insert a test strip;b. Select mode: Press the arrow buttons to enter control solution mode (indicated by a bottle icon);c. Apply solution: Shake the Assure Dose Control Solution, discard the first drop, and apply the second drop to the cap;d. Check range: Compare the result to the range printed on the test strip vial.- under the Troubleshooting and Tips section showed to use Assure Dose Control Solution (blue cap = normal, green cap = high). Make sure the test strips and control solutions are not past expiration date. The date is shown in the bottle. Discard control solution 90 days after the bottle is opened. Results that fall outside the range may be caused by the test strip bottle was opened for more than three months. 1. On 3/11/26 at 1606 hours, an observation of the glucometer quality control, review of the glucometer quality control record, and concurrent interview was conducted with LVN 3. When LVN 3 was asked to calibrate the glucometer, LVN 3 stated she did not know how to calibrate the glucometer. LVN 3 stated she was oriented by another charge nurse during her orientation period. When asked if she was taught how to calibrate the glucometer, LVN 3 stated she could not recall. On 3/13/26 at 1504 hours, an interview and concurrent employee file review for LVN 3 was conducted with the DON. Review of LVN 3's Medication Pass Guidelines (undated) showed under Insulins/Diabetic Management/Glucometer: a. Vials are dated when opened; b. Insulin suspensions are gently rolled in palms; and c. The clear rapid or short-acting insulin is drawn up first when insulins are mixed, LVN 3 had checks in #1 column for a, b, and c. The file showed LVN 3 was observed on 11/20/25 by the DON. However, the section did not show if the glucometer calibration was reviewed/observed for LVN 3. The DON stated the checked in column #1 meant yes showing LVN 3 passed the observations. The DON stated she was responsible for checking off the skills competency for licensed nurses. The DON stated she provided training and performed the glucometer calibration skills check to LVN 3 upon hire. The DON stated the competency skills check including calibration of the glucometer was done upon hire, annually, and as needed. The DON was informed and acknowledged the above findings. 2. Review of the facility's P&P titled Policy and Procedure of IV (undated) showed because of the complexity involved in the administration of infusion therapy, it is essential that responsibility not only be assigned and taught, but that accountability of each person involved in the delivery and maintenance of infusion therapy be stressed. The practicing nurse is ultimately responsible to be knowledgeable regarding the specific drug and therapy to effectively implement these policies and procedures in individual clinical applications. On 3/12/26 at 0908 hours, a medication administration observation for Resident 101 was conducted with RN 2. RN 2 stated she would be administering ertapenem (antibiotic) IV 500 mg to Resident 101. RN 2 stated Resident 101 received the antibiotic once daily since 3/7/26. The ertapenem medication vial showed one gram/10 ml. The pharmacy label attached showed ertapenem one gram/10 ml sterile water, then transfuse 5 ml (500 mg) into 50 ml NS piggyback, and infuse one IVPB over 30 minutes one time a day. RN 2 was observed diluting the one vial of ertapenem with 10 ml of NS, aspirated the whole amount in the vial which totaled to 10 ml, and mixed it in the 50 ml of NS piggyback. RN 2 was observed hanging the 50 ml of NS piggyback with the ertapenem medication. RN 2 connected the IV tubing to Resident 101's peripheral IV catheter in the right arm. RN 2 stated she would run the whole bag of NS IVPB for 30 minutes and would come back after that to recheck Resident 101 when asked if she would administer the whole bag of NS with the ertapenem medication. RN 2 was instructed by the surveyor not to administer the IV medication she prepared. RN 2 was informed by the surveyor the dosage she prepared was incorrect according to the physician's order. RN 2 acknowledged the above findings and stated she should have removed the other five ml of the ertapenem medication after she diluted the one vial with the 10 ml of NS. On 3/13/26 at 1504 hours, an interview and concurrent employee file review for RN 2 was conducted with the DON. Review of RN 2's Skills Checklist-LN-IV Therapy (undated) showed under IV Skills for Order Check: a. Order compared to label, and b. Label has date, time and initiated when hung was signed by the DON on 5/27/25. The DON stated she was responsible for checking off the skills competency for licensed nurses. The DON stated the competency skills check including IV Skills for RNs was done upon hire, annually, and as needed. The DON was informed and acknowledged the above findings. Cross reference to F755.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the correct dosage of the medication was administered as per physician's order for one of 19 final sampled residents (Resident 101) observed for medication administration. * RN 2 failed to ensure the correct dosage of Resident 101's IV ertapenem (antibiotic) medication was administered per physician's order. This failure posed the risk for negative health outcomes for Resident 101.Findings: Review of the facility's P&P titled Medication Administration revised 8/2021 showed the medications must be administered in accordance with the written orders of the attending physician. According to DailyMed, the most common clinically adverse effects of the ertapenem sodium medication overdosage were nausea, diarrhea, and transient dizziness. Review of the manufacturer's information titled Ertapenem (brand name Invanz), the Dosage and Frequency section showed for renal impairment: for patients with creatinine clearance, the dose should be reduced to 500 mg daily. On 3/12/26 at 0908 hours, a medication administration observation for Resident 101 was conducted with RN 2. RN 2 stated she would be administering the ertapenem IV 500 mg to Resident 101. RN 2 stated Resident 101 received the antibiotic once daily since 3/7/26. The ertapenem medication vial showed one gram/10 ml. The pharmacy label attached showed ertapenem one gram/10 ml sterile water, then transfuse 5 ml (500 mg) into 50 ml NS piggyback, and infuse one IVPB over 30 minutes one time a day. RN 2 was observed diluting the one vial of ertapenem with 10 ml of NS, aspirated the whole amount in the vial which totaled to 10 ml, and mixed it in the 50 ml of NS piggyback. RN 2 was observed hanging the 50 ml of NS piggyback with the ertapenem. RN 2 connected the IV tubing to Resident 101's peripheral IV catheter in the right arm. RN 2 stated she would run the whole bag of NS IVPB for 30 minutes and would come back after that to recheck Resident 101 when asked if she would administer the whole bag of NS with the ertapenem medication. RN 2 was instructed by the surveyor not to administer the IV medication she prepared. RN 2 was informed by the surveyor the dosage she prepared was incorrect according to the physician's order. RN 2 acknowledged the above findings and stated she should have removed the other five ml of the ertapenem medication after she diluted the one vial with the 10 ml of NS. Medical record review for Resident 101 was initiated on 3/12/26. Resident 101 was readmitted to the facility on [DATE], with diagnoses including Stage 1 CKD. Review of Resident 101's Basic Metabolic Panel result dated 3/3/26, showed the BUN was 44 mg/dL (normal range between 7-20 mg/dL) and the Creatinine was 1.8 mg/dL (normal range 0.7-1.3 mg/dL). Review of Resident 101's Order Summary Report showed a physician's order dated 3/7/26, to administer ertapenem sodium injection solution reconstituted 500 mg IV one time a day for lower UTI, ESBL of the urine until 3/17/26. On 3/12/26 at 1640 hours, an interview and concurrent medical record review for Resident 101 was conducted with the Pharmacy Consultant via telephone call. The Pharmacy Consultant stated the common general adverse reactions to the ertapenem medication overdosing were nausea, diarrhea and headache. The Pharmacy Consultant stated the ertapenem medication should be administered carefully to the residents with chronic kidney disease, especially if the BUN and Creatinine were not stable. The Pharmacy Consultant was informed regarding the findings for Resident 101 during the medication administration. The Pharmacy Consultant stated nurses should pay attention, read carefully the label of the medication, and administer the correct dosage per physician's order. The Pharmacy Consultant stated Resident 101's renal function at this time was stable based on the laboratory results. On 3/13/26 at 1504 hours, an interview and concurrent medical record review for Resident 101 was conducted with the DON. The DON stated the expectations for the nurses during medication administration were for them to check the orders and make sure the correct dosage was given to the resident per physician's order. The DON was informed and acknowledged the above findings for Resident 101. Cross reference to F726, example #2.

Based on observation, interview, and medical record review, the facility failed to provide the necessary pharmacy services to ensure proper labeling of the medications for three nonsampled residents (Residents 41, 52, and 69). * The facility failed to ensure the medications for Residents 41, 52, and 69 were properly labeled with open date. This failure had the potential for the residents to have received expired medications and risk of undermining the efficacy of the stored medications.Findings: On 3/11/26 at 1606 hours, an observation of Medication Cart A and concurrent interview was conducted with LVN 3. The following was observed in Medication Cart A:- The geri-tussin (medication for cough) 100 mg/5 ml liquid bottle for Resident 41 was not labeled with an open date;- The gabapentin (medication for seizure) 250 mg/5 ml liquid bottle for Resident 52 was not labeled with an open date; and- The megestrol acetate (medication for appetite loss and severe weight loss) 40 mg/ml liquid bottle for Resident 69 was not labeled with open date. LVN 3 verified the findings and stated the medications should be labeled with open dates. a. Medical record review for Resident 41 was initiated on 3/11/26. Resident 41 was admitted to the facility on [DATE]. Review of Resident 41's Order Summary Report showed a physician's order dated 3/7/26, to administer geri-tussin oral liquid 100 mg/5 ml by mouth every six hours as needed for cough. b. Medical record review for Resident 52 was initiated on 3/11/26. Resident 52 was admitted to the facility on [DATE]. Review of Resident 52's Order Summary Report showed a physician's order dated 2/24/26, to administer gabapentin oral solution 250 mg/5 ml by mouth every eight hours for neuropathic pain (chronic pain characterized by burning, shooting, or pins and needles sensation). c. Medical record review for Resident 69 was initiated on 3/11/26. Resident 69 was admitted to the facility on [DATE]. Review of Resident 69's Order Summary Report showed a physician's order dated 8/4/24, to administer megestrol acetate suspension 400 mg/10 ml by mouth one time a day for appetite stimulant. On 3/13/26 at 1504 hours, an interview and concurrent medical record review for Residents 41, 52 and 69 was conducted with the DON. The DON stated for the house stock medications, the facility goes by the manufacturer's expiration date and there was no need to label with open date. The DON stated for the medications prescribed specifically to the residents, it should be labeled with open dates because there were certain medications which were only good for certain days and it could also indicate if the medications were being administered properly or correctly regarding the ordered frequency and amount. The DON was informed and acknowledged the above findings.

Based on observation, interview, and facility P&P review, the facility failed to ensure the facility's garbages and refuse was properly disposed for one of three garbage dumpsters. * One blue garbage dumpster was not fully closed. This failure had the potential to cause unsafe sanitary conditions and potential to harbor pests and rodents.Findings: According to the USDA Food Code 2022, Section 5-501.113 Covering Receptacles: Receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered. (B) With tight-fitting or doors if kept outside the food establishment. Review of the facility's P&P titled Miscellaneous Areas dated 2023 showed the garbage and trashcans must be inspected daily that no debris is on the ground or surrounding area, and that the lids are closed. On 3/13/26 at 0652 hours, an observation was conducted of the facility's outside dumpsters located on the side of the facility. The lid of one of the three blue garbage dumpsters was observed open and not fully closed. On 3/13/26 at 0730 hours, an observation of the facility's outside dumpsters and concurrent interview was conducted with the DSS. The DSS verified the lid of a blue garbage dumpster was partially propped open with bags of trash. On 3/17/26 at 1047 hours, the Administrator, DON, DSS, and RD were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical record were complete and accurately documented for four of 19 final sampled residents (Residents 5, 32, 42, and 107). * The facility failed to ensure Resident 5's BP access site was accurately documented in the medical record. * Resident 32's Advanced Directive was missing a page and failed to show who he selected as his healthcare agent. * The facility failed to ensure the Narcotic and Hypnotic Record form was properly documented for Resident 42. * Resident 107's POLST showed the resident did not have an Advanced Healthcare Directive, however the resident did have one at her home. These failures have the potential for the residents' care needs not being met as their medical information was inaccurate and incomplete.Findings: 1. Review of the facility's P&P titled Care of Residents on Renal Dialysis, Hemodialysis Access Site, Care Plan Diet/Fluid Restriction revised 6/2009 showed it is the policy of this facility to provide standards of care of the residents on renal dialysis and the care of the vascular access site for hemodialysis. Blood pressures or venous punctures will not be performed on the extremity where AV fistula and AV graft sites are located. On 3/11/26 at 0808 hours, during the initial tour of the facility, Resident 5 was observed with upper right chest perma-catheter. Resident 5 stated that she goes to the dialysis and uses the perma-catheter for dialysis, Resident 5 further stated she has a new left upper arm fistula. Medical record review for Resident 5 was initiated on 3/11/26. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's H&P examination dated 10/10/25, showed the resident could make needs known and make medical decisions. Review of Resident 5's care plan for dialysis related to renal failure dated 10/29/24, showed interventions including to not draw blood or take blood pressure in the left arm. Review of Resident 5 Arteriovenous Access Creation/Surgery Discharge Instructions dated 2/10/26, showed the resident had a left arm AV fistula creation. Review of Resident 5's documentation of BP for March 2026 showed the following: - On 3/1/26 at 0732 hours, a BP reading of 148/59 mmHg on the left arm; - On 3/1/26 at 1410 hours, a BP reading of 132/72 mmHg on the left arm; - On 3/3/26 at 0732 hours, a BP reading of 126/68 mmHg on the left arm; - On 3/3/26 at 1151 hours, a BP reading of 145/66 mmHg on the left arm; - On 3/3/26 at 1817 hours, a BP reading of 156/65 mmHg on the left arm; - On 3/3/26 at 2118 hours, a BP reading of 139/59 mmHg on the left arm; - On 3/4/26 at 0739 hours, a BP reading of 143/57 mmHg on the left arm; - On 3/4/26 at 1145 hours, a BP reading of 144/58 mmHg on the left arm; - On 3/4/26 at 2157 hours, a BP reading of 142/69 mmHg on the left arm; - On 3/5/26 at 1214 hours, a BP reading of 156/66 mmHg on the left arm; - On 3/7/26 at 0759 hours, a BP reading of 128/61 mmHg on the left arm; - On 3/7/26 at 1155 hours, a BP reading of 141/65 mmHg on the left arm; - On 3/8/26 at 0811 hours, a BP reading of 124/60 mmHg on the left arm; - On 3/8/26 at 1310 hours, a BP reading of 125/68 mmHg on the left arm; - On 3/8/26 at 1727 hours, a BP reading of 125/60 mmHg on the left arm; - On 3/9/26 at 1149 hours, a BP reading of 148/65 mmHg on the left arm; - On 3/9/26 at 2000 hours, a BP reading of 124/68 mmHg on the left arm; - On 3/9/26 at 2152 hours, a BP reading of 132/66 mmHg on the left arm; - On 3/10/26 at 0739 hours, a BP reading of 118/60 mmHg on the left arm; - On 3/10/26 at 2104 hours, a BP reading of 138/60 mmHg on the left arm; - On 3/11/26 at 0052 hours, a BP reading of 114/55 mmHg on the left arm; - On 3/11/26 at 0645 hours, a BP reading of 120/60 mmHg on the left arm; - On 3/11/26 at 0806 hours, a BP reading of 118/68 mmHg on the left arm; - On 3/12/26 at 0543 hours, a BP reading of 111/61 mmHg on the left arm; - On 3/12/26 at 1214 hours, a BP reading of 122/61 mmHg on the left arm; - On 3/13/26 at 2203 hours, a BP reading of 142/68 mmHg on the left arm; - On 3/14/26 at 0813 hours, a BP reading of 105/58 mmHg on the left arm; - On 3/14/26 at 1226 hours, a BP reading of 125/61 mmHg on the left arm; - On 3/15/26 at 0801 hours, a BP reading of 137/57 mmHg on the left arm; - On 3/15/26 at 1143 hours, a BP reading of 134/65 mmHg on the left arm; - On 3/15/26 at 1438 hours, a BP reading of 130/62 mmHg on the left arm; and - On 3/16/26 at 0809 hours, a BP reading of 145/63 mmHg on the left arm; On 3/16/26 at 1009 hours, an interview was conducted with Resident 5. Resident 5 stated she never allowed the licensed nurses to take her BP on the left upper arm. On 3/16/26 at 1017 hours, an interview and concurrent medical record review for Resident 5 was conducted with RN 1. RN 1 verified blood pressures were not taken on Resident 5's left arm and the documentation for the BP readings for March 2026 were inaccurate. On 3/17/26 at 0902 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. Medical record review for Resident 42 was initiated on 3/11/26. Resident 42 was admitted to the facility on [DATE]. Review of Resident 42's Order Summary Report showed a physician's order dated 2/27/26, to administer oxycodone-acetaminophen (pain reliever) 10-325 mg one tablet by mouth every four hours as needed for moderate to severe pain (4-10, on the pain scale of 0 to 10 with 0 = no pain and 10 = worst). Review of Resident 42's MAR for March 2026 showed Resident 42 received the oxycodone-acetaminophen 10-325 mg medication on 3/10/26 at 1246 hours. On 3/11/26 at 1606 hours, a review of the facility's document titled Narcotic and Hypnotic Record and concurrent interview was conducted with LVN 3. Review of Resident 42's Narcotic and Hypnotic Record for the oxycodone-acetaminophen 10-325 mg showed the medication was given with an initial. However, the time the medication was given was left blank. LVN 3 verified the findings. On 3/13/26 at 1504 hours, an interview and concurrent medical record review for Resident 42 was conducted with the DON. The DON stated the nurses should document accurately and correctly. The DON was notified and acknowledged the above finding for Resident 42. 3. Review of the facility's P&P titled Documentation revised May 2021 showed the resident's medical record is a concise and accurate account of treatment and care. Review of the facility's P&P titled Advance Directives revised May 2021 showed the following:- prior to, or upon admission, the care plan team will ask residents, and/or their family members, about the existence of any Advance Directives; and- should the resident indicate that he or she has issued Advance Directives about his/her care and treatment, the facility will require that a copy of such directives be included in the medical record. a. Medical record review for Resident 32 was initiated on 3/11/26. Resident 32 was admitted to the facility on [DATE]. Review of Resident 32's H&P examination dated 2/21/26, showed the resident had no capacity to understand and make decisions. Review of Resident 32's POLST dated 2/19/26, signed by Family Member 1 showed the resident had an Advance Directive dated 2024 and the legally recognized decision maker was Family Member 1. Review of Resident 32's Advanced Directive Durable Power of Attorney for Health Care and Living Will dated 9/24/24, was missing page two and failed to show who the resident selected as his healthcare agent. On 3/12/26 at 1611 hour, an interview and concurrent medical record review for Resident 32 was conducted with the SSD. The SSD verified Resident 32's Advanced Directive was incomplete and did not show who the resident had selected as his healthcare agent. b. Medical record review of Resident 107 was initiated on 3/11/26. Resident 107 was admitted to the facility on [DATE]. Review of Resident 107's POLST dated 3/9/26, showed the resident did not have an Advance Directive. On 3/12/26 at 1013 hours, an interview was conducted with Resident 107. Resident 107 stated she had an Advance Directive, but it was at home on her desk. Resident 107 stated no one at the facility asked her about an Advance Directive. On 3/12/26 at 1608 hours, an interview and concurrent medical record review for Resident 107 was conducted with the SSD. The SSD stated she saw Resident 107 earlier today and the resident informed her she had an Advance Directive, but was unable to retrieve it, but would see if her family could try and retrieve it from her home. The SSD stated Resident 107's POLST should reflect the resident had an Advance Directive not currently available for review. The SSD reviewed Resident 107's POLST and verified it incorrectly showed the resident did not have one.

Based on interview and facility document review, the facility failed to implement the facility's QAPI plan and the past Recertification Survey POC for F554 and F761. * The facility failed to show audits and/or monitoring tools were completed per the facility's POC for F554 and F761. This failure had the potential for ongoing non-compliance and complete data being reviewed by the QAPI committee. Findings: During the survey process, the survey team identified repeat deficient practices from the facility's prior recertification survey conducted from 9/23/24 to 9/26/24, for F554 and F671. Review of the facility's 2024 Recertification Survey POC accepted by the department on 11/27/24, included the following:- for F554, the POC showed the Medical Records will perform chart reviews upon admission and check for any new orders. The DON or designee will report findings to the QA&A Committee monthly for six months. - for F761, the RN Supervisor/Designee will randomly check medication carts weekly for eight weeks, and then monthly to ensure proper medication storage. The DON or designee will report findings to the QA&A Committee monthly for six months. On 3/17/26 at 1317 hours, a review of the facility's QAPI binder and supporting documents was reviewed with the Administrator. The Administrator was unable to provide records to show Medical Records staff performed chart reviews of new admissions for new orders, and the RN Supervisor or designee performed medication cart checks weekly for eight weeks, and then monthly per the 2024 Recertification Survey's POC. The Administrator stated the audits were part of their routine process and therefore did not have records to show the above were completed.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were followed. * The facility records showed Resident 47 had a UTI, when the resident's symptoms did not meet criteria for a true infection. * The facility failed to ensure the Medication Cart A's fourth small drawer was free of medication spillage. In addition, the iron liquid bottle was observed with sticky spillage. * LVN 4 failed to perform hand hygiene and change gloves after touching Resident 87's surroundings, before checking the GT and administering the medications. These failures posed the risk for transmission of disease-causing microorganisms and infections to the residents, staff, and visitors.Findings: 1. Review of the facility's P&P titled Infection Prevention and Control Program revised October 2022 showed the facility will use McGeer's Criteria as a surveillance tool used to recognize the occurrent of infections, record the infection count and frequency. The facility will maintain a record of incidence per infection and actions taken. The IP will complete infection surveillance and report monthly to the Administrator and DON, and quarterly to the QAPI Committee. Medical record review for Resident 47 was initiated on 3/13/26. Resident 47 was admitted to the facility on [DATE]. Review of the facility's Infection Prevention and Control Surveillance Log for January 2026 showed Resident 47 started antibiotics for a HAI UTI. Review of Resident 47's Surveillance Data Collection Form for UTIs showed the resident's symptoms started on 1/4/26. The form showed the resident's symptoms including an increase in urinary urgency and frequency met criteria for a true infection. Review of Resident 47's medical record failed to show the resident had urinary urgency or frequency, and failed to show the resident met criteria for a UTI. On 3/13/26 at 1305 hours, an interview, medical record review for Resident 47 and concurrent facility document review was conducted with the IP and DSD. The IP and DSD verified Resident 47's Surveillance Data Collection Form showed the resident's UTI met criteria for a HAI infection. However, the IP and DSD verified review of Resident 47's medical record failed to show the resident's symptoms met the criteria, and was incorrectly reported to the QAPI Committee as a HAI UTI. 2. Review of the facility's P&P titled Medication Access and Storage revised 2/2019 showed medication storage areas are kept clean, well lit, and free of clutter. On 3/11/26 at 1606 hours, an observation of Medication Cart A and concurrent interview was conducted with LVN 3. Medication Cart A's fourth small drawer was observed with multiple medication spillage. Medication Cart A was observed with nine big bottles of liquid medications. LVN 3 stated the liquid medications were house stock and used for the residents in the facility. In addition, one big bottle of iron supplement liquid medication was observed with sticky spillage all over it. LVN 3 verified the findings and stated the medication carts should be maintained clean and free of any spillage. 3. Review of the facility's P&P titled Hand Washing revised 5/2021 showed it is the policy of the facility to cleanse hands to prevent transmission of possible infectious material and to provide clean, healthy environment for residents and staff. Review of the facility's P&P titled IPCP Standard and Transmission-Based Precautions revised 10/2022 showed under the Procedure section, the standard precautions are infection prevention practices that apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. Standard precautions include: proper selection and use of PPE, hand hygiene, safe injection practices, respiratory hygiene and cough etiquette, environmental cleaning and disinfection, and reprocessing of reusable medical equipment. On 3/12/26 at 0945 hours, a medication administration observation for Resident 87 was conducted with LVN 4. LVN 4 was observed performing hand hygiene and donned new gloves. LVN 4 stopped the tube feeding pump, repositioned Resident 87, and raised the resident's bed. LVN 4 proceeded with checking the GT for residual & administered the medications to Resident 87 without performing hand hygiene and changing with new gloves. On 3/12/26 at 1000 hours, an interview was conducted with LVN 4. LVN 4 acknowledged she did not perform hand hygiene and changed with new gloves after she touched Resident 87's surroundings. LVN 4 stated she should have done hand hygiene and donned new gloves for infection prevention. On 3/13/26 at 1451 hours, an interview was conducted with the IP. The IP was informed of the findings regarding the Medication Cart A and LVN 4 during medication administration for Resident 87. The IP stated she checked the medication carts weekly. The IP stated the facility should maintain the cleanliness of the medication carts or storage and the medication bottles used for the residents should be free of any leakage or spillage to prevent contamination. The IP stated the nurses were expected to perform hand hygiene and change with new gloves after touching the equipment or the surrounding in the resident's room before performing any task for the medical device attach to the resident and administering medications to prevent cross contamination. The IP acknowledged the above findings, On 3/17/26 at 1400 hours, an interview was conducted with the DON and Administrator. The DON and Administrator were informed and acknowledged the above findings.

Based on observation, interview, and facility document review, the facility failed to protect the residents' identifiable information.* The facility's survey results binder for public viewing included three confidential resident rosters. This failure resulted in confidential residents' information being accessible to the public.Findings: On 3/17/26 at 1019 hours, the Survey Inspection Results binder was observed on top of the Nursing Station 1 countertop and was posted for public view. Review of the Survey Inspection Results binder (undated) showed three Confidential Resident Rosters (a list which identified the names of the residents by their identifiers given for surveys to protect the residents' identities) for the following surveys:- a Concurrent Relicensing and Recertification Survey roster dated 9/24/24 - 9/26/24, with six residents identifiers and their names;- an Abbreviated Survey dated 7/9/25, with two resident identifiers and their names; and - an Abbreviated Survey dated 2/5/26, with three resident identifiers and their names. The rosters were identified as being confidential and had Confidential printed diagonally across the page in a large grey font. On 3/17/26 at 1055 hours, an interview and concurrent facility document review was conducted with the Administrator. The Administrator verified the three confidential resident rosters should not have been in the survey binder for public view.

Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for one of 19 final sampled residents (Resident 49). * The facility failed to ensure Resident 49's nasal cannula tubing was dated and labeled as per the facility's P&P. In addition, the facility failed to ensure the nasal cannula tubing was stored in a set-up bag when not in use for Resident 49. This failure had the potential for the residents not to receive the appropriate care and may negatively impact the resident's medical conditions.Findings: Review of the facility's P&P titled Use of Oxygen revised 5/2021 showed it is the policy of this facility to promote resident safety in administering oxygen. The oxygen cannula or mask will be changed at least every seven (7) days, as well as the disposable humidifier. The tubing, masks, humidifiers, and other disposables used for oxygen administration will be dated in an identifiable fashion. Labeled and dated bags should be provided for cannulas and masks to be placed in when not in use. On 3/11/26 at 0819 hours and 1027 hours, during the initial tour of the facility, Resident 49's nasal cannula tubing was observed unlabeled and undated. In addition, the nasal cannula tubing was placed on top of the resident bed and not stored in a set up bag. Resident 49 stated she removed the nasal cannula when she eats and there was no set up bag to put the nasal cannula when she removed the nasal cannula. Medical record review for Resident 49 was initiated on 3/11/26. Resident 49 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 49's H&P examination dated 2/21/26, showed Resident 49 had the capacity to understand and make decisions. Review of Resident 49's Order Summary Report showed a physician's order dated 3/10/26, to administer oxygen at two LPM via nasal cannula as needed for angina (a type of chest pain caused by reduced blood flow to the heart). Review of Resident 49's Care Plan Report dated 3/10/26, showed a care plan focus addressing the resident has as needed oxygen therapy related to history of respiratory failure, hypoxia and angina. The interventions included administering the oxygen via nasal cannula at two LPM as needed. On 3/11/26 at 1029 hours, an observation of Resident 49 and concurrent interview was conducted with LVN 2. LVN 2 verified the oxygen nasal cannula tubing was not labeled with the date when it was changed and was not stored in a set up bag. LVN 2 stated the nasal cannula should have been labeled with the date and should have been stored in a bag to keep it clean, sanitary and for infection control purposes. On 3/17/26 at 0902 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive care plan to reflect the individual care needs for one of three sampled residents (Resident 1). * The facility failed to develop a care plan to address Resident 1's alleged abuse incident on 1/9/26. This failure had the potential risk of not providing the appropriate, consistent, and individualized care to Resident 1.Findings: Review of the facility's P&P titled Care Planning revised 2/2021 showed it is the policy of this facility that the IDT shall develop a comprehensive care plan for each resident. Medical record review for Resident 1 was initiated on 1/22/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 10/17/25, showed the resident did not have the capacity to understand and make decisions. Review of Resident 1's Progress Note dated 1/9/26, showed at around noon, the police came in stating the resident's wife called them and claimed Resident 1 was abused, bruised and burned. Review of Resident 1's eINTERACT Change in Condition Evaluation - V 5.1 dated 1/9/26, showed the resident had right hand discoloration. Review of Resident 1's Progress Notes dated 1/9, 1/13-1/15/26, showed Social Services provided psychosocial support to the resident. Further review of the notes failed to show psychosocial support was provided from 1/10 - 1/12/26, after the incident occurred on 1/9/26. Review of Resident 1's medical record failed to show a care plan was developed to address the resident's alleged abuse on 1/9/26. On 2/3/26 at 1053 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified there was no care plan to address Resident 1's alleged abuse on 1/9/26. RN 1 stated the licensed nurse should have done a care plan for the alleged abuse so the staff could monitor Resident 1 and have goals and interventions in place. On 2/3/26 at 1607 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified there was no care plan to address the resident's alleged abuse on 1/9/26. The DON stated the staff did not do the alleged abuse care plan because it was unsubstantiated, no harm was done, and there was no change in condition. The DON further stated the social worker provided psychosocial support and visits daily. The DON stated the licensed nurse did a care plan for the resident's hand discoloration.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of seven final sampled residents (Resident 1) was informed of the indication for the use of medications affecting brain activities associated with mental processes and behavior. * The facility failed to ensure Resident 1's informed consent was obtained when the indication for the use of Ativan (lorazepam, a benzodiazepine class of medication used to treat anxiety) was changed in frequency in administration from every six hours to every eight hours. * The facility failed to ensure Resident 1's informed consent was obtained for the use of Depakote (an anticonvulsant medication for labile mood). These failures had the potential for Resident 1 not to be informed of the medications and potential side effects of the use of Ativan and Depakote medications.Findings: Review of the facility's P&P titled Psychotropic (medication affecting brain activities associated with mental processes and behavior) Drug Use revised 1/2023 showed upon initiation of a new order for psychoactive medications, the Licensed Nurses shall complete the Verification of Informed Consent form prior to the initiation of the new medication. Closed medical record review for Resident 1 was initiated on 9/2/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Facility Verification of Informed Consent form dated 8/9/25, showed Ativan 1 mg orally every eight hours as needed anxiety signed by the physician on 8/10/25. Review of Resident 1's H&P examination dated 8/10/25, showed the resident had no capacity to understand and make decisions. Review of Resident 1's Order Summary Report dated 8/20/25, showed the following orders: - dated 8/14/25, lorazepam 1 mg tablet by mouth every six hours as needed for anxiety manifested by inability to relax for 14 days, and - dated 8/13/25, Depakote 250 mg delayed release tablet by mouth to administer two times a day for mood disorder manifested labile mood. Review of Resident 1's MAR for August 2025 showed Resident 1 had received the following medications on the following dates/times: - Depakote 250 mg delayed release tablet by mouth two times a day since 8/14/25, and - lorazepam 1 mg tablet by mouth every six hours as needed for anxiety manifested by inability to relax since 8/14/25. On 9/2/25 at 1120 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON verified the Resident 1's Facility Verification of Informed Consent form dated 8/9/25 showed Ativan (lorazepam) 1 mg orally every eight hours as needed anxiety. The DON additionally verified Resident 1's medical record failed to show an informed consent was obtained for the use of the Depakote 250 mg medication. The DON stated the informed consent should have been obtained upon the change in the physician's order to indicate the lorazepam 1 mg tablet by mouth every six hours as needed for anxiety manifested by inability to relax and for use of the Depakote 250 mg delayed release tablet by mouth to administer two times a day for mood disorder manifested labile mood.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of seven sampled residents (Residents 1) was free from unnecessary psychotropic (medication affecting brain activities associated with mental processes and behavior) medications. * The facility failed to ensure Resident 1 was adequately monitored for the Depakote medication. This failure posed risk for Resident 1 to cause potential harm from adverse consequences and a significant decline in functioning. Findings: Review of the facility's P&P titled Psychotropic Drug Use revised 1/2023 showed it is the policy of this facility to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. These residents will be referred to the facility's Psychotropic Drug Review Committee and/or the Psychiatrist to ensure: a. Psychotropic medication was prescribed to treat a specific diagnosed condition, asdocumented in the clinical record;b. Not in excessive dosage;c. Behavior is not related to Delirium or other reversible conditions;d. Monitoring for adverse consequences and effectiveness of medications are in place;e. PRN medications are within guidelines;f. Informed consent was obtained prior to medication use;g. Review of plan of care shows individualized, person-centered care approaches tomanage behavior with non-pharmacological interventions;h. Attempt/consider a GDR (Gradual Dose Reduction), if appropriate, with consent ofphysician/psychiatrist. Closed medical record review for Resident 1 was initiated on 9/2/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 8/10/25, showed the resident had no capacity to understand and make decisions. Review of Resident 1's Order Summary Report dated 8/20/25, showed the following orders: - dated 8/14/25, for lorazepam 1 mg tablet by mouth every six hours as needed for anxiety manifested by inability to relax for 14 days, and - dated 8/13/25, for Depakote 250 mg delayed release tablet by mouth to administer two times a day for mood disorder manifested labile mood. Further review of Resident 1's medical record failed to show documented evidence Resident 1 was adequately monitored for the use of Depakote. On 9/2/25 at 1120 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON stated the residents taking psychotropic medications were monitored for adverse consequences and behavior manifestation for use of the medication. The DON verified Resident 1 was prescribed with Depakote 250 mg delayed release tablet by mouth to administer two times a day for mood disorder manifested labile mood. The DON verified the resident's medical records failed to show the resident was monitored for the behavior labile mood and for adverse reactions for use of the Depakote medication.

Based on interview and medical record review, the facility failed to ensure one of five sampled residents (Resident 5) reviewed for falls received the necessary care and services for the resident at risk for fall. * The facility failed to monitor and initiate a care plan when Resident 5 reported a fall on 9/1/25. This failure had the potential for the delay in providing the necessary care and services and posed a risk for Resident 5 to sustain serious injury.Findings: Review of the facility's P&P titled Psychotropic Drug Use not dated showed it is the policy of this facility to investigate the circumstances surrounding each resident fall and implement actions to reduce the incidence of additional falls and minimize potential for injury. If the resident sustains a fall, a Risk Management Assessment is completed to determine the cause of the fall, and an IDT meeting is also completed to identify internal and external factors that might have contributed to the fall. The care plan or an update to an existing care plan will then be generated. The Licensed Nurse will complete the documentation as follows:1. Briefly describe the fall2. Identify medications, environmental conditions, equipment involved, contributingmedical factor, and any other factors that may be related to the fall3. Identify fall patterns such as, time of day, location, and activity at time of fall, otherresident involvement that may have contributed to the fall4. Complete the conclusion section of the form and make a determination if possible as tothe cause of the fall5. Identify an action plan or approaches to be taken in an attempt to prevent further fallsbased on newly identified facts or risk factors6. If there is an existing plan of care in the resident's medical record pertaining to falls itshould be updated to reflect newly identified risk factors and approaches7. If there is no existing care plan entry pertaining to falls, a new entry must be developedSignificant information obtained as a result of the IDT should be reported to the physician andfamily and documented in the Medical Records. Medical record review for Resident 5 was initiated on 9/10/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 5's H&P examination dated 9/1/25, showed the resident had no capacity to understand and make decisions. Review of Resident 5's Nursing Notes dated 9/1/25 at 1227 hours, showed Resident 5 was observed with a bandage to his right hand. The resident claimed had a fall the night before on 8/31/25. Review of Resident 5's MDS assessment dated [DATE], showed resident had a BIMS score of 14, indicating the resident was cognitively intact. Review of Resident 5's eInteract SBAR Summary for Providers dated 9/7/25 at 0930 hours, showed the resident had a fall outside in front of the facility. Further review of the resident's medical record failed to show the following: follow up care or monitoring for the resident, a care plan or an update to an existing care plan, and an IDT meeting to identify internal and external factors that might have contributed to the fall after the resident's fall on 9/1/25. On 9/10/25 at 1515 hours, an observation and concurrent interview was conducted with Resident 5. Resident 5 stated he fell the night before he went to the acute care hospital and sustained a scab on the left knee. Resident 5 showed the scab on his left knee. On 9/11/25 at 1053 hours, an interview and concurrent medical record review for Resident 5 was conducted with RN 1. RN 1 verified Resident 5 reported he fell the night before on 9/1/25. RN 1 stated she did not complete a change of condition to monitor the resident. RN 1 verified a care plan for the fall was not updated, a Fall Risk Assessment and an IDT meeting was not completed. On 9/11/25 at 1245 hours, an interview was conducted with the DON. The DON stated she expected the licensed nurses to monitor the resident, update the resident's care plan, a fall Risk Assessment and an IDT meeting should be completed after each episode of a fall. The DON was informed and acknowledged the findings.

Based on observation, interview, medical record review, and facility P&P, the facility failed to ensure the protocols were followed for oxygen administration for four of four sampled residents (Residents 1, 2, 3, and 4). * Residents 2, 3, and 4 were administered with more than the liters per minute ordered by the physician. * Resident 1's MAR failed to show documentation of the administration of the oxygen PRN. These failures had the potential for adverse respiratory outcomes and resulted in inaccurate administration records for the residents. Findings: Review of the facility's P&P titled Oxygen Administration reviewed 2/2023 showed the oxygen shall be administered as ordered by the physician. Review of the facility's P&P titled Guidelines For Medication Administration (undated) showed the medication administration shall be recorded on the appropriate documentation record. 1. Medical record review for Resident 1 was initiated on 6/6/25. Resident 2 was readmitted to the facility on [DATE]. Review of Resident 2's Order Summary Report showed a physician's order dated 11/30/24, for continuous oxygen to be administered at 2 LPM via nasal cannula or mask. On 6/6/25 at 1348 hours, Resident 2 was observed lying in bed with the supplemental oxygen being administered via nasal cannula. The regulator dial showed 5 LPM was administered to the resident. On 6/6/25 at 1455 hours, an observation and concurrent interview was conducted with LVN 1 at Resident 2's bedside. LVN 1 observed Resident 2's oxygen regulator and verified the resident was currently receiving the oxygen at 5 LPM. On 6/6/25 at 1459 hours, a follow-up interview and concurrent medical record review for Resident 2 was conducted with LVN 1. LVN 1 reviewed Resident 2's physician's orders and verified the order for the oxygen administration was for 2 LPM. On 6/6/25 at 1502 hours, an interview was conducted with LVN 2. LVN 2 she was Resident 2's nurse and had not changed the resident's oxygen during her shift. 2. Medical record review for Resident 3 was initiated on 6/6/25. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's Order Summary Report showed a physician's order dated 5/28/25, to administer supplemental oxygen at 2 LPM PRN via nasal cannula or mask to keep the oxygen saturation levels above 90%. On 6/6/25 at 1344 hours, Resident 3 was observed sitting up in bed with the oxygen being administered via nasal canula. The regulator showed the oxygen was being administered at 4 LPM. On 6/6/25 at 1456 hours, an observation and concurrent interview was conducted with LVN 1 at Resident 3's bedside. LVN 1 observed Resident 3's oxygen regulator and verified the resident was currently receiving the oxygen at 4 LPM. The LVN stated she did not change the resident's oxygen during her shift. On 6/6/25 at 1459 hours, a follow-up interview and concurrent medical record review for Resident 3 was conducted with LVN 1. LVN 1 reviewed Resident 3's physician's orders and verified the order was for 2 LPM PRN. 3. Medical record review for Resident 4 was initiated on 6/6/25. Resident 4 was readmitted to the facility on [DATE]. Review of Resident 4's Order Summary Report showed a physician's order dated 4/19/25, to administer supplemental oxygen at 2 LPM PRN via nasal cannula or mask, to keep the oxygen saturation above 90%. On 6/6/25 at 1344 hours, Resident 4 was observed sitting up in bed with the oxygen being administered via nasal canula at 3 LPM. On 6/6/25 at 1456 hours, an observation and concurrent interview was conducted with LVN 1 at Resident 4's bedside. LVN 1 observed the resident's oxygen regulator and verified the resident was currently receiving the oxygen at 3 LPM. LVN 1 stated she did not adjust the resident's oxygen during her shift. On 6/6/25 at 1459 hours, a follow-up interview and concurrent medical record review for Resident 4 was conducted with LVN 1. LVN 1 reviewed Resident 3's physician's orders and verified the order was to administer the oxygen for 2 LPM PRN. 4. Closed medical record for Resident 1 was initiated on 6/6/25. Resident 1 was admitted to the facility on [DATE], and discharged to an acute care hospital on 5/19/25. Review of Resident 1's Order Summary Report showed a physician's order dated 4/16/25, for oxygen to be administered PRN at 2 LPM via nasal cannula or mask, to keep the resident's oxygen saturation levels above 90%. Review of Resident 1's MDS assessment dated [DATE], showed the resident was cognitively intact. Review of Resident 1's MAR for 5/2025 showed PRN oxygen at 2 LPM was administered on 5/19/25 at 0000 hours. There was no other documentation in the MAR to show the oxygen was administered on any other days. However, review of Resident 1's Weights and Vitals Summary showed the resident was on oxygen via nasal cannula daily from 5/1 to 5/19/25. Review of Resident 1's LN - Nursing Summary - Weekly dated 5/11/25, showed PRN oxygen was administered to the resident at 2 LPM. Review of Resident 1's LN - Nursing Summary - Weekly dated 5/16/25, showed the resident received continuous oxygen at 2 LPM. Review of Resident 1's Dialysis Communications Records showed the following: - On 5/1/25 at 1820 hours, Resident 1 was on oxygen via nasal cannula. - On 5/10/25 at 1835 hours, Resident 1 was on oxygen at 2 LPM via nasal cannula. Review of Resident 1's N Adv (Nursing Advanced) Skilled Evaluations showed the following: - dated 5/1, 5/3, 5/4, 5/5, 5/6, 5/7, 5/8, 5/9, 5/10, 5/11, 5/12, 5/13, 5/14, 5/15, 5/16, 5/17, and 5/18/25, showed Resident 1 received oxygen via nasal cannula. - dated 5/2 and 5/10/25, showed Resident 1 received PRN oxygen at 2 LPM via nasal cannula. On 7/2/25 at 0916 hours, a telephone interview was conducted with Resident 1. Resident 1 stated he was on continuous oxygen while at the facility. On 7/2/25 at 1033 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with LVN 3. LVN 3 stated Resident 1 was on continuous oxygen when she was assigned to him. LVN 3 reviewed Resident 1's physician's orders and verified the order was for PRN oxygen use. LVN 3 reviewed Resident 1's MAR for 5/2025 and verified the MAR failed to show Resident 1 frequently received the oxygen PRN. LVN 3 stated the oxygen administered should be documented in the MAR. On 7/2/25 at 1125 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with the DON. The DON stated per Resident 1's medical record, the resident was pretty much on continuous oxygen, and verified the order was for PRN and should have clarified the order to match the resident's needs.

Based on interview, clinical record review, and document review, the facility failed to ensure adequate supervision was provided during eating to one of two sampled residents (Resident 1) who was at high risk for aspiration. Resident 1 was left alone in his room to feed himself his dinner meal on [DATE]. As a result, the resident aspirated his food and was found unresponsive, pulseless, and not breathing. The licensed nurse performed the Heimlich maneuver after discovering food in the resident's mouth, initiated CPR, and called 911. Resident 1 was transported to an acute care hospital emergency department via paramedics where he subsequently died on [DATE], nine days after the incident. The Orange County Sheriff-Coroner's report dated [DATE], showed Resident 1's cause of death was anoxic brain injury due to aspiration of food contents. Failure to adequately supervise Resident 1 during meal time as assessed had resulted in aspiration, hospitalization , and subsequently death. Findings: The National Institute of Health/U.S. National Library of Medicine defines gastroesophageal reflux as a condition in which food or liquid travels backwards from the stomach to the esophagus (the tube from the mouth to the stomach). Closed clinical record review for Resident 1 was initiated on [DATE]. Resident 1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident 1's MDSs dated [DATE] and [DATE], showed the resident had severe cognitive impairment and required limited assistance from one staff member for eating. Review of Resident 1's hospital's H&P dated [DATE], showed his [DIAGNOSES REDACTED]. Review of Resident 1's Admit/Readmit Assessment form dated [DATE], showed the resident required supervision from staff for eating. Review of Resident 1's care plan problem dated [DATE], to address his impaired ADL skills showed an intervention to assist the resident with meals as needed. Review of Resident 1's Speech Therapy Initial Evaluation dated [DATE], showed the reason for the referral was due to the resident being observed to have cognitive impairment which hindered his ability to safely communicate as well as having signs and symptoms of aspiration while he was drinking thin liquids. The Assessment Summary showed Resident 1 had dysphagia concerns and would benefit from treatment in learning strategies to improve his swallow safety. Review of Resident 1's Speech Therapy Progress Note dated [DATE], showed the resident was observed having signs and symptoms of aspiration with large, consecutive swallows of thin liquids and required minimum cues to take small sips. The ST also documented Nursing informed of swallow recommendation and sign posted on wall. Review of the Speech Therapy Progress Note dated [DATE] at 1214 hours, showed Resident 1 was observed sitting upright at bedside during breakfast, was observed eating rapidly with large bites of food, had inadequate chewing, and was drinking a whole cup of liquids quickly. The ST documented the resident required moderate to maximum verbal and tactile cues to slow down to improve safety of swallow function during meals. Documentation showed the ST recommended to continue monitoring for signs and symptoms of aspiration and teaching of strategies such as small bites, altering liquids/solids, and swallowing small bites/sips before taking another. Review of the resident's plan of care and progress notes found no documented evidence staff implemented the ST's evaluation regarding aspiration precautions or recommendations documented on [DATE] at 1214 hours. Review of the Neuropsychological Consultation note dated [DATE], showed Resident 1's insight/judgment was impaired. On the section for Discussion/Recommendations, the psychologist documented Resident 1 required a structured and supervised environment to remain safe. Review of the Progress Notes for Resident 1 showed a late entry dated [DATE] at 1800 hours. Documentation showed at 1710 hours, when the licensed nurse was passing medications, a code blue was called into Resident 1's room. The licensed nurse documented the resident was unresponsive and his mouth was full of food. In addition, the LVN documented the Heimlich maneuver was repeated on the resident and during a mouth sweep, the nurse was able to remove unchewed food from Resident 1's mouth. Review of Resident 1's Nursing Home to Hospital Transfer Form dated [DATE], showed the resident needed assistance with eating. Review of the paramedic report dated [DATE], showed the facility called the paramedics at 1731 hours. The paramedics arrived at the facility at 1750 hours and found Resident 1 unconscious/unresponsive, pulseless, and not breathing. The paramedic documented the resident had partial airway obstruction and had food in his mouth/throat. During an interview on [DATE] at 1232 hours, CNA 1 stated Resident 1 was not able to verbalize his needs. CNA 1 stated the resident did not need assistance with eating and he always ate in his room. CNA 1 stated Resident 1 was on limited assistance with eating. When CNA 1 was asked what kind of assistance she provided to Resident 1 during meal time, she stated she would just place his tray on the overbed table and then open his milk carton, and apply butter on his bread. On [DATE] at 1252 hours, an interview with the ADON was conducted. She stated on [DATE] at 1710 hours, LVN 1 was the nurse who found Resident 1 unresponsive with a mouth full of food. The ADON stated LVN 1 performed the Heimlich maneuver on Resident 1 and did a mouth sweep to determine if additional food was in the resident's mouth and suctioned the resident's mouth. The ADON stated the CPR was initiated to Resident 1 at 1717 hours. The ADON stated there was no facility Code Blue sheet to document the steps the staff had taken during the Code Blue. The ADON was unaware if Resident 1 had episodes of choking. On [DATE] at 1345 hours, the DON was interviewed. When asked about the incident involving Resident 1, the DON stated on [DATE], Resident 1 was found face down on the side of his bed while the resident was eating dinner and the CPR was started. She stated Resident 1 had not completed his dinner as the meal tray still had food on it. The DON stated Resident 1 had severe cognitive impairment and was confused. During a telephone interview on [DATE] at 1307 hours, Resident 1's family member stated he had visited Resident 1 at the facility one day and noticed the resident had no supervision while eating. He stated when Resident 1 was at other facilities, he was never left alone to eat; he had supervision while eating. A telephone interview was conducted on [DATE] at 1350 hours, and a follow-up phone call on the same day at 1402 hours was conducted with LVN 1. LVN 1 stated on [DATE], while he was administering the medications to another resident, he heard an overhead page for Rapid Response (Code Blue) to Resident 1's room. LVN 1 stated when he entered Resident 1's room, he observed Resident 1 had a lot of food in his mouth. LVN 1 stated Resident 1 was unresponsive, so he performed the Heimlich maneuver on the resident and the resident expelled the food from his mouth. During a telephone interview on [DATE] at 1611 hours, the Dietary Supervisor confirmed on [DATE], Resident 1 was given rice with his meal per the resident's request for his evening meal. She stated the resident was served steamed rice most of the time. During a telephone interview on [DATE] at 1700 hours, with CNA 2, she stated on [DATE], she was assigned as the caregiver for Resident 1. CNA 2 stated she started passing the residents' dinner trays between 1630 to 1700 hours. CNA 2 stated she did not stay in Resident 1's room after he received his dinner tray. CNA 2 stated Resident 1 was independent with eating. CNA 2 stated the charge nurse did not instruct her that Resident 1 required supervision when he was eating. When CNA 2 was asked if she was aware of a sign posted on the wall in Resident 1's room to address the resident's need for supervision while eating, she stated no. On [DATE] at 1645 hours, a telephone interview was conducted with ST 2. She stated Resident 1 was observed to have cognitive impairment which hindered his ability to safely communicate, in addition to having signs and symptoms of aspiration when he was drinking liquids. When ST 2 was asked to define signs and symptoms of aspiration, she stated coughing during the swallowing process. ST 2 stated Resident 1 was observed chugging down his drinks which placed the resident at a high risk for aspiration. ST 2 stated Resident 1 needed to take small sips of liquids with cueing and needed supervision. When ST 2 was asked if the nursing staff were aware of Resident 1's high risk for aspiration, she stated yes. In addition, ST 2 stated she had posted a sign above Resident 1's bed on [DATE], that read Aspiration precautions: Patient instructed to take small sips, supervision required. When ST 2 was asked to clarify supervision required, she stated a staff member needed to stay with Resident 1 while he was eating or drinking to provide him cues verbally and/or physically to slow down. ST 2 stated Resident 1 ate very rapidly. Review of the Orange County Sheriff Coroner's report dated [DATE], showed Resident 1's cause of death was anoxic brain injury due to aspiration of food contents. Further review of the coroner's report showed the following: * On [DATE] at 0451 hours, the coroner received a call from the acute care hospital's RN and was informed Resident 1 was admitted to the hospital on [DATE], after being found pulseless and he had rice in his mouth. The paramedics report identified the resident's airway had a partial obstruction; he was resuscitated and transported to the emergency department on [DATE], where they were initially unable to intubate the resident because the resident's throat was full of rice, but eventually the resident was intubated but never regained consciousness. * On [DATE] at 0840 hours, the coroner called the facility and was informed Resident 1 was last seen on [DATE] at 1630 hours, when the staff brought the resident his food to his room. The facility's staff informed the coroner on [DATE] at 1710 hours, a code blue was called to Resident 1's room after he was found unresponsive with a mouth full of rice. * On [DATE] at 0854 hours, the coroner received a call from the acute care hospital's admitting physician. The physician confirmed the resident came in the hospital with an airway obstruction and noted to have either rice or some sort of pasty type food. The physician stated the family had expressed concerns with the facility's lack of monitoring or placing Resident 1 on a special diet.

Based on interview and clinical record review, the facility failed to provide the necessary care and services to attain the highest practicable physical, mental, and psychosocial well-being for one of two sampled residents (Resident 1). Resident 1 had a change in condition with his level of consciousness, increased weakness, and had no urine output in his indwelling urinary drainage catheter (rubber tube inserted into the bladder to drain urine) for over eight hours. The facility failed to thoroughly assess Resident 1's decline in medical condition, resulting in an emergency hospitalization for [DIAGNOSES REDACTED]. In addition, the facility failed to transfer the resident to the acute care hospital ED for over 10 hours after noticing a decline in Resident 1's medical condition. This caused a delay in the resident's medical treatment. Findings: Clinical record review for Resident 1 was initiated 11/20/14. Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. The resident had an indwelling urinary drainage catheter. Review of Resident 1's physician's orders [REDACTED]. Review of physician's orders [REDACTED]. Review of Resident 1's H&P dated 9/15/14, showed the resident had the capacity to understand and make decisions. Review of Resident 1's MDS dated [DATE], showed the resident had moderately impaired cognition. Review of Resident 1's plan of care identified the following: * A care plan problem dated 9/13/14, addressed the resident's potential for discomfort and complications related to his [MEDICAL CONDITION]. The interventions included to assess the resident for any bladder distention or dysuria (difficulty urinating) and notify the physician. * A care plan problem dated 9/13/14, addressed the risk for dehydration and potential fluid deficit. The interventions included to monitor for decreased urine output, sudden weight loss, and to notify the physician of these changes. * A care plan problem revised on 9/25/14, addressed his potential for recurrence of UTI. Staff were to report to any changes in the resident's mood, mental status, or sudden behavior changes to the physician. Review of the Physician's Progress Note dated 9/22/14, showed Resident 1 was doing well and to begin discharge planning. Review of the Multidisciplinary Care Conference Notes dated 9/26/14, showed Resident 1 had episodes of confusion and forgetfulness and required cueing, reassurance, and reminders. In addition, Resident 1's POLST was listed Resident 1 as wanting full medical treatment to prolong his life. Review of the Nurse's Weekly Summary dated 10/1/14, showed Resident 1 was alert and oriented with periods of forgetfulness and had no change in his level of consciousness. His speech was clear with distinct intelligible words. In addition, Resident 1's indwelling urinary drainage catheter was in place with no [MEDICAL CONDITION] (inability to empty the bladder completely), dysuria, or hematuria (blood in the urine) noted. Review of Resident 1's Intake and Output Record showed his urinary output on 10/2/14, for the 3-11 pm (8 hours) shift was 50 ml (Resident 1's average urinary output for the 3-11 pm shift was 525 ml). However, there was no documented evidence the staff assessed and notify the physician of the resident's decreased urinary output during the last eight hours. Review of Resident 1's Progress Notes dated 10/2/14, and the physician's orders [REDACTED]. * At 0353 hours, Resident 1 had no change in his level of consciousness and his indwelling urinary drainage catheter was draining yellow colored urine. There was no dysuria or [MEDICAL CONDITION]. * At 1216 hours, LVN 1 documented Resident 1 had increased sleepiness and body weakness. The resident was verbally responsive but unable to open his eyes. Resident 1's indwelling urinary drainage catheter was intact and patent. The resident refused to eat lunch. The LVN documented Resident 1's NP was contacted and an order for [REDACTED]. * At 1307 hours, LVN 1 obtained a physician's orders [REDACTED]. * At 1309 hours, staff obtained an order for [REDACTED]. * At 1609 hours, LVN 1 documented he had called the laboratory company regarding the delay in obtaining Resident 1's STAT laboratory tests. He was told the person assigned to draw Resident 1's blood samples was stuck in traffic. However, there was no documented evidence the physician was notified of the delay in obtaining STAT laboratory tests and UA C&S. There was no document evidence the staff assessed the resident while waiting for the laboratory staff to come to draw blood since the resident was identified to have a change in condition at 1206 hours. * At 2151 hours, LVN 2 documented Resident 1 had been sleeping for over 14 hours straight, only responded with "yes" when she tried to wake him up, and could not follow commands. After almost eight hours from the time the physician ordered to obtain the urine for a UA C&S (at 1309 hours), LVN 2 documented she had tried to collect a urine specimen from Resident 1's indwelling urinary drainage catheter collection bag; however, the collection bag was empty. LVN 1 documented Resident 1's physician was notified of the resident's change of condition. * At 2224 hours, LVN 2 obtained an order to transfer Resident 1 to the ED. * At 2233 hours, LVN 2 documented a BLS (non-emergency) ambulance company was contacted to transport Resident 1. The ambulance company's dispatcher told LVN 2 they would be at the facility in 25 minutes. LVN 2 called the receiving hospital ED and gave report to the ED staff regarding Resident 1's condition. * At 2300 hours, LVN 2 documented Resident 1 was transferred from the facility by a BLS ambulance and transported to the ED. Review of a facsimile sent by the laboratory company showed Resident 1's laboratory tests were drawn on 10/2/14 at 1735 hours. At the top of this report showed no urine was collected to complete the resident's urinalysis. The report of Resident 1's laboratory results were faxed to the facility on [DATE] at 2100 hours. Review of the laboratory reports showed Resident 1's abnormal laboratory tests were as follows: * Abnormal BUN level of 86 mg/dl (normal level: 7-23), * Abnormal creatinine level of 5.9 mg/dl (normal level: 0.6-1.4), and * Abnormal WBC of 20.60 10^3/ul (normal level: 4.0-11.0). There was no documented evidence to show Resident 1 was assessed for bladder distention, urinary blockage, or dislodgement of his indwelling urinary drainage catheter as the potential cause of no urinary output. In addition, there was no documentation available to show Resident 1's physician was notified that staff were not able to obtain urine for the urine specimen related to no urinary output or the delay in obtaining STAT laboratory tests. Review of the Transfer and Referral Record form dated 10/2/14, showed Resident 1 was difficult to arouse and with critical value laboratory results (WBC 20.60 10^3/ul , BUN 86 mg/dl, and creatinine 5.9 mg/dl). Review of the laboratory results dated [DATE], showed the results were faxed to the facility and called to the facility's staff on 10/2/14 at 2100 hours. Review of the acute care hospital H&P dated 10/3/14, showed Resident 1 was admitted to the hospital on [DATE], and assessed to be very obtunded (decreased level of consciousness and diminished sensation of pain). The physician documented Resident 1 "did not have much urine output overnight; however, on flushing the indwelling catheter, Resident 1 had 1500 ml of urine output, which is bloody as expected due to the release of bladder distention and [MEDICAL CONDITION]." Resident 1's medical impressions were metabolic [MEDICAL CONDITION] due to [MEDICAL CONDITIONS] (a blood infection that can lead to organ failure and death) acute on [MEDICAL CONDITION] due to a blocked indwelling urinary catheter and hematuria due to the release of bladder distention, [MEDICAL CONDITION], and UTI. Documentation showed Resident 1 was expected to improve now that his indwelling urinary drainage catheter obstruction had been relieved. On 11/20/14 at 1005 hours, an interview was conducted with LVN 1. LVN 1 stated Resident 1 was confused at times. He stated Resident 1 was slow to respond (on 10/2/14) to commands. LVN 1 confirmed he obtained a physician's orders [REDACTED]. LVN 1 stated when a laboratory test was ordered "STAT" it meant the specimen should be drawn/collected within three hours from the time it was ordered. He stated after three hours of Resident 1's laboratory tests not being collected, he called the laboratory company and was told the laboratory technician was on his way but was stuck in traffic. LVN 1 was unable to show documented evidence staff was assessing Resident 1's for bladder distention or notified the physician when there was no urinary output. On 11/20/14 at 1310 hours, an interview was conducted with the DON. She stated Resident 1 was alert and oriented upon admission to the facility but had an immediate decline in his medical condition and became weak on 10/2/14. The DON stated she was unaware of the reason it took 10 hours before Resident 1 was transferred to the ED after showing signs of a change of condition. During a telephone interview conducted on 11/20/14 at 1337 hours, LVN 2 stated she was the licensed nurse who arranged Resident 1 to be transferred to the ED on 10/2/14. She stated she was aware Resident 1 had not had any urinary output from his indwelling urinary drainage catheter for over eight hours. She also acknowledged she was aware of his critical laboratory test results. When LVN 2 was asked why Resident 1 was transferred to the ED using BLS verse calling 911 on 10/2/14. LVN 2 stated because Resident 1 was still responsive. On 11/20/14 at 1430 hours, a telephone interview was conduced with the BLS dispatcher. The dispatcher confirmed there was a call received from the facility on 10/2/14 at 2230 hours. She stated a LVN 2 had called the ambulance dispatcher and requested a BLS transport for Resident 1 from the facility to the ED. She stated the facility was aware their ambulance company did not do emergency transports. On 11/20/14 at 1530 hours, a follow-up interview was conducted at the facility with LVN 2. LVN 2 stated during the change of shift on 10/2/14, LVN 1 had told her he was unable to obtain a urine specimen from Resident 1's indwelling urinary drainage catheter. LVN 2 stated she clamped Resident 1's indwelling urinary drainage catheter to try to obtain a urine specimen, but after three hours, the catheter still had no urine in the tubing. She stated she was very surprised why Resident 1 was sleeping a lot during her shift (on 10/2/14), could not follow verbal commands, and did not open his eyes. She stated Resident 1 only answered "yes" when she asked him questions. LVN 2 confirmed she did not call 911 because Resident 1 was responsive, had no shortness of breath, and his pulse, blood pressure, and respirations were stable.