Every finding on record at Tampico Healthcare Center

Based on interview and record review, the facility failed to be in compliance with state regulation when they did not report an unusual occurrence to the California Department of Public Health (CDPH) within 24 hours, for one of 22 sampled residents (Resident 1), when Resident 1 had an unwitnessed fall that resulted in a hip fracture. This failure had the potential to cause a delay in investigations and affect Resident 1's physical well-being.During a review of Resident 1's admission Record, printed 8/19/26, the Record indicated Resident 1 was admitted to the facility in 2026 with a diagnosis of history of falling. During an interview on 8/19/26, at 2:39 p.m., with Registered Nurse (RN) 1, RN 1 stated Resident 1 had an unwitnessed fall on 7/28/26. RN 1 stated Resident 1 was found on the floor, with left leg swelling, 10 out of 10 pain and couldn't lift their left leg. RN 1 stated they called 911 and sent Resident 1 to the emergency room because Resident 1 may have had a fracture. During an interview on 8/19/26, at 4:13 p.m., with Administrator (ADM), ADM stated Resident 1's fall was not reported to CDPH as it was not considered unusual occurence. During a review of Resident 1's Change in Condition Evaluation, dated 7/28/26, the Evaluation indicated, Situation. Falls. patient was on the floor. pain in L [Left] hip. Not able to lift L [left] leg. swelling noted. Stated that pt [patient] slipped on the way back from bathroom . During a review of Resident 1's Hospitalist H&P Note, dated 7/28/26, the Note indicated . presents to the ED [emergency department] on 7/28/2026 for mechanical fall. presents with mechanical fall resulting in hip fracture. During a review of the facility's policy and procedure (P&P) titled, Unusual Occurrence Reporting, dated 10/1/23, the P&P indicated, The facility will follow all applicable stated and federal laws and regulations regarding the reporting of unusual occurrences. The P&P indicated, Unusual occurrences are reported to the appropriate agency within 24 hours by telephone and the confirmed in writing. According to California Code of Regulations Title 22, Section 72541, .unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department.

Based on interview and record review, the facility failed to ensure comprehensive skin assessment was conducted and pressure injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence) prevention for one of two sampled residents (Resident 1) when:Resident 1's skin injury on the right buttock, described as a bump with purple discoloration, did not have the exact measurements and specific anatomical (structure of the body) location documented. Resident 1's cause of skin injury was not investigated.Resident 1's physician's order to apply preventive boot for Stage I (skin intact with redness) pressure injury on left heel was not implemented.This failure placed Resident 1 at risk for further skin breakdown, infection, and delayed wound healing. During a record review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility in October 2025 with diagnoses: congestive heart failure (the heart can't pump enough blood), atrial fibrillation (heart condition causing an irregular, often rapid heart rate), and history of fall.During a record review of Resident 1's record eINTERACT Change in Condition Evaluation (CIC) dated 11/12/25, the CIC indicated Resident 1 had purple bump to buttock. The CIC's Skin Evaluation portion did not indicate the precise anatomical location and measurement (length, width, depth) of the newly identified skin abnormality. Further review of the record indicated no documentation that the facility investigated the possible cause or origin of the skin injury.During a record review of Resident 1's Wound Assessment Note (WAN), signed by the physician and dated 11/13/25, the WAN indicated Resident 1's wound was identified as an abrasion on the right buttock. The WAN did not indicate a wound measurements and did not specify precise anatomical location of the right buttock. The WAN also indicated Resident 1 had a pressure injury on the left heel and the physician ordered a protective boot (medical device designed to elevate the heel) to offload the pressure; however, there was no documentation the facility implemented the ordered protective device.During a record review and interview on 3/5/26 at 11:10 a.m. with Treatment Nurse (TN), Resident 1's Progress Note dated 11/12/25 and WAN dated 11/13/25 were reviewed. TN stated if Resident 1 had a new bump and purple discoloration on the right buttock, an investigation should have been conducted to determine the cause of the skin injury. TN stated the purple bump could have been a result of trauma or injury. TN further stated complete assessment of the skin injury should have been done including the wound measurement and the exact anatomical (structure of the body) location of the skin injury.During an interview on 3/5/26 at 12:24 p.m. with the Director of Nursing (DON), the DON stated Resident1's purple bump on the right buttock should have been investigated to determine the cause and to prevent recurrence. DON stated without the exact wound measurement, it would be difficult to determine if the skin injury was improving or declining. DON stated the physician's order for a pressure injury preventive boot for the left heel was not entered in Resident 1's record and there was no documentation showing the physician's order had been implemented. DON further stated Resident 1 was at risk for worsening of pressure injury on the left heel when the preventive boot was not provided.During a record review of the facility's policy and procedure (P&P), titled, Wound Management dated 10/1/23, the P&P indicated, To provide a system for the treatment and management of residents with wounds including pressure and non-pressure ulcers (type of wound).A resident who has a wound will receive necessary treatment and services to promote healing, prevention infection and prevent new pressure ulcers from developing.I. Assessment.A. A Licensed Nurse will perform skin assessment.as needed for each resident.B. Upon identification of a new wound the nurse will.i. Measure the wound (length, width, depth).C. Implement a wound treatment per physician's order.III. Documentation.A. New pressure ulcers or wounds will be documented on the 24 Hour Log and an incident report will be completed by the Licensed Nurse.B. Wound documentation will occur at a minimum of weekly.Documentation will include.i. Location of wound.ii. Length, width, and depth measurements recorded in centimeters.

Based on interview and record review, the facility failed to ensure for one out of four residents (Resident 1), the accuracy of data collection during respiratory illness outbreak. Resident 1 was not included in respiratory illness outbreak line list (infection control tracking tool used to collect data and active monitoring of both residents and staff during suspected outbreak). This failure resulted in unreliable data for analysis and identifying the root cause of infection.Findings:A review of the facility's admission Record, indicated Resident 1 was admitted on [DATE], with diagnoses that included Chronic obstructive pulmonary disease with (acute) exacerbation. During a review of facility's Change in Condition Evaluation dated 04/27/2025, it indicated Resident 1 had Shortness of breath. Resident 1 was transferred to hospital for evaluation. Resident 1's laboratory result dated 04/27/2025 indicated positive for Coronavirus 0C43, (common human coronaviruses, that usually cause mild to moderate upper-respiratory tract illnesses).During a concurrent interview and record review on 01/28/2026 at 11:57 a.m. with Licensed Vocational Nurse/Infection Preventionist (LVN/IP), LVN/IP stated the facility had a respiratory illness outbreak that started 04/07/2025. During a concurrent interview and record review on 01/28/2026 at 01:21 p.m. with LVN/IP, LVN/IP reviewed facility's line list for the 04/07/2025's respiratory illness outbreak. LVN/IP stated that Resident 1 was not listed in the line list. LVN/IP stated Resident 1 should have been included in the list because Resident 1 tested positive for respiratory illness. During a review of facility's policy and procedure titled Infection Prevention and Control Program indicated I. The Facility must establish an Infection Prevention and Control Program under which it- A. Identified, investigates, control, and prevents infection in the Facility; . C. Maintains a record of incidents and corrective actions related to infections. III. The Facility will appoint a full-time Infection Preventionist. Procedure. I. The Infection Preventionist is responsible to coordinating and development and monitoring of the Facility's established infection control policies and procedures. D. Collecting, analyzing and providing infection data and trends.

Based on observation interview and record review the facility failed to observe infection control measures for Residents 1,2 and 3 when the following items were found in the shared room sink of Residents 1, 2 and 3:a. One open, unlabeled toothbrush exposed to air and one tube of unlabeled toothpaste were stored in an unlabeled kidney basin (Kidney basin is a shallow, kidney-shaped tray, also known as an emesis basin or kidney dish, used in medical settings to collect bodily fluids like urine or vomit, medical waste, and surgical supplies). b. One unlabeled open tube of triad paste was stored together with two open, unlabeled tubes of toothpastes in a kidney basin (Triad paste is a cream applied to various wounds, including pressure ulcers of the residents).These deficient practices had the potential to transmit infectious microorganisms among residents. Findings: During a concurrent observation and interview on 9/11/25 at 10:52 a.m., with Licensed Vocational Nurse (LVN) 1 and with Certified Nursing Assistant (CNA) 1 in Resident 1, 2 and 3's room:a. One unlabeled toothbrush exposed to air, and one open tube of unlabeled toothpaste were observed to be stored in a kidney basin on top of Residents 1, 2 and 3's shared room sink. LVN 1 and CNA 1 stated they did not know who owned the items. LVN 1 also stated that the unlabeled toothbrush and the unlabeled tubes of toothpastes should be labeled with the names of the clients who own them, and should be stored separately. b. One unlabeled open tube of triad paste was stored together with two open and unlabeled tubes of toothpastes in a kidney basin on top of Residents 1,2 and 3's shared room sink. LVN 1 and CNA 1 stated, they did not know to who the said items belonged to. LVN 1 stated the triad paste should not be stored with the toothpastes because the triad paste was used to treat skin conditions. LVN 1 further stated that the risk of storing the said items with the unlabeled tubes of toothpastes had the potential to spread infection among the residents.During an interview on 9/11/25 at 1:26 p.m., with the Infection Preventionist (IP), IP stated that storage of the residents' toothbrush should be stored in a clean plastic bag and should be labeled with the resident's name and properly stored with the resident's drawer to prevent contamination. IP stated that the risk of storing the residents' oral care products on top of the shared room sink unlabeled, and exposed to air could cause cross contamination when a resident would use another resident's tooth brush and or toothpaste. Further stated that it is not good practice to co-mingle oral care products with skin care products.During an interview on 9/11/25 at 2:30 p.m. with Director of Nursing (DON), DON stated, the risk of improper storage of the residents' unlabeled toothbrush, toothpastes and storing the triad paste with the toothpastes had the potential to spread infection among Residents 1,2 and 3.During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 10/1/23, the P&P indicated, Purpose: To ensure the Facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements .

Based on observation, interview, and record review, the facility failed to store and prepare food in safe and sanitary manner when, large baking sheet trays with ground meat patties were not fully covered and stored near fresh vegetables, and foods were stored without identifying labels and use-by-dates. These failures had the potential for contamination of food resulting in food borne illness. Findings: During a concurrent observation and interview on 03/24/25 at 10:25 A.M., in the kitchen with Dietary Supervisor (DS), DS stated the facility had one reach-in refrigerator. In the reach-in refrigerator there was one container labeled beans with DM date: 3/16/25 and UBD: 3/21/25, DS stated the beans was past it's Use by date. There was another container did not have a label to identify it and open or use by date. DS stated the container labeled beans was kidney beans, and the other container without the identifying label was grape jelly. During a concurrent observation and interview on 03/24/25 at 10:35 A.M., in the walk-in refrigerator with DS, there were five large size baking sheet trays with ground meat patties covered with parchment paper. The baking sheets were stacked overlapping each other. Two of the five baking sheet trays were stacked on top of each other. The five baking sheet trays with ground meat patties were placed in the middle shelves, and baking sheet trays were placed on top of clear bins with vegetables. Above the baking sheet trays with ground meat patties were boxes of vegetables. DS said the baking sheet trays needed to be fully covered with plastic wrap. There was one opened juice bottle on the shelf, DS stated it was staff drink. There was an apple sauce cup, a single butter serving cup, and a lid were on the floor underneath the shelves. During a review of facility's policy and procedure titled Food Storage indicated Food items will be stored, thawed, and prepared in accordance with good sanitary practice. I. Raw Meat/Poultry/Seafood Storage Guidelines. A. Raw meat is to be stored separately from cooked meat . IX. Fresh Vegetable Storage Guidelines . C. Unwashed produce should not be placed in the refrigerator near ready to serve foods.

Based on observation, interview, and record review, the facility failed to ensure food served was palatable and at proper temperature. The oven BBQ beef roast was dry and non-tender, the vegetables were bland, and cheddar biscuit was dry. These failures had the potential to affect resident's well-being due to lack of enjoyment, satisfaction, and decrease in nutrients from their meals. Findings: During an interview on 03/24/25 at 10:48 A.M., with Resident 115's Responsible Party (RP)1, RP 1 stated Resident 115 had been eating a lot less because he did not like the food. RP 1 stated Resident 115 enjoyed soup, salad, fruit, and fish. During an interview on 03/24/25 at 11:21 A.M., with Resident 33, Resident 33 stated she did not like the food because it was either cold or bland to taste. During an interview on 03/25/25 at 12:14 P.M., with Resident 112, Resident 112 stated she did not like the food in the facility because it was always cold, bland, and no variety. During an interview on 03/25/25 at 12:17 P.M., with Resident 371, Resident 371 stated she was not happy with the food since it was always served cold. During an interview on 03/24/25 at 12:53 P.M., with Resident 7, Resident 7 stated she did not like the food the facility offered because it was nasty, cold, unappealing, overcooked, and lacking nutrients. During an interview on 03/24/25 at 10:45 A.M., with Resident 29, Resident 29 stated the facility served the same food all the time, and it's like cat food, mushy and bad. Resident 29 added the facility used a lot of canned food. During an interview on 03/24/25 at 11:17 A.M., with Resident 31, Resident 31 stated food from the facility was not good and not appetizing. Furthermore, Resident 31 added the food was yuck. During a concurrent observation and interview on 03/26/25 at 11:36 A.M., in the kitchen with Cook, [NAME] checked the food temperature: oven BBQ beef roast at 168 ° (degrees) Fahrenheit (F), zucchini and carrots at 141° F, mashed sweet potato at 161° F, cheddar biscuit at 190° F, pureed zucchini and carrots at 182 ° F, pureed beef at 146 °F, and pureed cheddar biscuit at 156 ° F. During an observation on 3/26/25 at 12:05 P.M., in the kitchen, the first cart of food tray was sent out to the large dining room. The last cart of food tray was sent out of the kitchen at 12:54 P.M. During a concurrent observation and interview on 03/26/25 01:02 P.M., during test tray sample with Dietary Supervisor (DS), there were two plates served. First plate had oven BBQ beef roast at 151° F, zucchini and carrots at 131° F, and mashed sweet potato at 156 ° F. Second plate had pureed oven BBQ beef roast at 151.6 ° F, pureed zucchini and carrots at 137.6 ° F, and pureed cheddar biscuits at 137.7 ° F. The oven BBQ beef roast was non-tender and dry, the BBQ sauce had a strong flavor of vinegar, zucchini and carrots had a strong margarine flavor, but lack of dill flavor, and cheddar biscuits was dry. DS stated the facility used frozen carrots and canned sweet potatoes. During a review of facility's Recipe: Fresh Zucchini and carrots indicated Ingredients: Fresh carrots, fresh zucchini, margarine, melted, drill, dried . Serve on trayline at the recommended temperature of 160°F - 180° F or less. During a review of facility's Recipe: Mashed Sweet Potatoes indicated Ingredients: Fresh or frozen sweet potato, peeled, cubed, water for boiling, milk, margarine. Serve on trayline at the recommended temperature of 160 °F - 180° F.

Based on observation, interview, and record review, the facility failed to ensure pureed texture meal was prepared in a manner that is flavorful, appetizing, and with good nutritional value. These failures had the potential to affect the resident's overall nutritional status. Findings: During a concurrent observation and interview on 03/26/25 at 01:02 P.M., with Dietary Supervisor (DS), one test plate of pureed texture food consisted of oven-roasted BBQ beef, pureed fresh zucchini and carrots, and cheddar biscuits. The pureed BBQ beef was light brown with dark brown BBQ sauce, pureed fresh zucchini and carrots was light green and looked like a slime (squishy sensory toy), and pureed cheddar biscuit was paper white. Pureed oven BBQ beef roast did not have a strong flavor of beef; the BBQ sauce which tasted vinegary over powered the flavor of the oven roasted BBQ beef. The pureed zucchini and carrots did not taste like vegetables, and the consistency and texture were gummy/slimy. Pureed cheddar biscuit did have any flavor, and the texture was starchy. During a concurrent observation and interview on 03/26/25 at 01:46 P.M., with Cook, [NAME] stated he prepared the pureed texture food for nine residents. [NAME] stated he used the Robot Coupe (food processor, that can hold 3.5 quartz). [NAME] stated he tasted the pureed oven BBQ beef roast, and [NAME] stated that it did not have a lot of flavors. [NAME] stated that there was not enough BBQ beef extra to use for pureed texture. [NAME] stated for cheddar biscuits, he added 12 portions of biscuit in the Robot Coupe processor, and mixed it with water and milk. [NAME] stated he added the liquid up to max up to fill line (3.5 quartz) of Robot Coupe food processor. [NAME] stated after the cheddar biscuit was pureed, he transferred it in a bin, and he added thickener. [NAME] was not able to say the amount of thicker he used, but stated he added enough thickener until it was scoopable. [NAME] stated for zucchini and carrots, he added water until the max fill line of the food processor. [NAME] transferred the purred zucchini and carrots to a bin and added the powder thickener until its scoopable. During an interview on 03/27/25 at 09:27 A.M., with DS, DS stated [NAME] used the oven roasted BBQ beef drippings to add flavor to the pureed food, the drippings had a lot of fat/oil, so the cook probably added water. During a review of facility's recipe titled Pureed (IDDSI [ International Dysphagia Diet Standardization Initiative] Level 4) Meats indicated Directions: . 2. Puree on low speed to a paste consistency before adding any liquid. 3. Gradually add warm liquid (low sodium broth and gravy. For 12 servings, the amount of liquid needed was 12 to 24 ounces. The choice of liquid listed were Warm liquid such as gravy, or low sodium broth. If the meat is moist, you can start with only a few ounces of liquid . Furthermore, the recipe indicated If needed: Stabilizer: instant potato, non-fat dry milk breadcrumbs, toast, instant cream of rice or farina, or commercial instant thickener listed the amount of 6 to 12 tablespoons for 12 servings. During a review of facility's recipe titled Pureed (IDDSI Level 4) Vegetables indicated Directions: . 2. Puree on low speed to a paste consistency before adding any liquid. 3. Gradually add warm liquid (low sodium broth or milk) if needed . For 12 servings, the amount of liquid needed was 2 to 6 ounces. The choice of liquid was Warm fluid such as milk, or low sodium broth, There are suggested amounts and may vary from vegetable to vegetable. Some vegetables man not require any liquid at all. Furthermore, the recipe indicated If needed: Stabilizer: instant potatoes or commercial instant food thickener. During a review of facility's recipe titled Pureed (IDDSI Level 4) Breads, Cakes, Cookies, . and Other Bread Products indicated Directions: . 2. Puree on low speed adding milk gradually. See above recommended amounts of milk, starting with the smaller amount and adding in more as needed to achieve the desired consistency. 3. Add stabilizer to increase density to the pureed food, if needed. Breaded items may not need stabilizer . For 12 servings amount of cliqued needed was 12 to 24 ounces. The choices of cliqued listed were Warm milk or cold milk if product is to be served cold. Furthermore, the recipe indicated If needed: Stabilizer: instant potato, non-fat dairy milk, or commercial instant food thickener.

Based on observation, interview and record review, the facility failed to label medications and properly dispose of expired medications for two of 26 sampled residents (Residents 24 and 28): 1. Resident 24's one open inhaler (inhaler: a devise used for delivering medicines into the lungs through breathing) was used beyond the use by date. 2. Resident 28's one discontinued inhaler was found in the medication cart. This failure exposed Resident 24 in receiving an inhaler with questionable potency and efficacy. This failure also resulted in a lack of oversight for Resident 28's discontinued inhaler. Findings: 1. During a review of Resident 24's admission Record (information containing contact details, brief medical history at-a-glance) indicated, Resident 24 was admitted to the facility on [DATE]. During a concurrent observation and interview on 3/25/25, at 1:05 p.m., with Licensed Vocational Nurse (LVN) 2, while inspecting medication cart one, Resident 24 had one opened medication box which contained Wixela or fluticasone propionate and salmeterol powder 100/50 inhaler box which had an open date of 1/17/25. The box also indicated, to dispose the inhaler 30 days after removal from foil pouch (foil pouch was the wrapper of the inhaler). LVN 2 acknowledged that the inhaler should have been disposed after 30 days from the date when it was opened. Further stated, the risk of giving an expired medication was for the resident receiving the inhalation medications with less potency (Wixela is the brand name for fluticasone propionate and salmeterol powder. Wixela is a medication used as maintenance treatment of chronic obstructive pulmonary disease or COPD - a lung disease that causes difficulty or discomfort in breathing; 100/50 is a form of measurement). A review of Resident 24's monthly physician order, for March 2025, indicated an order dated 1/29/25 for Fluticasone-Salmeterol Inhalation Aerosol Breath Activated 100-50 mcg/act (fluticasone salmeterol), one puff inhale orally two times a day for COPD. During a review of Resident 24's Medication Administration Record (MAR) indicated; Fluticasone-Salmeterol Inhalation Aerosol Breath Activated 100-50 mcg/act or Wixela inhaler was last given on 3/25/25 at 9:00 a.m. During a telephone interview on 3/26/25 at 2:47 p.m., with the Consultant Pharmacist (CP), CP stated the facility should have followed the manufacturer's guidelines in discarding Wixela inhaler after it has been opened. 2. Resident 28 was admitted to the facility on [DATE] with diagnoses which included COPD . During an observation on 3/25/25, at 1:05 p.m., with LVN 2, while inspecting medication cart one, Resident 28 had one opened medication box which contained Combivent Respimat or Ipratropium- Albuterol Inhalation Aerosol Solution 20-100 mcg/act inhaler. The box had an open date of 12/23/24 (Combivent Respimat is the brand name for Ipratropium- Albuterol. Combivent Respimat is a medication used as a treatment of COPD; 20-100 mcg/act is a form of measurement). Review of Resident 28's Physician's order dated 12/16/24, indicated an order of Ipratropium- Albuterol Inhalation Aerosol Solution 20-100 mcg/act (Ipratropium- Albuterol) one puff inhale orally every six hours as needed for shortness of breath, wheezing and cough. This order was discontinued by the physician on 12/17/24. During a telephone interview on 3/26/25 at 2:47 p.m., with the CP, the CP stated, medications should be removed by the licensed nurses from the medication carts once the medications have been discontinued by the physician. A review of the facility's policy and procedure (P&P) titled, Medication Storage, Storage of Medications, dated 9/2018, the P&P indicated, Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration . 14. Outdated, contaminated, discontinued or deteriorated medications . are immediately removed from stock, disposed of .

Based on observation, interview and record review, the skilled nursing facility staff did not honor personal choices for one of 26 sampled residents (Resident 51). Resident 51 had complained to staff that his bed was not long enough and he wanted regular utensils with his meals as opposed to the plastic ones being served. Staff did not abide by his requests. This resulted in Resident 51 feeling Frustrated. Findings: Record review of the document admission Record showed the facility admitted Resident 51 on 2/27/2025. Diagnoses included epilepsy (seizure disorder). Review of the document MDS 3.0 Nursing Home Comprehensive (NC) Version 1.19.1 dated 3/6/2025, (resident assessment) showed Resident 51 was alert and oriented. During an interview on 3/24/2025 at 10:15 a.m. Resident 51 stated he had not been sleeping well since his bed was too short. In a concurrent observation Resident 51 was bent over in his bed reading. He stated sleeping in this position makes him wake up Sore. He is also being served his meals but with plastic utensils and wanted real ones. He expressed frustration and stated he had reported these concerns to the staff but nothing was done. During an interview on 3/25/2025 at 10:41 a.m. Resident 51 stated staff had gotten him a longer bed the night before on 3/24/2025 and that he had Finally slept better. During an interview on 3/26/2025 at 12:30 p.m. Licensed Vocational Nurse 4 (LVN 4) stated she had not been aware of problems with the bed and was unsure why he was getting plastic utensils. During an interview on 3/26/2025 Certified Nursing Assistant 4 (CNA 4) stated Resident 51 had complained to her about the plastic utensils but she was unaware of any problems with the bed. She stated she then told LVN 4 and the Assistant Director of Nursing (ADON) about the utensils. During an interview on 3/26/2025 at 12:45 p.m. the ADON stated he was not sure why Resident 51 was getting plastic utensils. He stated they were typically used for residents with aggressive histories which Resident 51 did not have. The ADON stated he had been getting plastic utensils since admission on [DATE] but had it changed to regular that day (3/26/2025). During an interview on 3/27/2025 at 12:21 p.m. the Maintenance Director (MD) stated he had only been made aware of an issue with Resident 51's bed on 3/24/2025. He then switched the bed out that night. Review of the document Resident Rights - Accommodation of Needs dated 10/1/2023, showed the purpose was To ensure that the Facility provides an environment and services that meet residents' individual needs.

Based on observation, interview and record review, the skilled nursing facility's staff did not set up a dental appointment for one of 26 sampled residents (Resident 51). Resident 51 had no natural teeth and had poor fitting dentures. This resulted in Resident 51 feeling Frustrated. Findings: Record review of the document admission Record showed the facility admitted Resident 51 on 2/27/2025. Diagnoses included epilepsy (seizure disorder). Review of the document Nursing admission Assessment, dated 2/27/2025 showed, under the section Natural Teeth and Dentures, nothing had been checked off to indicate he had no teeth or dentures. Review of the document MDS 3.0 Nursing Home Comprehensive (NC) Version 1.19.1 dated 3/6/2025, (resident assessment) showed Resident 51 was alert and oriented. Review of the section Oral/Dental Status showed he had No natural teeth or tooth fragment(s) and had Mouth or facial pain, discomfort or difficulty with chewing. Review of the document Inventory of Personal Effects dated 2/27/2025, showed Resident 51 entered the facility at that time with upper and lower dentures. On 3/24/2025 at 10:15 a.m. Resident 51 was observed to have no teeth. In a concurrent interview he stated he owned dentures but they were Hard to eat with. He stated he felt Frustrated that staff had not helped him address the issue with his dentures. During an interview on 3/24/2025 at 10:50 a.m., the Director of Social Services (SS2) stated she was unaware Resident 51 had dentures that did not fit properly. During an interview on 3/26/2025 at 12:30 p.m. Licensed Vocational Nurse 4 (LVN 4) stated she had never seen Resident 51 with teeth and did not report it because she Never thought it was an issue. Review of the document RAI process (Resident Assessment Instrument) dated 10/1/2023, showed the purpose was To ensure the RAI is used, in accordance with specified format and timeframes, in conducting comprehensive assessments as part of an ongoing process through which the facility identifies each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessment once problems have been identified.

The facility failed to assist one out of three sampled residents (Resident 73) obtain Medi-Cal authorization for dental services in a timely manner.This failure had the potential to cause Resident 73 to be without dentures longer than necessary, which could result in weight loss, unhappiness, and stress. Findings: During a review of Resident 73's admission Record, dated 3/27/25, Resident 73 was admitted to the facility on [DATE] with multiple diagnoses including homelessness, depression, and hypertension (high blood pressure). During an interview on March 24, 2025 at 11:55 a.m. with Resident 73, Resident 73 stated his teeth were removed several months ago, he wanted dentures, and he did not understand what was happening with his dental insurance. Resident 73 stated he was feeling very stressed about dental insurance and that if he understood about the share of cost, he would not have consented to have his teeth removed. Resident 73 stated not having teeth or dentures makes him feel like crap. During an interview on March 25, 2025 at 3:35 p.m. with Licensed Vocational Nurse 1 (LVN1), LVN1 stated when Resident 73 came back from having his teeth removed she was surprised because the facility did not know he was going to the dentist to have his teeth removed. During a concurrent interview and record review on March 25, 2025 at 3:35 p.m. with LVN1, Resident 73's progress note dated 3/6/25 at 17:49 was reviewed. LVN1 stated the progress note indicates she called Resident 73's dentist and dental insurance on 3/6/25 to try to assist Resident 73 understand what was happening with his dentures. LVN1 stated the resident asked her for help and was upset because he did not have dentures. During a concurrent interview and record review on 3/25/25 at 4:07 p.m. with Social Services Designee 2 (SS2) the Progress Notes for Resident 73 dated 1/14/25 to 3/25/25 were reviewed. The Progress Notes indicated Resident 73's teeth were removed on 1/14/25. SS2 stated on 3/6/25 she wrote a note stating that she contacted the dentist to discuss the share of cost of $1884 for dentures for Resident 73 and the dentist referred SS2 to call Denti-Cal (dental insurance for people on Medi-Cal). SS2 stated the reason for the delay between Resident 73's teeth being removed on 1/14/25 and her contacting the dentist on 3/6/25 was because it wasn't known by the facility that there was going to be a share of cost because Resident 73 was enrolled in Mastercare (an agency that assists residents discharge from skilled nursing facilities). During a concurrent interview and record review on 3/26/25 at 12:10 p.m. with SS2, an email from Mastercare to SS2, dated 3/4/25, was reviewed. SS2 stated the email was the first time the facility became aware that the resident had a share of cost for his dentures. SS2 stated usually the facility would coordinate dental work and insurance, but in this circumstance, Mastercare facilitated the dental work. SS2 stated there is no list of things that Mastercare handles instead of the facility. SS2 stated there could have been better communication between the facility and Mastercare in coordinating care for Resident 73. During an interview on 3/26/25 at 3:21 p.m. with the facility administrator (ADM), ADM stated the facility is liable and responsible for all residents, including residents who are working with Mastercare. ADM stated that there should be coordination and communication between Mastercare and social services regarding dental care and insurance for residents. ADM stated there is no contract between the facility and Mastercare. ADM stated there is currently no policy regarding how to communicate and coordinate services with Mastercare.

Based on observation, interview and record review the facility failed to provide reasonable accommodations and/or alternative measures to address visual deficit (partial or total inability of visual perception) for one sampled resident (Resident 112). This failure caused Resident 112 to become tearful and feel worthless. Findings: A record review of Resident 112 's admission record, printed on 3/26/25, indicated Resident 112 was admitted to the facility on [DATE]. During a record review of Resident 112 ' s Minimum Data Set (MDS, an assessment used to guide care) dated 3/1/25, it indicated Resident 112 had moderately impaired vision. The MDS assessment indicated Resident 112 ' s Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 15 out of 15, score for intact cognition. The assessment indicated Resident 112 required supervision and/or hand over hand assistance with eating and oral hygiene. The assessment indicated Resident 112 had diagnosis of cataracts (clouding of the normally clear lens of the eye), glaucoma (group of eye conditions that can cause blindness) or macular degeneration (eye disease that causes vision loss). During an observation on 03/25/25 at 12:02 p.m., Resident 112 had lunch tray in front of her. Resident 112 became tearful and used call light to request assistance in setting up meal tray and opening serving dishes. No large print of monthly calendar, daily menu, nor alternative menu were observed in Resident 112 's room. During an interview on 03/25/25 at 12:14 p.m., Resident 112 stated her left eye was completely blind and had limited vision in the right eye. Resident 112 stated the staff do not provide menus that she can read. Resident 112 also stated she felt worthless when she did not have a menu to guide her on the choice of foods that were available to her. During an interview on 03/26/25 at 02:07 p.m. Social Services Director (SS2) stated Resident 112 should have a magnifying glass, large print reading materials, and additional night light to accommodate visual deficit. SS2 stated dim lighting does not allow her to see the contents of her meal tray to ascertain she was not served with food which she disliked or was allergic to. During an observation and concurrent interview on 03/26/25 at 02:44 p.m.with Licensed Vocation Nurse (LVN 5), LVN5 stated Resident 112 had left eye impairment with limited right eye functionality. Certified nursing assistants and nursing staff should explain the food set up on the meal trays using the clock method, and provide assistance as needed until Resident 112 completes her meal. LVN5 stated postings should be within Resident 112's range of vision. LVN5 confirmed Resident 112's room did not have large print posting of monthly menu, and alternative menu. LVN5 stated Resident 112 should be given a a copy of the menu and alternate menu in large print and placed at a specific side of her bed where she could readily reach for it. During an observation and concurrent interview on 03/26/25 at 02:51 p.m. Resident 112 sat in her wheelchair which was a foot and a half away from the wall where the alternate menu was posted. She was straining to read the posting and admitted she could not read the posting as it was beyond her range of vision, During a record review of Resident 112 ' s untitled care plan dated 2/22/25, it indicated Resident 112 had impaired visual function related to glaucoma. The care plan goal was: resident will be comfortable and safe in her environment and interventions listed were: alter the environment for visual assistance. Review of an untitled Care Plan dated 2/24/25 indicated Resident 112 required visual aids (large prints), Resident 112 prefers to have her room and things arranged to promote independence, and staff will consistently tell Resident 112 where essential items are placed. During record review of the facilities policy and procedure (P&P) titled Resident Rights-Accommodation of Needs, dated 10/1/23, the P&P read: Residents ' individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and review on an ongoing basis .in order to accommodate residents ' individual needs and preferences, Facility staff will assist residents in maintaining independence, dignity and well-being to the extent possible according to residents ' wishes.

Based on observation, interview, and record review, the facility failed to ensure for one out of 26 sampled residents (Resident 99), Resident 99's head of the bed (HOB) was elevated at a minimum of 30 degrees during tube feeding administration. This failure had a potential to affect Resident 99's health due to accidental inhalation of stomach contents to lungs. Findings: A review of facility's admission Record indicated Resident 99 was admitted on [DATE], with diagnoses that included protein-calorie malnutrition and cancer of upper opening of the stomach. Resident 99's Minimum Data Set (MDS - resident assessment tool) dated 12/18/2024, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score of 00, (BIMS score of 00 - 07, severe impairment). During a review of Resident 99's physician's Order Summary Report (OSR) for the month of 3/2025 indicated Enteral Feed Order two times a day Nocturnal feeding: Jevity (complete balanced nutrition formula) 1.2 cal @ 65 ml (millimeter)/HR x 20 HRs [hours] VIA PUMP/JTUBE . (jejunostomy tube -tube placed through the abdominal wall to the midsection of the small intestine). Furthermore, Resident 99's physician OSR indicated Elevate HOB to 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after feeding stopped. During a concurrent observation and interview on 03/24/25 10:53 A.M., Resident 99 was lying on her right and she slid down towards the middle of the bed. Resident 99's HOB was slightly elevated but less than 30 degrees. Resident 99's tube feeding was infusing at 65 ml/hr. Certified Nursing Assistant (CNA) 1 stated Resident 99's HOB had to be least 75 to 90 degrees during tube feeding. CNA 1 stated she would raise Resident 99's HOB, and move Resident 99 towards the HOB. CNA 1 adjusted the bed to a flat position, and CNA 1 stated she would get someone to help her move Resident 99 back up towards the HOB. Resident 99 was lying flat, and her tube feeding was infusing. CNA 1 exited the room to find someone to assist her. CNA 1 came back to the room with CNA 2, and they lifted Resident 99 towards the HOB. CNA 1 then elevated Resident 99's HOB to at least 30 degrees. During an observation on 03/25/25 at 09:37 A.M., Resident 99's HOB was positioned to less than 30 degrees, with tube feeding infusing at 65 ml/hr. During a concurrent observation and interview on 03/25/25 at 09:43 A.M., with CNA 3, CNA 3 went to see Resident 99 in her room. CNA 3 stated she would raise Resident 99's HOB to 30 degrees. During a concurrent interview and record review on 03/25/25 at 03:29 at P.M., with Director of Nursing (DON), DON stated there was a physician's order to keep Resident 99's HOB to at least 30 degrees during feeding administration. DON reviewed Resident 99's care plan and stated the intervention was to keep Resident 99's HOB at least at 30 degrees during j-tube feeding.

Based on interview and record review the skilled nursing facility did not make an appointment to assess poor vision for one of 26 sampled residents (Resident 51). Resident 51 had broken his glasses and could not adequately see. This resulted in Resident 51 feeling Frustrated. Findings: Record review of the document admission Record showed the facility admitted Resident 51 on 2/27/2025. Diagnoses included epilepsy (seizure disorder). Review of the document Nursing admission Assessment 5.4 dated 3/6/2025, showed Resident 51 had Adequate vision without the use of corrective lenses. Review of the document MDS 3.0 Nursing Home Comprehensive (NC) Version 1.19.1 dated 3/6/2025, (resident assessment) showed Resident 51 was alert and oriented. Review of the section Hearing, Speech, and Vision showed Resident 51 used Corrective Lenses. During an interview on 3/24/25 at 10:15 a.m. Resident 51 stated he had seizures and broke his glasses in October. He stated he could not see this surveyor as his vision was Blurry and he was frustrated since staff had not assisted him in obtaining an eye appointment. Resident 51 stated he had reported this to staff but Nothing happens. During a second interview at 1:30 p.m. Resident 51 stated he had been unable to see during his entire stay in the facility and it Brings him back to high school when he was too [NAME] to get glasses. He stated he has started to be able to identify staff by How they walk and the Outline of their body. During an interview on 3/24/2025 at 10:50 a.m. the Social Services Director (SS2) stated she not been made aware of any issues with Resident 51's vision and typically nursing staff would report this to her. During an interview on 3/26/2025 at 12:30 p.m., Licensed Vocational Nurse 4 (LVN 4) stated she had not been made aware of any issues with Resident 51's vision. During an interview on 3/26/2024 at 12:40 p.m. Certified Nursing Assistant 4 (CNA 4) stated she was not aware of any issues with his vision. Record review of the document Order Entry dated 3/24/2025 (survey start date) showed a referral was made to an ophthalmologist for Resident 51. Review of the document RAI process (Resident Assessment Instrument) dated 10/1/2023, showed the purpose was To ensure the RAI is used, in accordance with specified format and timeframes, in conducting comprehensive assessments as part of an ongoing process through which the facility identifies each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessment once problems have been identified.

Based on observation, interview, and record review, the facility failed to ensure for one out of 26 sampled residents (Resident 88), foot care on a regular basis. Resident 88 had long, thickened, and cracked toenails, and his feet and ankles had layers of scaly dry skin. This failure resulted in Resident 88's feelings of well-being being affected due to lack of foot care. Findings: A review of the facility's admission Record indicated Resident 88 was admitted on [DATE] with diagnoses that included failure to thrive. Resident 88's Minimum Data Set (MDS - resident assessment tool) dated 2/5/2025, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score of 14, (BIMS score of 13 - 15, cognitively intact). Resident 88's MDS Section GG- Functional Abilities for Self-Care indicated Resident 88 needed partial to moderate assistance for shower/bathe self, lower body dressing, putting on/taking off footwear, and personal hygiene During a concurrent observation and interview with Resident 88 on 03/24/25 at 11:25 a.m., in his room, Resident 88 stated he had long toenails, and it hurt when he put on his shoes. Resident 88 removed his socks, and pieces of dried flaky skin came out of his socks and feet. Resident 88's feet and ankles were severely dried with layers of scaly skin that dropped when he moved. Resident 88's toenails were thick, jagged and cracked. Resident 88's left foot toenails were thick and curved inward, which caused Resident 88 pain. Resident 88 stated he was offered shower, but he refused since it's very cold, and he wore three layers of socks. Resident 88 stated no one had checked his feet since he was admitted . Resident 88 stated he was told he could see a podiatrist, but it may take months for an appointment, and he will be going home soon. During a concurrent observation and interview on 3/24/25 at 11:40 a.m., at Resident 88's room with Director of Nurses (DON), DON looked at Resident 88's feet and agreed that Resident 88's feet and ankles had layers of severely dried skin and toenails which were overgrown. DON stated Resident 88 was offered shower, but he refused. During an interview on 03/24/25 at 01:40 p.m., with Resident 88, Resident 88 stated he asked a nurse to get his toenails trimmed, but he was instructed to see the social services, and request to get an appointment to see a podiatrist.

Based on interview and record review the skilled nursing facility staff did not accurately assess the needs for one of 26 sampled residents (Resident 51). Resident 51 had difficulty eating with poor-fitting dentures and impaired vision due to broken eyeglasses. This resulted in Resident 51 feeling Frustrated. Findings: Record review of the document admission Record showed the facility admitted Resident 51 on 2/27/2025. Diagnoses included epilepsy (seizure disorder). Review of the document Nursing admission Assessment dated 2/27/2025, showed under the section Natural Teeth and Dentures, staff had not checked the appropriate boxes which would indicate Resident 51 had no natural teeth or dentures. Review of the document MDS 3.0 Nursing Home Comprehensive (NC) Version 1.19.1 dated 3/6/2025, (resident assessment) showed Resident 51 was alert and oriented. Review of the section Oral/Dental Status showed he had No natural teeth or tooth fragment(s) and had Mouth or facial pain, discomfort or difficulty with chewing. Review of the section Hearing, Speech, and Vision showed Resident 51 used Corrective Lenses. Review of the document Inventory of Personal Effects dated 2/27/2025, showed Resident 51 entered the facility at that time with upper and lower dentures. On 3/24/2025 at 10:15 a.m. Resident 51 was observed to have no teeth. In a concurrent interview he stated he owned dentures but they were Hard to eat with. He stated he felt Frustrated that staff had not helped him address the issue with his dentures. During an interview on 3/24/2025 at 10:50 a.m., the Director of Social Services (SS2) stated she was unaware Resident 51 had dentures that did not fit properly. During an interview on 3/26/2025 at 12:30 p.m. Licensed Vocational Nurse 4 (LVN 4) stated she had never seen Resident 51 with teeth and did not report it because she Never thought it was an issue. There was no documentation in the clinical record which showed staff had addressed the fact that Resident 51 had no teeth and was not using his dentures. During an interview on 3/24/25 at 10:15 a.m. Resident 51 stated he had seizures and broke his glasses in October. He stated he could not see this surveyor as his vision was Blurry and he was frustrated since staff had not assisted him in obtaining an eye appointment. Resident 51 stated he had reported this to staff but Nothing happens. During a second interview at 1:30 p.m. Resident 51 stated he had been unable to see for the entire time he had been at the facility and it brought him back to high school when he was Too [NAME] to get glasses. He stated he has started to be able to identify staff by How they walk and the Outline of their body. During an interview on 3/24/2025 at 10:50 a.m. the SS2 stated she not been aware of any issues with Resident 51's vision and typically nursing staff would report this to her. During an interview on 3/26/2025 at 12:30 p.m., LVN 4 stated she had not been made aware of any issues with Resident 51's vision. During an interview on 3/26/2024 at 12:40 p.m. Certified Nursing Assistant (CNA 4) stated she was not aware of any issues with his vision. There was no documentation in the clinical record which showed Resident 51's poor vision had been addressed. Record review of the document Order Entry dated 3/24/2025 showed a referral was made to an ophthalmologist for Resident 51. Review of the document RAI process (Resident Assessment Instrument) dated 10/1/2023, showed the purpose was To ensure the RAI is used, in accordance with specified format and timeframes, in conducting comprehensive assessments as part of an ongoing process through which the facility identifies each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessment once problems have been identified.

Based on interview and record review, the skilled nursing facility's licensed nursing staff did not provide care according to professional standards for 2 of 26 sampled residents (Residents 90 and 111). Residents 90 and 111 had elevated blood pressures that were not treated with available medication or reported to the doctor. This resulted in the potential for a stroke. (bleed or clot in the brain) Findings: Record review of the document admission Record showed the facility admitted Resident 90 on 1/24/2025. Diagnoses included End Stage Renal Disease. During an interview on 3/25/2025 at 2:55 p.m. the Director of Nursing (DON) stated the dialysis center had called on 3/15/2025 to ask that Resident 90's blood pressure medication be adjusted as his blood pressure became too low at dialysis. The DON stated the medication was changed to prn (as needed) as opposed to regularly scheduled. Record review of the document Order Summary Report dated 3/25/2025 showed Hydralazine (blood pressure medication) was to be given by mouth every 8 hours as needed for SBP greater than 170. (SBP: systolic blood pressure - top number of a blood pressure reading) Review of the document Weights and Vitals Summary (WVS) dated 3/25/2025 showed Resident 90's blood pressure on 3/18/2025 was 176/92. Review of the document Progress Notes *New* dated 3/1/2025 to 3/25/2025 showed on 3/18/2025 Resident 90 was given Hydralazine which lowered his blood pressure to 149/74. Further review of the WVS showed Resident 90's blood pressure was 198/94 on 3/19/2025. There was no documentation which showed a second blood pressure had been taken. Review of the Medication Administration Record (MAR) showed no Hydralazine had been given on 3/19/2025. In a concurrent interview on 3/19/2025 at 3:22 p.m. the DON confirmed there was no further blood pressure check, hydralazine given, or doctor notified. The DON stated the doctor should have been called because it was a change in condition which could lead to a stroke. Record review of the WVS showed on 3/21/2025 at 7:04 a.m. Resident 90's blood pressure was 183/84. There was no documentation in the MAR which showed hydralazine had been given or the doctor notified. In a concurrent interview the DON confirmed the elevated blood pressure had not been treated and no call was made to the doctor. The DON stated she would have Expected staff to call. Record review of the WVS showed Resident s 90's blood pressure was 178/85 at 3:59 a.m. on 3/25/2025. There was no documentation in the MAR which showed hydralazine had been given. There was no documentation the doctor had been notified. In a concurrent interview on 3/25/2025 at 2:55 p.m. the DON confirmed hydralazine had not been given and the doctor notified. The DON stated They should have called. Record review of the document admission Record showed the facility admitted Resident 111 on 2/26/2025. Diagnoses included Atherosclerosis of Coronary Artery Bypass Grafts. (heart disease) Record review of the document Order Summary Report dated 3/26/2025 showed staff were to notify the doctor for an SBP greater than 140. Resident 111 was on Losartan and Carvedilol medications to control blood pressure. Review of the WVS document showed the following blood pressures for Resident 111: 171/101 on 3/3/2025 at 7:38 a.m. 167/96 on 3/3/2025 at 8:08 a.m. 175/108 on 3/3/2025 at 11:42 p.m. 155/95 on 3/4/2025 at 7:37 a.m. 166/81 on 3/24/2025 at 6:58 a.m. There was no documentation in the clinical record which showed the doctor had been notified for the elevated blood pressures. In a concurrent interview on 3/26/2025 at 11:40 a.m. the DON confirmed there was no documentation the doctor had been notified. Record Review of the document Blood Pressure, Measuring dated 9/2010, showed Hypertension should be reported to the physician. Review of the document Change of Condition Notification dated 10/1/2023, showed the purpose was To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner.

Based on interview and record review, the facility failed to ensure two (Resident 1 and 3) of three sampled residents were free from verbal and physical abuse when, 1. Resident 2 screamed, hit and made verbal threats to harm Resident 1 during an altercation in the hallway; and 2. Resident 2 threw an object at Resident 3 who reacted by pushing the table, lost his balance and fell at a bingo game in the dining room. This failure caused repeated resident-to-resident altercations, emotional distress and potential to result in injuries for residents in the facility. Findings 1. Review of Resident 2 ' s progress notes dated 3/12/24 indicated Resident 2 screamed, hit and made verbal threats to harm Resident 1. Resident 2 was angry that Resident 1 was in the room next to Resident 2. Resident 2 demanded that Resident 1 leave her side of the hallway. During an interview with Resident 1, on 4/3/24, at 11:26 a.m., Resident 1 stated he went to visit one resident in the room next to Resident 2 ' s room, when Resident 2 came out of her room and started screaming at him and made racist remarks at him. Resident 1 further stated Resident 2 hit him in the chest area. Resident 1 stated he was upset because he was not free to go where he wanted in the facility. During an interview with Resident 2, on 4/3/24, at 12:30 p.m., Resident 2 stated Resident 1 called her yellow and made racist remarks at her. Resident 2 stated she had a shouting match with Resident 1 because she was upset about the name calling and did not want Resident 2 coming around the hallway towards her room. Resident 2 stated Resident 1 spit in her face. Review of Resident 1's Minimum Data Set (MDS- an assessment and care screening tool used to guide care), dated 9/13/21, indicated Resident 1 ' s Basic Interview of mental status (BIMS) score was 15 (meaning cognitively intact). Resident 1 had no behavioral symptoms. Resident 1 ' s diagnosis included congestive heart failure. Review of Resident 2's Minimum Data Set, dated dated [DATE], indicated Resident 2 ' s Basic Interview of mental status (BIMS) score was 15. Resident 2 had mood symptoms of feeling down, depressed or hopeless. Resident 2 had no physical or verbal behavioral symptoms, such as hitting, kicking, pushing, screaming, cursing and threatening others. Resident 2 ' s diagnosis included schizophrenia (a disorder that affects a person ' s ability to think, feel and behave clearly) and dementia (a group of thinking and social symptoms that interferes with daily functioning). Review of Resident 2's behavioral care plans, undated, indicated, Resident 2 had behavioral changes related to schizophrenia and dementia manifested by angry outbursts, yelling, screaming, not wanting visitors for roommate, not wanting to be greeted by another male resident, refusal of medication, physical and verbal aggression towards other residents. The care plan interventions included refer to behavioral treatment facility. During an interview on 4/3/24, at 1:53 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated she heard Resident 2 yell at Resident 1 to get out of the hallway. LVN 1 said Resident 2 stated Resident 1 spat in her face and Resident 2 made threats to harm Resident 1. During an interview on 4/3/24, at 1:59 p.m., with Certified Nursing Assistant (CNA 1), CNA 1 stated Resident 2 took a swing at Resident 1 and hit Resident 1 in the chest. CNA 1 further stated Resident 2 was upset that Resident 1 was in the hallway near Resident 2 ' s room. 2. Further review of Resident 2 ' s progress notes, dated 2/9/24, indicated Resident 2 joined other residents to play bingo game in the dining room. Resident 3 put one bingo card on top of Resident 2's card. Resident 2 got upset. Resident 2 asked for an empty box of chocolate and threw it at Resident 3. Resident 3 got upset, stood up and reacted by pushing the table. Resident 2 pushed back on the table which caused Resident 3 to lose balance and fall. Review of Resident 3's Minimum Data Set, dated dated [DATE], indicated Resident 3 ' s Basic Interview of mental status (BIMS) score was 13 (meaning cognitive intact). Resident 3 was not able to report correct day of the week. Resident 3 had episodes of feeling bad about himself. Resident 3's diagnoses included mood disorder. During an interview on 4/3/24, at 1:11 p.m., with Social Services Assistant (SSA), SSA stated while she assisted residents back to their rooms after the Bingo activity, Resident 2 pushed at the table. Resident 3 pushed back at the table, lost his balance and fell in the dining room. The facility ' s policy and procedure, titled, Abuse Prevention Policy and Prohibition Program, dated 10/1/23, indicated, each resident has the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. Based on interview and record review, the facility failed to ensure two (Resident 1 and 3) of three sampled residents were free from verbal and physical abuse when, 1. Resident 2 screamed, hit and made verbal threats to harm Resident 1 during an altercation in the hallway; and 2. Resident 2 threw an object at Resident 3 who reacted by pushing the table, lost his balance and fell at a bingo game in the dining room. This failure caused repeated resident-to-resident altercations, emotional distress and potential to result in injuries for residents in the facility. Findings 1. Review of Resident 2's progress notes dated 3/12/24 indicated Resident 2 screamed, hit and made verbal threats to harm Resident 1. Resident 2 was angry that Resident 1 was in the room next to Resident 2. Resident 2 demanded that Resident 1 leave her side of the hallway. During an interview with Resident 1, on 4/3/24, at 11:26 a.m., Resident 1 stated he went to visit one resident in the room next to Resident 2's room, when Resident 2 came out of her room and started screaming at him and made racist remarks at him. Resident 1 further stated Resident 2 hit him in the chest area. Resident 1 stated he was upset because he was not free to go where he wanted in the facility. During an interview with Resident 2, on 4/3/24, at 12:30 p.m., Resident 2 stated Resident 1 called her yellow and made racist remarks at her. Resident 2 stated she had a shouting match with Resident 1 because she was upset about the name calling and did not want Resident 2 coming around the hallway towards her room. Resident 2 stated Resident 1 spit in her face. Review of Resident 1's Minimum Data Set (MDS- an assessment and care screening tool used to guide care), dated 9/13/21, indicated Resident 1's Basic Interview of mental status (BIMS) score was 15 (meaning cognitively intact). Resident 1 had no behavioral symptoms. Resident 1's diagnosis included congestive heart failure. Review of Resident 2's Minimum Data Set, dated dated [DATE], indicated Resident 2's Basic Interview of mental status (BIMS) score was 15. Resident 2 had mood symptoms of feeling down, depressed or hopeless. Resident 2 had no physical or verbal behavioral symptoms, such as hitting, kicking, pushing, screaming, cursing and threatening others. Resident 2's diagnosis included schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly) and dementia (a group of thinking and social symptoms that interferes with daily functioning). Review of Resident 2's behavioral care plans, undated, indicated, Resident 2 had behavioral changes related to schizophrenia and dementia manifested by angry outbursts, yelling, screaming, not wanting visitors for roommate, not wanting to be greeted by another male resident, refusal of medication, physical and verbal aggression towards other residents. The care plan interventions included refer to behavioral treatment facility. During an interview on 4/3/24, at 1:53 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated she heard Resident 2 yell at Resident 1 to get out of the hallway. LVN 1 said Resident 2 stated Resident 1 spat in her face and Resident 2 made threats to harm Resident 1. During an interview on 4/3/24, at 1:59 p.m., with Certified Nursing Assistant (CNA 1), CNA 1 stated Resident 2 took a swing at Resident 1 and hit Resident 1 in the chest. CNA 1 further stated Resident 2 was upset that Resident 1 was in the hallway near Resident 2's room. 2. Further review of Resident 2's progress notes, dated 2/9/24, indicated Resident 2 joined other residents to play bingo game in the dining room. Resident 3 put one bingo card on top of Resident 2's card. Resident 2 got upset. Resident 2 asked for an empty box of chocolate and threw it at Resident 3. Resident 3 got upset, stood up and reacted by pushing the table. Resident 2 pushed back on the table which caused Resident 3 to lose balance and fall. Review of Resident 3's Minimum Data Set, dated dated [DATE], indicated Resident 3's Basic Interview of mental status (BIMS) score was 13 (meaning cognitive intact). Resident 3 was not able to report correct day of the week. Resident 3 had episodes of feeling bad about himself. Resident 3's diagnoses included mood disorder. During an interview on 4/3/24, at 1:11 p.m., with Social Services Assistant (SSA), SSA stated while she assisted residents back to their rooms after the Bingo activity, Resident 2 pushed at the table. Resident 3 pushed back at the table, lost his balance and fell in the dining room. The facility's policy and procedure, titled, Abuse Prevention Policy and Prohibition Program, dated 10/1/23, indicated, each resident has the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property.

Based on interview and record review, the facility failed to ensure a resident was free from physical abuse when Resident 2 punched her roommate (Resident 1) on the left arm with her right hand. This failure had the potential for physical injury from retaliation in response to the roommates's aggressive behavior. Findings: Review of Resident 1's Admission Record, dated 10/19/23, indicated Resident 1 had a diagnosis of Dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with behavioral disturbances and schizophrenia (a mental disorder in which a person loses touch with reality). Review of the clinical record for Resident 1, the Minimum Data Set (MDS-a comprehensive assessment tool) dated 8/10/23, indicated Resident 1 had severe memory and judgement impairments. Review of Resident 1 ' s Care Plan, indicated Resident 1 had behavior problems of saying profanities and throwing things on the floor. Review of Resident 1's interdisciplinary team (IDT, staff from different departments who coordinate the resident ' s care) notes dated 10/19/23, indicated, Resident 1 threw a glass of milk to her roommate and her roommate hit Resident 1 ' s left arm. The IDT notes also indicated; Resident 1 was at risk for behavioral changes related to roommate hitting her on the left arm. During a phone interview on 12/5/23, at 11:29 a.m., with Certified Nursing Assistant (CNA) 1, stated, on 10/19/23, she was helping Resident 2, who was in lying in her bed, to be cleaned up. Stated, at that time, Resident 1 was also lying in her bed and was beside Resident 2. Stated, she stepped out of the room for a minute and when she reentered the room, Resident 2 was reaching to Resident 1 and was punching Resident 1 in the left arm with her right hand while saying, I want to beat your ass, I want to kill you. Also stated, Resident 2 told her that Resident 1 threw milk at Resident 2. CNA 1 stated, she saw that the lower right-side of Resident 2 ' s bed was wet with milk and there was an empty glass on the floor. During an interview with Resident 2 on 12/5/23 at 1:49 p.m., Resident 2 admitted that she hit Resident 1 ' s left arm with her right hand because Resident 1 threw a glass of milk at her. Stated she did not want Resident 1 to throw more things at her. A review of the clinical record for Resident 2, the MDS dated [DATE], indicated, Resident 2 had a Brief Interview for Mental Status (BIMS, an assessment tool that helps determine a patient ' s cognitive understanding) score of 15 (BIMS score of 13-15 indicates cognitively intact). During a review of the facility ' s policy and procedure titled, Abuse Prevention and Prohibition Program, dated 10/1/23, indicated, Each resident has the right to be free from abuse, neglect, mistreatment and/or misappropriation of property .The facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff, other residents .

Based on interview and record review, the facility failed to ensure nursing staff followed policies and procedures for safe medication administration when: 1. For one (Resident 5) of five sampled residents, Registered Nurse 1 (RN 1) left six prescription medications on Resident 5 ' s bedside table unmonitored. 2. For three of five sampled residents (Resident 5, Resident 2, and Resident 4), nursing staff did not use two resident identifiers (Information directly associated with a person that reliably identifies the individual as the person for whom the service or treatment is intended) before administration of medications. The failure to monitor the medications left on Resident 5 ' s bedside table resulted in Resident 5 taking medications prescribed for another resident and required two days in an acute care hospital to monitor Resident 5 for adverse side effects from the medications. The failure to use two resident identifiers resulted in Resident 5 receiving medications not prescribed for Resident 5 and had the potential to result in administration of the wrong medications to Resident 2 or Resident 4 with resultant adverse consequences from unprescribed medications. See also tag F 760. Findings: 1. During a review of Resident 5 ' s Admission Record, undated, the Admission Record indicated Resident 5 was admitted to the facility in June 2023, with a diagnosis of diabetes (a chronic disease caused by high levels of blood sugar, which leads over time to serious damage to the heart, blood vessels, eyes, kidneys, and nerves), asthma (difficulty in breathing), and muscle weakness. During an interview on 8/21/23, at 9:36 a.m., with Registered Nurse (RN) 1, RN 1 stated, on the morning of 7/8/23, she had taken medications to Resident 5 ' s room and placed the medications on Resident 5 ' s bedside table. RN 1 stated she left Resident 5 ' s room to document Resident 5 ' s medication administration and noticed she had given medications prescribed for another resident. RN 1 returned to Resident 5 ' s room and Resident 5 said she had already taken the medications left on the bedside table. RN 1 stated she was in a hurry that morning and did not use two patient identifiers prior to leaving the medications at the bedside or review the medications with Resident 5. RN 1 stated she had told Resident 5 that she had taken six medications that belonged to another Resident. RN 1 stated after Resident 5 took the medications, RN 1 had informed the Nursing Supervisor (NS) of the event. RN 1 stated the NS had called the Medical Doctor (MD) and Family Representative (FR) about Resident 5 receiving unprescribed medications. During a review of Resident 5's nursing progress notes dated 7/8/23 at 10 a.m., the notes indicated, 0800 pt [patient, Resident 5] was given [Resident 1's] medications while eating her breakfast. The medications given were: Alogliptin Benzoate Oral Tablet 12.5 MG [milligrams] (Alogliptin Benzoate) for DMZ [diabetes], Cymbalta Oral Capsule Delayed Release Particles 60 MG (Duloxetine HCI) for pain management r/t [related to]neuropathy (nerve pain), Depakote Oral Tablet Delayed Release 250 MG (Divalproex Sodium) for seizure disorder, Enalapril Maleate Oral Tablet 2.5 MG (Enalapril Maleate) for HTN [hypertension, known as high blood pressure], Jardiance Oral Tablet 10 MG (Empagliflozln) for DMZ, QUEtiapine Fumarate Oral Tablet 50 MG (Quetiapine Fumarate) for . visual hallucination. Pt reports dizziness. Noticed 1 episode of feeling drowsy MD notified .send to ER [emergency room ] for close monitoring. Called 911 for ambulance to come During a review of Resident 5 ' s, Physician Order Summary dated 7/8/23, the Summary indicated an order, OK to send patient to hospital for evaluation. During a review of Resident 5 ' s hospital document titled, ED (emergency department) Triage (order of priority) Note, dated 7/8/23 at 10:07 a.m., the ED Triage Note indicated Resident 5 was received in the ED for receiving wrong the wrong medications at the skilled nursing facility. The Note indicated, Pt (patient) feeling sleepy. During a review of Resident 5 ' s hospital document titled, H&P (history and physical), dated 7/08/23 at 1:07 p.m., the H&P indicated the Chief Complaint: Accidental Medication .presents with accidental overdose . admit for overnight observation. During a review of Resident 5 ' s, Physician Order Summary, dated 7/10/23, the Physician Order Summary indicated an order to admit Resident 5 to the facility. During an interview on 8/21/23 at 09:48 a.m., with the Director of Nursing (DON), she stated she expected all licensed staff to follow the 10-rights of medication administration. During a concurrent interview and record review on 8/21/23 at 12:30 p.m., with the DON, the documents titled, Inservice Education Record for Medication Administration and Med Error Prevention (Medication Pass Review) Attendance Sheets, dated 7/12/23 and 7/18/23 were reviewed. The in-service records indicated, .Resident must be identified prior to administration .the nurse administering the medication must also ensure the resident swallows the medication before the nurse may leave. All doses of all medication passes must be observed as being consumed by the resident in the presence of the nurse passing the medication . During a review of the facility ' s policy titled Medication Administration, dated 2007, indicated, .Residents should be observed swallowing all medications 2. During a review of Resident 2 ' s Admission Record, undated, the Admission Record indicated Resident 2 was admitted to the facility in July 2023 with a diagnosis of hypertension (high blood pressure). During an observation and interview with Licensed Vocational Nurse 1 (LVN 1) on 8/21/23 at 8:27 a.m., LVN 1 walked into Resident 2 ' s room carrying medications in a medicine cup. The medications included glipizide (used to stimulate the release of insulin from the pancreas) 5 mg (milligram, a unit of measurement) tablet, plavix (used to prevent blood clots) 75mg tablet, atorvastatin (used to reduce the risk of heart attack and stroke) 80mg tablet, and pantoprozole (used to treat heartburn) 40 mg tablet. LVN 1 handed the medication cup to Resident 2, who swallowed the medications. LVN 1 stated she had not checked any resident identifiers before giving the medications to Resident 2 because she knew all her residents. LVN 1 stated the policy was to check resident identifiers before administration of medications. 3. During a review of Resident 4 ' s Admission Record, undated, the Admission Record indicated Resident 4 was admitted to the facility in 2022, with a diagnosis of muscle weakness. During an observation and interview with Licensed Vocational Nurse 3 (LVN 3) on 8/21/23 at 8:49 a.m., LVN 3 walked into Resident 4 ' s room carrying medications in a medicine cup. The medications included, Apixaban (used to prevent stroke) 5 mg (1 tablet), and Allopurinol (used to prevent or lower acid levels in blood) 100 mg 1 tablet. LVN 3 handed the medication cup to Resident 4, who swallowed the medications. LVN 3 stated she had not checked any resident identifiers before the medications were administered because the Medication Administration Record (MAR) had a picture of Resident 4, and she knew the resident. During an interview on 8/21/23 at 9:48 a.m., with the Director of Nursing (DON), the DON stated licensed staff had been trained on proper medication administration and were expected to check two resident identifiers prior to any medication administration. During a review of the facility ' s policy titled Medication Administration, dated 2007, indicated, .10. Residents are identified before medication is administered using at least two resident identifiers. Methods of identification may include a) Check identification band, b) Check photograph attached to medical record, c) Verify resident information with other nursing care center personnel. Note: the resident ' s room number or physical location is not used as an identifier

Based on observation, interview, and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1, who was at high risk for falls, was provided a one-one sitter after Resident 1 was deemed needing constant supervision to prevent further fall incidents. Also, Resident 1 was not evaluated, and new interventions were not implemented after each fall incident. This failure resulted in Resident 1 incurring eight fall incidents over 28 days. On 6/30/21, Resident fell and obtained a facial laceration (cut) on the forehead. Resident 1 was sent to the hospital and was diagnosed with a subdural hematoma (condition when a pool of blood develops between the brain and its covering, usually from head trauma) and was hospitalized for nine-days. Findings: Review of Resident 1's Facesheet ( information containing contact details, brief medical history at-a-glance) indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included repeated falls, difficulty walking and muscle weakness, laceration on the head, dementia (memory loss and impaired decision-making capacity), traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head), major depressive disorder (a mental disorder characterized by persistently depressed mood and loss of pleasure and interest in life), and psychotic disorder (a mental illness). Review of Resident 1's Hospitalist (physician specialist in hospital care) History and Physical (H & P) dated 5/18/21 indicated, before Resident 1 was admitted to the facility Resident 1 presented to the hospital Emergency Department on 5/18/21 after an unwitnessed fall at Resident 1's former board and care home. Resident 1 hit his head and sustained a laceration on the scalp. Review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 6/19/21 under Section C, indicated Resident 1's short and long term memory was impaired, and had moderately impaired decision-making capacity (decisions poor, cues/supervision required). The MDS Section G titled, Functional Status indicated, Resident 1 was not steady, and only able to stabilize with staff assistance when moving from seated to standing position, walking, turning around, moving on and off toilet and during surface-to-surface transfer (such as when transferring between bed and chair or wheelchair). Resident 1's MDS indicated a need for ADL (activities for daily living) support with at least one person providing physical assist. Review of Resident 1's H & P by Attending Physician (AP) dated 6/15/21 indicated Resident 1 was a fall risk who had a prior intracerebral hemorrhage (bleeding within the brain) and recurrent falls. The H & P also indicated Resident 1 was a wanderer and at risk for going missing from the facility. During an interview and concurrent review of Resident 1's Fall Risk with Registered Nurse (RN) 1 on 7/21/21 at 11:55 a.m., Resident 1's fall risk score was 8 (score of 10 and above should be considered at high risk). RN 1 scored Resident 1's history of falls as zero (no falls in past 3 months). RN 1 stated, she was not aware of Resident 1's fall history from three months ago. RN 1 stated, she did not review Resident 1's chart when the fall assessment was conducted. RN 1 also stated, Resident 1's fall history should have been scored a 2 (one to two falls in the past 3 months) instead of a 0 (no falls in the past 3 months). Review of Resident 1's Physician Orders for June 2021 indicated, Resident 1 took four medications that would have affected Resident 1's risk of falling. Under G. Medications on the Fall Risk Assessment, RN 1 entered a score of 2 (takes one to two medications within the last seven days) instead of 4 (takes three to four medications within the last seven days). RN 1 stated, the fall assessment score should have been a 12, instead of 8 and Resident 1 was considered at High Risk for fall. Review of Resident 1's Care Plan for Fall- High Risk dated 6/14/21 indicated Resident 1 was considered as high risk for falls due to the following: History of falls, use of psychoactive (group of drugs that include stimulants, depressants, narcotics. that causes changes in mood awareness, thoughts, feelings or behavior) drugs, use of cardiovascular (body's circulatory system) medications, poor safety awareness, dementia, decline in functional status, unsteady gait, impaired balance and wandering. The approaches to minimize recurrence/risk of falls included to assess cause, pattern of falls, and activities; evaluate possible medical, physical, cognitive, and psychiatric (mental health disorder) conditions. Further review of the Resident 1's care plan indicated a care plan was created dated 7/8/21 with the same interventions listed on the 6/14/21 care plan. The 7/8/21 care plan did not include new interventions to prevent future falls. Review of Resident 1's Departmental Notes revealed Resident 1 had eight fall episodes from 6/18/21 through 7/15/21. Review of Resident 1's Departmental Notes revealed Resident 1 had an unwitnessed fall on 6/18/21 at 10:30 a.m. Resident 1 was found on the floor in his room. Review of Resident 1's Departmental Notes revealed Resident 1 had an unwitnessed fall on 6/19/21 at 8:30 p.m. Resident 1 was found on the floor mat beside his bed. Review of Resident 1's Departmental Notes revealed Resident 1 had an unwitnessed fall on 6/20/21 at 9:30 p.m. Resident 1 was found on the landing mat near the bed in prone position (lying on the stomach). Review of Resident 1's fall care plan indicated problem need, concern: Unwitnessed fall residents' room, the date section indicated 6/18/21. Further review indicated 6/19/21 and 6/20/21 was added under date but did not indicate any revision of current interventions or if any new intervention was implemented after the 6/19/21 and 6/20/21 fall incidents. Review of Resident 1's Departmental Notes revealed Resident 1 had an unwitnessed fall on 6/30/21 at 2:45 a.m. Resident 1 was noted on the floor near the foot of the bed. Resident 1 sustained a 2 centimeters laceration above the right eyebrow that was bleeding. Resident 1 was transferred to the hospital at 5:00 a.m. Review of Resident 1's Neurosurgery (brain or spinal cord surgery) Consultation Note dated 6/30/21 indicated, Resident 1 had abrasions (scrapes) on the right side of the face. Resident 1's Computed Tomography (CT- a medical imaging technique to get detailed images of the body) scan indicated small acute right-sided subdural hematoma that needed to be followed with serial Head CT (repeat scans taken in intervals) scans to establish clinical stability. The note indicated Resident 1 was admitted to the Neuro Intensive Care Unit (ICU), a place devoted to caring for those with immediately life-threatening neurological problems. Review of Resident 1's Face Sheet indicated Resident 1 was discharged from the hospital and was readmitted to the facility on [DATE]. Review of Resident 1's Departmental Notes revealed Resident 1 had an unwitnessed fall on 7/10/21 at approximately 11 a.m. The housekeeper found Resident 1 head-first on the ground and had sustained a raised red bump on the left side of the forehead measuring 1 inch. Review of Resident 1's record revealed a fall care plan was created on 7/10/21. The care plan indicated problem need, concern Unwitnessed fall residents' room, the same interventions listed on the 6/18/21 care plan was listed in the approach/action section. The care plan did not indicate it was revised or evaluated to include new interventions to prevent future falls. Review of Resident 1's Departmental Notes revealed Resident 1 had an unwitnessed fall on 7/11/21 at 9:22 p.m. Resident 1 was found on the landing mat. Review of Resident 1's record revealed a fall care plan was created on 7/11/21. The care plan indicated problem need, concern: Unwitnessed fall residents' room, the same interventions listed on the 6/18/21 and 7/10/21 care plan was listed in the approach/action section. The care plan did not indicate it was revised or evaluated to include new interventions to prevent future falls. Review of Resident 1's Departmental Notes revealed Resident 1 had a fall on 7/15/21 at 7:56 p.m. Resident 1 attempted to stand up without staff assistance and slid down to the floor. Review of Resident 1's record revealed a fall care plan was created on 7/15/21. The care plan indicated problem need, concern: Unwitnessed fall residents' room, the same interventions listed on the 6/18/21, 7/10/21 and 7/11/21 care plan was listed in the approach/action section. The care plan did not indicate it was revised or evaluated to include new interventions to prevent future falls. During an interview and concurrent review of Resident 1's fall care plan with the Licensed Vocational Nurse 2 (LVN 2) on 7/21/21 at 12:05 p.m., LVN 2 stated, fall care plan interventions/approaches were not reviewed/updated even after multiple unwitnessed falls. LVN 2 stated the care plan should have been reviewed to evaluate if they were effective in preventing another fall or future fall. During an interview with the Nursing Supervisor (NS) on 7/21/21 at 1:05 p.m. and concurrent review of Departmental Notes, NS stated she was part of the facility's Interdisciplinary Team (IDT, a group of individuals representing different departments of the facility). NS stated, the IDT had a meeting on 6/23/21 to discuss Resident 1's fall incident on 6/18/21. NS stated during the meeting, IDT was not aware of Resident 1's fall incident on 6/19/21. NS stated, IDT knew of Resident 1's fall incident on 6/20/21 but did not discuss the incident. NS stated, for every time there was a fall incident, the licensed nurse who completed the incident report was also responsible for updating/revising the care plan to see if current interventions worked. During a telephone interview on 9/27/21 at 1:34 p.m., with LVN 3. and concurrent review of Resident 1's Departmental Notes dated 6/27/21, LVN 3 stated the facility management did not offer options other than to have the Certified Nursing Assistants (CNAs) and Licensed Nurses check on Resident 1 frequently. During an observation and concurrent interview with NS on 7/21/21 at 1:40 p.m., NS stated, on 6/23/21, Resident 1 was moved to Room A, closer to the nurse's station for increased supervision by staff. Room A was two resident rooms away from the nurse's station where one could not see the residents while inside the room. During a telephone interview with LVN 4 on 7/26/21 at 11:33 a.m., LVN 4 stated, on 6/30/21 at 4:25 a.m. CNA 1 notified LVN 4 that Resident 1 was found already on the floor and had sustained a cut on the head with a lot of blood. LVN 4 stated, she knew Resident 1 was a fall risk, and was very concerned when Resident 1 was transferred to Room A as there were only two CNAs on that unit to watch and assist a total of up to 35 residents. LVN 4 stated, because of Resident 1's very random behavior (walking around the facility non-stop no matter what time of day), a sitter that could provide 24/7 supervision would have helped to reduce the falls. LVN 4 stated, multiple staff have been insisting for Resident 1 to have increased supervision even before the fall incident on 6/30/21. During a telephone interview with NS on 7/26/21 at 2:37 p.m., NS stated, IDT had met with RP on 7/12/21 to discuss the need for Resident 1 to have a 24/7 sitter to provide supervision every minute of the day but the Responsible Party (RP) could not provide a sitter. NS stated hourly monitoring was implemented instead which also did not work because Resident fell again on 7/15/21. During a telephone interview with Assistant Administrator (AA) on 7/21/21 at 4:22 p.m., AA stated, providing for a sitter for supervision could have been considered much sooner.

Based on interviews and record review, the facility failed to ensure one (Resident 1) of 3 sampled residents was free of significant medication errors. Resident 1 received all the morning medications meant for another resident when the licensed nurse failed to follow the facility's policy and procedure for identifying a resident. This error jeopardized the health of Resident 1, who was sent emergently to the hospital with a severely low blood pressure and change in level of consciousness. Findings: On 5/18/15, a relative of Resident 1 reported to the Department that Resident 1 was given the wrong medications which caused his blood pressure to drop. During a phone interview on 5/27/15, Resident 1's relative stated, She gave him all of another patient's medications. My mother was at the bedside and saw his (Resident 1) eyes roll up. She yelled to call 911. The nurse came in and said it was her fault, that she gave him the wrong medications. On 5/28/15, review of the medical record showed Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a nurse's note, signed by RN 1, dated 5/16/15 at 10:00 a.m., showed, Administered medication to patient at approximately 8:30 a.m. Discovered I had administered the wrong medications at about 9:10 a.m. I immediately notified my supervisor and took vital signs: 70/40, pulse 58 and oxygen saturation (the percentage of oxygen reaching the extremities) was 95 % on room air. The patient was no longer able to respond to commands. I lowered the patient's head of bed. I explained to the patient's wife what had happened and apologized. I phoned the physician and received an order to call 911. We called 911 at approximately 9:20 a.m. Emergency services arrived 10 minutes later and the patient was out of the building by 9:50 a.m. Review of the Post Incident Report, dated 5/16/15, showed, Patient was given medications meant for Resident 2. He was given [MEDICATION NAME] 100 mg (milligrams) (an anti-hypertensive drug), [MEDICATION NAME] 4 mg. (an anti- hypertensive drug), Edarbi 40 mg (an anti- hypertensive drug), [MEDICATION NAME] HCL 200 mg. (corrects the heart rhythm), [MEDICATION NAME] ER 120 mg. (anti- hypertensive that also corrects abnormal heart rhythm), [MEDICATION NAME] MN ER 60 mg. (cardiac drug that prevents [MEDICAL CONDITION] or heart pain), [MEDICATION NAME] 40 mg. (a diuretic which increases the secretion of urine), [MEDICATION NAME] 40 mg (an anti- coagulant or blood thinner) and [MEDICATION NAME] sulfate 325 mg (iron supplement). Patient's blood pressure was monitored closely, 15 minutes later, BP was 73/40, 5 minutes later systolic blood pressure (top number) was in 60's. MD was called with orders to send patient out to the emergency room 911. Wife present at bedside. Patient is DNR (do not resuscitate) but wife wants him to be sent. During interview on 5/28/15 at 12:40 p.m., the Director of Nurses (DON) stated, RN 1 did not look at the (Resident 1's) name band and he (the resident) did not correct her when she called him the wrong name. RN 1 realized later that she made this error. Review of the hospital emergency room physician's notes, dated 5/16/15, showed, The patient was opening his eyes and got to the ER around 10:00 a.m. and has some orientation to person. The patient was evaluated by MD. Had a CT scan with no acute lesion and .lab and chest x-ray were ordered. The patient was presented for admission. He is following commands and able to move all extremities, although he seems very weak and his BP was around 76 (systolic, top number) initially. Home medications Resident 1 was on: Aspirin 81 mg (anticoagulant), [MEDICATION NAME] 10 mg (anti-hypertensive), [MEDICATION NAME] 100 mg (anti-[MEDICAL CONDITION]), Losartin 50 mg (anti-hypertensive) Prevastatin 10 mg (cholesterol lowering), [MEDICATION NAME] (insulin). Review of the facility's policy and procedure, titled, Identification of a Resident, revised 5/27/15, showed, 1. All residents shall be identified by an identifier (ID) bracelet on the resident's wrist or ankle as soon as possible after admission. 2. A picture of the resident will be taken by medical records staff and uploaded into the electronic medical record. 3. The staff member providing medications, treatment, diagnostic testing, etc. shall identify resident by using TWO of the following methods: a. checking arm band, b. checking photo, C. asking resident his/ her name if able to answer questions, d. asking resident his/ her birthdate, e. Checking with another staff who has provided care for the resident, f. asking friend or family member to confirm resident ID.

Based on clinical record review, and staff interview, the facility failed to ensure that one of three residents (Resident 1) received the correct medication. Resident 1 received pain medication ([MEDICATION NAME] 120 mg) that was ordered for another resident. This failure resulted with Resident 1 becoming unresponsive requiring transfer to the acute hospital. Findings: Clinical record review on 10/1/12 at 9:17 a.m. showed that Resident 1 was admitted to the facility on [DATE] on hospice with [DIAGNOSES REDACTED]. He had a history of [REDACTED]. He was a comfort diet, and was to be given a pureed diet with honey thick liquids. Resident 1 did not speak English. Resident 1 had two orders for pain medications dated 8/13/12 to be given as needed: [MEDICATION NAME] 20 mg.(milligrams in one milliter solution and give .25 ml (milliters) orally every 4 hours as needed for mild pain and [MEDICATION NAME] 650 mg suppository per rectum every 6 hours as needed for mild pain. Review of the MAR (medication administration record) for September 2012 showed that Resident 1 was monitored for pain daily and did not have pain and the [MEDICATION NAME] and [MEDICATION NAME] suppository were not given. Review of the facility's "Departmental notes" (nurses notes) dated 9/15/12 at 9 a.m. indicated RN 1 gave Resident 1 medications that belonged to Resident 2. On 9/15/12 RN 1 noted a resident that did not have a name band on and checked his picture on the computer and thought Resident 1 was Resident 2. RN 1 proceeded to give Resident 1 [MEDICATION NAME] sulfate 360 milligrams extened release tabs that belonged to Resident 2. Resident 1 became sleepy later that morning and returned to bed, by 3:00 p.m. he was unresponsive and 911 was called. The paramedics arrived and administered [MEDICATION NAME] and transported the resident to the local acute care hospital. During an interview on 11/19/12 at 10:20 a.m. RN 1 stated she was passing her morning medications around 9 a.m.and she noted that a resident had no name band. She went to the computer to check his photo and it looked like the resident 2 and proceeded to give him the medications. The facility's policy showed that the procedure for "Administration of Medications" was the licensed nurse should check the resident's identity by armband with name and date of birth or medical record number; a photo ID and date of birth or verbal confirmation of name by resident by another care giver prior to administering medication.