Every finding on record at The Springs Health and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure safety and sanitation were observed in he kitchen when:1. Multiple ham and cheese sandwiches found undated in the kitchen and at Station 2 Clean utility room refrigerators;2. A plastic container of ketchup was found in the kitchen refrigerator with the corner of the lid open to air;3. Two packages of meat were found in the freezer undated;4. Multiple food items were found in the Clean Utility Room of Station 3 refrigerator not labeled and undated;5. A small amount of orange colored residue was found on a plastic piece of the ice machine in the Clean Utility Room of Station 2; 6. A large tomato sauce can was placed on a tray with parchment paper that was going to be used to cook the lunchtime garlic bread and;7. A Dietary Aide (DA) left the kitchen and returned to work with food products without washing hands.These failures had the potential to result in the spread of foodborne illness to the vulnerable residents who consumed meals in the facility kitchen.Findings:On December 8, 2025, at 10 a.m., the initial kitchen inspection was conducted with the Dietary Manager (DM). The following were found:- Refrigerator 1 had multiple undated ham and cheese sandwiches placed inside individual plastic bags. The DM stated the ham and cheese sandwiches should have a date when it was prepared;- Refrigerator 4 had a plastic container of ketchup with the lid open to air. The DM stated the ketchup lid should not be open to air.- The refrigerator inside the Clean Utility Room in Station 2 had multiple ham and cheese sandwiches that were undated. The DM stated the ham and cheese sandwiches should be dated when it was prepared;- The ice machine in the Clean Utility Room at Station 2 had orange colored residue on a white rubber piece in the ice machine.-The refrigerator in the Clean Utility Room at Station 3 had multiple food items that were undated and unlabeled; and- Two packages of meat were undated and stored inside the freezer.On December 11, 2025, at 12:44 p.m., an observation of kitchen staff preparing for tray line was made. A large can of tomato sauce was observed placed on a tray to be used for garlic bread on top of the kitchen counter. In a concurrent interview with the DM, he stated the can of tomato sauce should not be placed on top of the tray to be used for garlic bread.The dietary aide (DA) was at the counter area where food was being prepared for trayline. The DA was observed covering the dessert. The DA was observed to leave the kitchen and returned to the area he was working at and assisted with getting the desserts ready, without washing her hands. In a concurrent interview, the DM stated the DA should have washed his hands after leaving and prior to going back for food prep.A review of the policy and procedure titled, Food Storage, revised September 1, 2021, indicated, .Frozen Meat/Poultry and Food Guidelines .label and date all food items.any opened products should be placed in storage containers with tight fitting lids.A review of the policy and procedure titled, Use and Storage of Food Brought to Resident, revised March 2023, indicated, .foods brought into the facility by family members should be in re-sealable containers with tight-fitting lids when retained in resident's room, perishable foods must be stored in the refrigerator, in re-sealable containers with tightly fitting lids. Containers will be labeled with the resident's name, and the manufacturer use by date, as applicable.the Food and Nutritional Services department or designated facility staff is responsible for discarding perishable foods on or before the manufacturer's use by date.A review of the policy and procedure titled, Ice Machine - Operation and Cleaning, revised September 1, 2021, indicated, .Procedure: The dietary staff will operate the ice machine according to the manufacturer's guidelines. The ice machine will be cleaned routinely.On no less than a monthly basis, remove all ice to wash the inside of the machine. Wash the inside of the machine using manufacturer recommended solution and rinse well.Sanitize the inside of the machine using a sanitizing solution and a clean cloth.Allow the inside of the machine to air dry, then refill the machine with ice.A review of the policy and procedure titled, Infection Prevention and Control Program, revised October 24, 2022, indicated, .intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.A review of the policy and procedure titled, Hand Washing Procedure, revised 2018, indicated, .When hands need to be washed: Before starting work in kitchen.before and after handling foods with the hands.

Based on interview and record review, the facility failed to ensure care and treatment was provided, for two of 32 sampled residents (Residents 163 and 8) when: 1. For Resident 163, hydralazine (medication used to treat high blood pressure) was not administered according to the physician's order; and 2. For Resident 8, blood sugar was not closely monitored related to use of long-acting insulin. These failures had the potential for a delay in care and treatment and could cause a decline in the residents' overall health condition. Findings: 1. On December 11, 2025, a review of Resident 163's admission Record, indicated Resident 163 was admitted to the facility on [DATE], with diagnoses which included heart failure and hypertensive (high blood pressure) chronic kidney disease. A review of Resident 163's medical records indicated the following physician's orders: - hydralazine HCl tablet 25 mg (milligram - unit of measurement). Give 1 (one) tablet by mouth every 12 (twelve) hours as needed for HTN (hypertension - pressure in blood vessels is too high), administer if SBP (systolic blood pressure - the top number in a blood pressure reading when the heart contracts [beats]) is greater than 150 mmHg (millimeters of mercury, a unit of pressure), date ordered March 7, 2025; and - Monitor Blood Pressure every 12 hours for hydralazine use every 12 hours for HTN, Give PRN (as needed) if SBP greater than 150 mmHg, date ordered May 30, 2025. A review of Resident 163's Care Plan Report, dated March 24, 2025, indicated, Focus.The resident has Hypertension.Interventions.Give anti-hypertensive (medication used to lower blood pressure) medications as ordered. A review of Resident 163's Medication Administration Record (MAR), and blood pressure results dated March 7, 2025 through December 9, 2025, indicated nursing staff did not administer hydralazine when Resident 163's SBP was greater than 150 mmHg on the following dates and times (22 days): - March 10, 2025, at 01:28 (1:28 a.m.), SBP 152 mmHg; - March 12, 2025, at 16:08 (4:08 p.m.), SBP 159 mmHg; - March 17, 2025, at 09:31 (9:31 a.m.), SBP 158 mmHg; - March 25, 2025, at 11:48 a.m., SBP 153 mmHg; - March 30, 2025, at 18:49 (6:48 p.m.), SBP 155 mmHg; - April 7, 2025, at 10:01 a.m., SBP 152 mmHg, - April 14, 2025, at 00:21 (12:21 a.m.), SBP 151 mmHg; - May 6, 2025, at 00:29 (12:29 a.m.), SBP 159 mmHg; - May 15, 2025, at 09:22 (9:22 a.m.), SBP 152 mmHg; - May 18, 2025, at 08:17 (8:17 a.m.), SBP 152; - May 20, 2025, at 00:03 (12:03 a.m.), SBP 153; - May 23, 2025, at 17:21 (5:21 p.m.), SBP 155; - June 1, 2025, at 21:00 (9:00 p.m.), SBP 160; - August 27, 2025, at 9:00 a.m., SBP 159 mmHg; - September 2, 2025, at 21:00 (9:00 p.m.), SBP 155 mmHg; - September 27, 2025, at 9:00 a.m., SBP 152 mmHg; - October 29, 2025 at 9:00 a.m., SBP 155; - October 31, 2025, at 21:00 (9:00 p.m.), SBP 153 mmHg; - November 19, 2025, at 9:00 a.m., SBP 152 mmHg; - November 20, 2025, at 21:00 (9:00 p.m.), SBP 154 mmHg; - November 25, 2025, at 9:00 a.m., SBP 152 mmHg; and - December 9, 2025, 21:00 (9:00 p.m.), SBP 151 mmHg. On December 10, 2025, at 4:19 p.m., an interview and concurrent record review was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated she had taken care of Resident 163 over the last 1.5 months. LVN 1 stated the nursing staff measured Resident 163's blood pressure during each shift (morning, evening, and NOC [overnight]). Regarding Resident 163's hydralazine order, LVN 1 stated It is only given if SBP greater than 150. On December 10, 2025, at 4:26 p.m., an interview and concurrent record review was conducted with ADON 2. ADON 2 reviewed Resident 163's physician's order for hydralazine and stated the nursing staff should have monitored Resident 163's blood pressure every shift and should have administered hydralazine every 12 hours when the SBP was greater than 150 mmHg. ADON 2 reviewed Resident 163's MAR and blood pressure results as listed above and acknowledged hydralazine was not administered on the above dates and times when Resident 163's SBP was greater than 150 mmHg and stated hydralazine should have been given. On December 12, 2025, at 12:29 p.m., an interview and concurrent record review was conducted with the Director of Nursing (DON). The DON reviewed Resident 163's physician's order for hydralazine, MAR, and the blood pressure results as listed above. The DON acknowledged the nursing staff did not administer hydralazine on the above dates and times when Resident 163's SBP was greater than 150 mmHg according to the provider's order. The DON stated hydralazine should have been given and the expectation was for the nursing staff to administer medications according to the physician's order. A review of the policy and procedure titled Administering Medications, revised March 2023, indicated, .Medications must be administered in accordance with orders. 2. On December 12, 2025, at 10:33 a.m., a concurrent observation and interview was conducted with Resident 8. Resident 8 was observed laying in bed and watching television. In a concurrent interview, Resident 8 stated she had been diagnosed with diabetes mellitus (DM – abnormal blood sugar) and on dialysis (a life-sustaining medical treatment that filters waste products and excess fluid from your blood when your kidneys fail) for about four to five years. Resident 8 stated she had been receiving insulin medication once a day and the nursing staff checks her blood sugar. Resident 8 stated she was uncertain of her blood sugar levels. On December 12, 2025, at 11:20 a.m., a concurrent interview and review of Resident 8's record was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 stated Resident 8 leaves the facility for dialysis every Tuesdays, Thursdays, and Saturdays, at around 6 a.m. and returns to the facility by noon. LVN 2 stated they were checking Resident 8's blood sugar levels before meals and at bed time recently when a short acting insulin was started in September 2025. LVN 2 stated the licensed nurses did not check Resident 8's blood sugar levels at least daily as there was no order to check the blood sugar prior to routine blood sugar check which started in September 2025. LVN 2 stated Resident 8 had episodes of non-compliance with diabetic diet as would be snacking with food given by family and roommate. On December 12, 2025, Resident 8's record was reviewed. Resident 8 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (DM) and end stage renal disease (when your kidneys are failing and can no longer filter waste and fluids from your blood effectively enough to sustain life). A review of Resident 8's Minimum Data Set (MDS – a resident assessment tool), dated October 13, 2025, indicated Resident 8 had a BIMS (Brief Interview of Mental Status) score of 15 (cognitively intact). A review of Resident 8's care plan, date initiated on October 23, 2021, indicated, At risk for hypo/hyperglycemia (low/high blood sugar) r/t (related to) Dx (diagnosis) of DM, long-term insulin therapy.Interventions.Diabetes medication as ordered by the doctor. Monitor/document for side effects and effectiveness.Fasting Serum Blood Sugar as ordered by doctor.Identify areas of non-compliance or other difficulties in resident diabetic management.Monitor lab work as ordered.Collaborate with pharmacist and attending physician to adjust insulin and frequency of blood sugar checks as needed. A review of Resident 8's physician orders, dated July 17, 2023, which indicated, Lantus SoloStar Subcutaneous Solution .(Insulin Gargline – medication to treat DM) Inject 10 unit.in the morning .AND Inject 20 unit.in the morning. (discontinued on September 12, 2025). A review of Resident 8's Progress Notes, indicated the following: -January 24, 2025, at 10:16 p.m., indicated, .resident noted to have episode of hyperglycemia of 490mg/dl (milligram/deciliter – unit of measurement).routine lantus 20 units given at HS (bedtime), ineffective sugar went up to 502mg/DL.no s/s (signs and symptoms) of hyperglycemia.MD (Medical Doctor) aware and order to give 15units lispro (type of short acting insulin) one time only. -January 24, 2025, at 11:34 p.m., indicated, .CN (charge nurse) administer (sic) 15units of lispro one time only, resident's BS (blood sugar) is now 343mg/DL. MD aware and order to give another 10 units in 3 hours and recheck at 5am (5 a.m.).endorse to next shift. -January 25, 2025, at 7:55 a.m., indicated, .Resident on monitoring for non productive cough, malaise and hyperglycemia .blood sugar at 156 at 0530 (5:30 a.m.). -January 25, 2025, at 10:29 p.m., indicated, .on monitoring for non productive cough/malaise and hyperglycemia, resident still noted with high blood sugar of 441mg/DL at 2056 (8:56 p.m.) routine 20 units lantus given, check after 1 (one) hour resident's blood sugar is 449mg/DL. MD aware and still waiting for response. -January 25, 2025, at 11:01 p.m., indicated, .received order from MD to inject 10 units of lispro one time only. Further review of Resident 8's record indicated there was no monitoring of blood sugar on January 25, 2025, between 7:55 a.m. to 11:01 p.m. -January 26, 2025, at 7:34 a.m., indicated, .Resident on monitoring for HYPERGLYCEMIA.at 0030 (12:30 a.m.) blood sugar at 336.(name of MD0 ordered one time dose of 10units Lispro and recheck again at 0400 (4 a.m.) at 0430 (4:30 a.m.) Blood sugar was at 140. -January 26, 2025, at 10:24 p.m., indicated, .resident still noted with high blood sugar of 468mg/dl. Routine lantus 20units given, in-effective, check after 1 hour blood sugar is 554mg/dl. MD aware and awaiting for response. -January 26, 2025, at 11:03 p.m., indicated, .received order from MD to give 0 units of lispro. Further review of Resident 8's record indicated there was no monitoring of blood sugar on January 26, 2025, between 7:34 a.m. to 11:03 p.m. -January 27, 2025, at 7:48 a.m., indicated, .Resident noted with BG (Blood Glucose) of 571 at 2355 (11:55 p.m.) on 1/26/25 (January 26, 2025).with order to give 20 units of Lispro and to recheck BG at 0700 (7 a.m.).BG recheck at 0700 with result of 181. -January 27, 2025, at 11:02 p.m., indicated, .resident's blood sugar is still 493mg/dl even with routine lantus 20units. MD aware and order 15 units of lispro one time only. A review of Resident 8's Lab Results Report, indicated Hemoglobin A1C (HgbA1C - a blood test showing your average blood sugar (glucose) levels over the past 2-3 months). A review of Resident 8's Progress Notes, dated September 3, 2025, at 11:28 p.m., indicated, .Blood sugar was 421 at 2139 and rechecked again at 2200 (10 p.m.), and blood sugar was 402.Resident stated I ate a bag of potato chips A review of Resident 8's Progress Notes, dated September 5, 2025, at 2:01 p.m., indicated, .Resident on monitor for.hyperglycemia. No orders to check blood sugar this shift. A review of Resident 8's Progress Notes, dated September 5, 2025, at 10:26 p.m., indicated, .Residents (sic) blood sugar checked and was noted at 478. MD ordered to start lispro sliding scale achs (AC – before meals and HS – at bedtime).BS retaken and was at 429, MD ordered to give 8 lispro units. BS went down to 368.BS rechecked at 10pm and was 257. Further review of Resident 8's record indicated there was no order to check blood sugar in a regular frequency since July 17, 2023 (when lantus insulin was ordered) until September 5, 2025 (when short acting insulin was ordered with sliding scale coverage). Resident 8's Weights and Vitals Summary, indicated Resident 8's blood sugar level were checked at least three times a week prior to dialysis appointments. A review of Resident 8's Lab Results Report, dated September 8, 2025, indicated HbgA1C level of 8.7 (normal range 4.0 to 6.0). A review of Resident 8's dialysis laboratory results indicated the following HgbA1C results: -February 20, 2025; 7.1; -May 8, 2025; 7.2; -August 21, 2025; 8; Further review of Resident 8's records indicated there was no documented evidence Resident 8's HgbA1C result of 8 was addressed with evaluation of Resident 8's insulin therapy and monitoring of blood sugar levels. On December 12, 2025, at 11:47 a.m., a concurrent interview and record review was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated the physician determines how often resident's blood sugar is to be checked. ADON 1 stated if a resident is currently on long acting insulin and no sliding scale coverage for short acting insulin, the physician would order specific blood sugar check, either daily or weekly). ADON 1 stated Resident 8's BS was being checked at least three times a week prior to dialysis appointment. ADON 1 stated there was no order for BS to be checked routinely from January 2025 to September 4, 2025, despite Resident 8 having BS more than 400 mg/dl (elevated) on several occasions in January 2025. ADON 1 stated Resident 8's long term insulin therapy should have been evaluated for the need for routine blood sugar monitoring to ensure effectiveness of insulin therapy. A review of the facility's policy and procedure titled, Diabetes Clinical Protocol, dated February 2024, indicated, .To provide staff with clinical practice guidelines to care for residents with Diabetes.Finger stick glucose tests may be ordered several times a day or repeated at least once during the following week.Monitoring.The physician will follow up on acute episodes associated with a significant change in blood sugar or deterioration of previous glucose control and document resident status during subsequent visits until the acute situation is resolved.The physician, as indicated, may order blood glucose parameters to monitor the resident's blood glucose status.The physician will order appropriate lab tests (for example, periodic finger sticks or hemoglobin A1c.and adjust treatments based on these results and other parameters.Resident receiving insulin who are well controlled: monitor blood glucose levels twice daily if on insulin or as ordered by the physician; monitor 3 to 4 times a day if on intensive insulin therapy or sliding-scale insulin.Adjust monitoring frequency depending on glucose control and resident preference.

Based on observation, interview, and record review, the facility failed to implement required infection control interventions, use appropriate personal protective equipment (PPE - specialized gear like gloves, gowns, masks, and goggles used by healthcare workers to create a physical barrier against infectious agents, protecting them from blood, body fluids, and germs, ensuring safety during patient care by preventing transmission pathways) and follow Centers for Disease Control and Prevention (CDC) guidance, for two of 78 sampled residents when: 1. The Treatment Nurse (TN) did not use PPEs while providing wound care to Resident 33, who was placed on Enhanced Barrier Precautions (EBP - infection control measures, primarily in nursing homes, requiring staff to wear gowns and gloves for all high-contact care activities for residents with wounds, indwelling devices, or known colonization/infection with multidrug-resistant organisms);2. A Certified Nurse Assistant (CNA) was observed transporting a large soiled linen bag from a resident's room to the soiled utility room without wearing gloves, and with the soiled linen bag touching her clothing.3. A Physical Therapy Assistant (PTA) and a Certified Occupational Therapy Assistant (COTA) were observed not using PPEs while transferring Resident 200 from wheelchair to bed.These failures had the potential to result in the transmission of infectious organisms (a single-celled bacterium), placing residents at increased risk for infection, illness and hospitalization. Findings: 1.On December 8, 2025, at 11:06 a.m., an EBP (enhanced barrier precautions) signage was observed outside of Resident 33's room, with no visible PPE gowns stocked. On December 8, 2025, at 3:20 p.m., a review of the EBP signage indicated, .Enhanced Barrier Precautions .Providers and Staff Must .Wear gloves and a gown for High-Contact Care Activities ., with images of a stop sign, gloves and a gown along the sides of the written instructions for enhanced barrier precautions. On December 8, 2025, at 3:24 p.m., a concurrent observation and interview was conducted with Resident 33. Upon entering Resident 33's room, there were no PPE gowns stocked in the room closet or outside the room. Resident 33 was observed sitting in his wheelchair at bedside. Resident 33 stated he had a stage 3 pressure ulcer (damaged skin and underlying tissue from constant pressure, often over bony areas) to the left buttocks that developed while in the hospital. Resident 33 stated he received daily wound care and weekly wound specialist evaluations. Resident 33 stated the staff wore gloves, but did not wear gowns while providing wound care and during indwelling catheter (a soft tube left inside the body (usually the bladder) for continuous urine drainage, held in place by an inflated balloon, used for urinary retention, surgery recovery, or incontinence, allowing urine to flow into a bag or through a valve to a toilet, maintaining bladder function without frequent insertion) care.On December 11, 2025, at 9:43 a.m., Resident 33's record was reviewed. Resident 33 was admitted to the facility on [DATE], with diagnoses which included pressure ulcer of the left buttocks.A review of Resident 33's Minimum Data Set (MDS - a resident assessment tool), dated December 4, 2025 , indicated Resident 33 had a BIMS (Brief Interview of Mental Status) score of 15 (cognitively intact).On December 11, 2025, at 11:25 a.m., a concurrent observation and interview with the Treatment Nurse (TN) was conducted. The TN observed the EBP signage outside Resident 33's door. The TN observed that the PPE was not stocked in or outside Resident 33's room. The TN further stated gloves were stocked in resident's room, PPE gowns were available from the central supply closet down the hall, and masks were at the nurse's station. The TN stated the wound care process and preparation for Resident 33's wound care as follows: wash his hands and apply gloves, then perform wound care. The TN read the EBP signage outside Resident 33's room and stated he should wear a gown while performing wound care. Resident 33's medical records were concurrently reviewed with the Treatment Nurse which indicated the following physician orders:- September 12, 2025, Enhanced Barrier Precaution due to indwelling foley catheter, every shift; and- November 4, 2025, Enhanced Barrier Precaution due to Left gluteal (relating to the gluteus muscle in the buttocks) fold wound, every shift.A review of Resident 33's Care Plan, dated September 12, 2025, indicated, .Focus: Enhanced Barrier Precaution Related to: foley catheter (a thin, flexible tube inserted through the urethra into the bladder to drain urine) .Goals: Will minimize risk and complications of infection .Interventions: Health Teaching to resident, family members, and staff about importance of Enhanced Barrier Precaution including proper hand hygiene and wearing of personal protective equipment ( PPE ) during high-contact resident activities .A review of Resident 33's Care Plan dated November 4, 2025, indicated, .Focus: Enhanced Barrier Precaution due to Left gluteal fold wound .Goals: Will minimize risk and complications of infection .Interventions: Health Teaching to resident, family members, and staff about importance of Enhanced Barrier Precaution including proper hand hygiene and wearing of personal protective equipment (PPE) during high-contact resident activities .On December 11, 2025, at 12:20 p.m., a concurrent observation and interview with Restorative Nurse Assistant (RNA) 1 was conducted. RNA 1 stated Resident 33 has EBP for urinary catheter care. RNA 1 stated EBP requires staff to wear PPE while providing direct patient care. The RNA stated the staff are required to wear a yellow PPE gowns and gloves, even if not performing urinary catheter care. RNA 1 observed Resident 33's room and closet and stated that there were no PPE gowns and they needed to be restocked. RNA 1 stated she should get PPE gowns from the supply closet down the hall prior to providing care. On December 12, 2025, at 12:38 p.m., an interview with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1 stated EBP is for residents that have intravenous line (IV - a needle or tube inserted into a vein), urinary catheter, or gastrostomy tube (GT - a direct opening from the outside of the abdomen into the stomach). CNA 1 stated staff were required to wear gloves and PPE gown before high interaction with the resident. On December 15, 2025, at 3:16 p.m., a concurrent interview and record review with the Director of Nursing (DON) was conducted. The DON stated the staff were required to wear a gown and gloves when there was significant contact with a resident such as wound care, transfers, activities of daily living (ADLS), urinary catheter care, IV care and GT care to those residents requiring EBP. The DON stated the staff were required to wear a gown and gloves even when there were no direct touching or care to the area of concern. The DON stated if a resident that was on EBP returns to the room from an activity such as: dining room, rehab, shower, and required two staff member assistance to transfer from wheelchair to bed, the staff members should wear a gown and gloves due to significant contact with the resident. A review of the facility's policy and procedure titled, Enhanced Barrier Precautions, dated April 1, 2024, indicated, .infection control intervention .designed to reduce transmission of multi-drug -resistant organisms .gown and glove use during high contact resident care activities .dressing .bathing/showering .transferring .device care or use: central line, urinary catheter, feeding tube .wound care .EBP should be followed when .anticipating close contact .while assisting .transfers and mobility .2. On December 10, 2025, at 10:59 a.m., CNA 2 was observed transporting soiled linen in the hallway. CNA 2 was carrying a large, clear, secured bag with soiled linens without wearing gloves. CNA 2 was observed with the soiled linen bag touching her clothing. CNA 2 was observed taking the soiled linen bag to soiled utilities closet. On December 15, 2025, at 2:39 p.m., an interview with the Infection Preventionist (IP) was conducted. The IP stated the soiled linen bag should not touch a staff members body while transporting from the resident's room to the soiled utilities closet, because the soiled linen bag has touched the floor and was considered dirty.On December 15, 2025, at 3:16 p.m., an interview with the DON was conducted. The DON stated when transporting a soiled linen bag from a resident's room to the soiled utilities closet, the bag should be away from the clothing and body. A review of the facility's policy and procedure titled, Soiled Laundry & Bedding, revised date July 1, 2015, indicated, .Anyone who handles soiled laundry .wears protective gloves .and other protective appropriate protective equipment .3. On December 10, 2025, at 10:34 a.m., EBP signage was observed outside of Resident 200's room, with no visible PPE gowns stocked. The EBP signage indicated, .Enhanced Barrier Precautions .Providers and Staff Must .Wear gloves and a gown for High-Contact Care Activities ., with images of a stop sign, gloves and a gown along the sides of the written instructions for enhanced barrier precautions. On December 11, 2025, at 12:38 p.m., Resident 200's record was reviewed. Resident 200 was admitted to the facility on [DATE], with diagnoses which included bacteremia (the presence of bacteria in the bloodstream).A review of Resident 200's MDS, dated November 26, 2025, indicated, Resident 200 had a BIMS score of 15 (cognitively intact). A review of Resident 200's physician orders indicated the following:- Enhanced Barrier Precaution due to enteral feeding (delivering liquid nutrition (formula) directly into the stomach), every shift, date ordered December 9, 2025; and- Enhanced Barrier Precaution due to RUA (right upper arm) PICC line (a type of long catheter that is inserted through a peripheral vein), every shift, date ordered December 9, 2025.A review of Resident 200's care plan, dated December 9, 2025, indicated the following:- .Focus: Enhanced Barrier Precaution Related to: Enteral feeding .Goals: Will minimize risk and complications of infection .Interventions: Promote proper EBP signage .Health Teaching to resident, family members, and staff about importance of Enhanced Barrier Precaution including proper hand hygiene and wearing of personal protective equipment ( PPE ) during high-contact resident activities .- .Focus: Enhanced Barrier Precaution Related to: RUA PICC line .Goals: Will identify Signs and Symptoms of active infection .Interventions: Promote proper EBP signage .Health Teaching to resident, family members, and staff about importance of Enhanced Barrier Precaution including proper hand hygiene and wearing of personal protective equipment ( PPE ) during high-contact resident activities .Environmental Cleaning on resident's room, equipment and devices .On December 11, 2025, at 12:40 p.m., Resident 200 was observed returning to his room from rehab gym by wheelchair, with two therapy staff members. The PTA and COTA were observed transferring Resident 200 with a gait belt from the wheelchair to bed while wearing gloves. The PTA and COTA were in close contact with Resident 200 during the transfer and was observed not wearing a yellow gown.On December 11, 2025, at 12:48 p.m., an interview with the COTA and PTA was conducted. The COTA stated Resident 200 was on EBP precautions for IV and GT. The PTA stated staff were required to wear gowns and gloves when providing care to the residents with IV line or GT. The EBP signage was reviewed with the COTA and PTA. The COTA and PTA stated transferring a resident from wheelchair to bed was considered a high contact activity and they should have been wearing gowns and gloves when transferring Resident 200 from wheelchair to bed.On December 15, 2025, at 3:16 p.m., a concurrent interview and record review with the DON was conducted. The DON stated the staff were required to wear gowns and gloves when there was significant contact with a resident such as wound care, transfers, activities of daily living (ADLS), urinary catheter care, IV care and GT care. The DON stated the staff were required to wear gowns and gloves even when there was no direct contact or care to the area of concern. The DON stated if a resident that was on EBP returns to the room from an activity such as: dining room, rehab, shower, and required two staff member assistance to transfer from wheelchair to bed, the staff members should wear gowns and gloves due to significant contact with the resident. A review of the facility's policy and procedure titled, Enhanced Barrier Precautions, dated April 1, 2024, indicated, .infection control intervention .designed to reduce transmission of multi-drug-resistant organisms .gown and glove use during high contact resident care activities .dressing .bathing/showering .transferring .device care or use: central line, urinary catheter, feeding tube .wound care .EBP should be followed when .anticipating close contact .while assisting .transfers and mobility .

Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) recommendation were acted upon, for two of seven residents reviewed for unnecessary medications (Residents 7 and 8) when:1.For Resident 7, the duration of heparin (an anticoagulant [blood thinner] solution used to prevent and treat blood clots in various medical conditions and procedures) therapy was not indicated. This failure had the potential for Resident 7 to be exposed to unnecessary medication and placed the resident at risk for adverse effects; and2.For Resident 8, episodes of blood sugar levels above 300 mg/dl (milligram/deciliter - unit of measurement)was not evaluated by the physician. This failure had the potential for the medications not being optimized for best possible health outcome for Resident 8. Findings:1.On December 11, 2025, at 11:36 a.m., a concurrent observation and interview with Resident 7 was conducted. Resident 7 was observed sitting on a wheelchair in the dining room in front of the dining table waiting for lunch to be served. In a concurrent interview with Resident 7, he stated he is able to propel his wheelchair inside the facility.On December 11, 2025, at 11:40 a.m., Restorative Nursing Assistant (RNA) 2 was interviewed. RNA 2 stated she had been RNA for more than four years and have provided RNA exercises to Resident 7. RNA 2 stated Resident 7 was on ambulation program with the use of front wheel walker (FWW) five (5) times a week and the resident is able to ambulate about 150 feet with steady gait.On December 11, 2025, Resident 7's record was reviewed. Resident 7 was admitted to the facility on [DATE], with diagnoses which included wedge compression fracture of the lumbar verterbrae (a common spinal injury, usually from weak bones (osteoporosis), where the front of a lower back vertebra collapses, forming a wedge shape).A review of Resident 7's Order Summary Report, included physician's order, dated May 7, 2025, which indicated, .Heparin Sodium Injection Inject 1 (one) ml (milliliter - unit of measurement) subcutaneously (under the skin) every 12 hours for DVT (deep vein thrombosis - is a serious medical condition where a blood clot forms in a deep vein) ppx (prophylaxis - taking preventive measures (like drugs or vaccines) to stop a disease, infection, or complication before it starts, or preventing recurrence).A review of the facility document titled, Consultant Pharmacist's Medication Regimen Review, dated May 17, 2025, indicated, .please provide a duration of therapy for Heparin.On December 12, 2025, at 3:41 p.m., a concurrent interview and record review was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated there was no documentation the pharmacist recommendation to evaluate the duration of heparin therapy was referred to the physician for appropriate action. ADON 1 stated the pharmacist recommendation for Resident 7 should have been acted upon.2. On December 12, 2025, at 10:33 a.m., a concurrent observation and interview was conducted with Resident 8. Resident 8 was observed laying in bed and watching television. In a concurrent interview, Resident 8 stated she had been diagnosed with diabetes mellitus (DM - abnormal blood sugar) and on dialysis (a life-sustaining medical treatment that filters waste products and excess fluid from your blood when your kidneys fail) for about four to five years. Resident 8 stated she had been receiving insulin medication once a day and the nursing staff checks her blood sugar. Resident 8 stated she was uncertain of her blood sugar levels.On December 12, 2025, Resident 8's record was reviewed. Resident 8 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus and end stage renal disease (when your kidneys are failing and can no longer filter waste and fluids from your blood effectively enough to sustain life).A review of Resident 8's Minimum Data Set (MDS - a resident assessment tool), dated October 13, 2025, indicated Resident 8 had a BIMS (Brief Interview of Mental Status) score of 15 (cognitively intact).A review of Resident 8's care plan, date initiated on October 23, 2021, indicated, At risk for hypo/hyperglycemia (low/high blood sugar) r/t (related to) Dx (diagnosis) of DM, long-term insulin therapy.Interventions.Diabetes medication as ordered by the doctor. Monitor/document for side effects and effectiveness.Fasting Serum Blood Sugar as ordered by doctor.Identify areas of non-compliance or other difficulties in resident diabetic management.Monitor lab work as ordered.Collaborate with pharmacist and attending physician to adjust insulin and frequency of blood sugar checks as needed.A review of Resident 8's physician orders, dated September 12, 2025, indicated, Lantus SoloStar Subcutaneous Solution .(Insulin Gargline - medication to treat DM) Inject 10 unit.in the morning .AND Inject 25 unit.in the morning.A review of Resident 8's Weights and Vital Summary, indicated the following:- 22 episodes of blood sugar levels above 300 mg/dl from September 12, 2025 to September 30, 2025; and-27 episodes of blood sugar levels above 300 mg/dl from October 1 to 31, 2025.A review of the facility document titled, Consultant Pharmacist's Medication Regimen Review, dated October 22, 2025, indicated, .Resident's blood sugar has been > (more than) 300 on several occasions. Please ensure MD (Medical Doctor) is aware to evaluate.A review of Resident 8's Physician's Progress Notes, dated November 4, 2025, at 11:13 a.m., did not indicate evaluation of episodes of blood sugar levels > 300mg/dl.Further review of Resident 8's record indicated there was no documented evidence the pharmacy consultant recommendation to evaluate Resident 8's blood sugar of more than 300 mg/dl was referred to the physician for appropriate action.On December 12, 2025, at 1:42 p.m., a concurrent interview and record review was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated there was no documentation the pharmacy consultant recommendation to evaluate Resident 8's blood sugar levels of > 300mg/dl was referred to the physician for appropriate action. ADON 1 stated the pharmacy consultant's recommendation should have been acted upon.A review of the facility's policy and procedure titled, Medication Regimen Review, dated January 2025, indicated, .The facility licensed pharmacy shall review, at least monthly, each resident's drug regimen to maintain the highest practicable level of physical, mental, and psychosocial well-being to prevent or minimize adverse consequences related to medication therapy to the extent possible.The pharmacist performing the monthly medication regimen review will review the resident's medication regimen and ensure the medications each resident receives are clinically indicated.Review of the medical record as part of the MRR may decrease the potential for errors due to drug-drug interactions, omissions, duplication of therapy, or miscommunication during transition from one team of care providers to another.The pharmacist reviews the medical record to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities to the extent possible.The consultant pharmacist will evaluate.Whether the medication dose, frequency, route of administration, and duration are consistent with the resident's condition.Whether the physician and staff have documented progress towards, decline from, or maintenance of the resident's goal(s) for the medication therapy.The facility staff will encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the Director of Nursing to act upon the recommendations including acceptance or rejection.The attending physician shall document in the residents' health record, either on the MRR or in the progress notes, that the identified irregularity has been reviewed and what action (s) have been take to address it.The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility.

Based on observation, interview and record review, the facility failed to ensure, for one of two IV (intravenous, into the vein) Medication Emergency Kits (E-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) was replaced timely after being opened in accordance with the facility's policy and procedure. This failure resulted in the potential for emergency medications to be unavailable when needed, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions.Findings:On December 8, 2025, at 11 a.m., an observation and concurrent interview was conducted with Assistant Director of Nursing (ADON) 1 in the medication storage room at nursing station 1. One IV Medication E-kit was identified sealed with a yellow lock. ADON 1 stated the yellow lock indicated the IV Medication E-kit had been opened by nursing staff and needed to be replaced by the pharmacy. ADON 1 stated the following regarding the e-kit process and the expectation from the nursing staff after the e-kit was opened: -Should fill out the medication slip;-Leave one copy of the slip in the logbook and one copy of the slip inside the e-kit;-Reseal the e-kit with a yellow lock; -The nursing staff should immediately call the pharmacy to reorder the e-kit; and-The pharmacy should replace the e-kit within 72 hours.In a concurrent interview with ADON 1, she was unable to locate the medication slips and unable to identify when the IV medication E-kit was opened. The pharmacy label observed on outside of the IV Medication E-kit indicated it was filled by the pharmacy on November 27, 2025. ADON 1 stated the e-kit would have been opened by nursing staff sometime after November 27, 2025. ADON 1 compared the remaining contents inside the IV Medication E-kit to the inventory list to identify which medication(s) were removed. ADON 1 identified there were two medications removed: one Vancomycin (antibiotic to treat infections) 1 g (gram, unit of measurement) vial; and one Ertapenem (antibiotic to treat infections) 1 g vial. ADON 1 stated she needed to review medical records to identify when the medications were removed and stated she will follow-up. On December 10, 2025, at 10:12 a.m., a follow-up interview and concurrent record review was conducted with ADON 1. ADON 1 stated a nursing progress note dated November 30, 2025, indicated one Ertapenem 1 g vial was removed from the IV Medication E-kit. ADON 1 stated another nursing progress note, dated December 3, 2025, indicated one Vancomycin 1 g vial was removed from the IV Medication E-kit. ADON 1 acknowledged the IV Medication E-kits were not replaced within 72 hours according to the facility's policy and stated it should have been. On December 12, 2025 at 12:28 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was for nursing staff to have called the pharmacy immediately after an e-kit was opened and the pharmacy was expected to replace the opened e-kit within 72 hours to ensure the emergency medications were available for other residents when needed.A review of the facility's policy and procedure titled, Emergency Pharmacy Service and Emergency Kits, revised June 2016, indicated, .Opened kits are replaced with sealed kits within 72 hours of opening .

Based on interview and record review, the facility failed to ensure, for one of five sampled residents (Resident 16) was free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when Resident 16 was administered lorazepam (used to treat anxiety) without adequate behavioral monitoring during the use of lorazepam. This failure had the potential to result in unnecessary use of medications for Resident 16 which increased the potential for medication interactions, adverse reactions, and unidentified risks associated with the use of lorazepam that included but not limited to sedation, dizziness, unsteadiness, and difficulty concentrating. Findings:On December 10, 2025, at 10:39 a.m., a group interview was conducted with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) 1 regarding the facility's psychotropic medication management process. The DON and ADON 1 stated all psychotropic medication orders were expected to include an order to monitor the target behavior. ADON 1 stated all medication and monitoring orders were documented by the nursing staff in the resident's Medication Administration Record (MAR).On December 10, 2025, a review of Resident 16's admission Records, indicated, the admission Records indicated Resident 16 was originally admitted to the facility on [DATE], and readmitted to the facility on [DATE] with diagnoses which includes dementia (loss of brain function impacting memory, thinking, and daily tasks), psychosis (when a person has trouble telling the difference between what's real and what's not), and depression.A review of Resident 16's medical records included a physician's order, dated December 8, 2025, which indicated, Lorazepam Oral Concentrate (a strong liquid medicine) 2 (two) mg (milligram - unit of measurement) per 2 (two) ml (milliliters - unit of measurement), give 0.5 ml by mouth every 4 (four) hours as needed for Anxiety M/B (manifested by) SOB (shortness of breath).A review of Resident 16's medical record indicated there was no physician's order to monitor the target behavior Anxiety M/B SOB during use of lorazepam.A review of Resident 16's MAR, and Progress Notes, dated December 8, 2025, to December 11, 2025, indicated Resident 16 was administered lorazepam eight (8) times and there was no documented evidence that the target behavior Anxiety M/B SOB was monitored and documented by nursing staff during the use of lorazepam on the following dates & times: - December 8, 2025, at 16:45 (4:45 p.m.);- December 9, 2025, at 18:46 (6:46 p.m.);- December 10, 2025, at 03:13 (3:13 a.m.);- December 10, 2025, at 08:57 (8:57 a.m.);- December 10, 2025, at 16:47 (4:47 p.m.);- December 10, 2025, at 20:52 (8:52 p.m.);- December 11, 2025, at 01:16 (1:16 a.m.); and- December 11, 2025, at 10:14 a.m.On December 11, 2025, at 12:26 p.m., a group interview and concurrent record review was conducted with the DON, ADON 1, and ADON 2. The group reviewed Resident 16's medical record, including Resident 16's physician's orders and the MAR for December 2025. The DON and ADON 2 confirmed there was no physician's order to monitor the target behavior Anxiety M/B SOB when lorazepam was administered to Resident 16. The DON stated there should have been an order for monitoring target behavior when an as needed psychotropic medication was administered. On December 12, 2025, at 12:45 p.m., a follow-up interview and concurrent record review was conducted with the DON. The DON stated the expectation was for the nursing staff to document the target behavior Anxiety M/B SOB during the use of lorazepam for Resident 16. A review of the policy and procedure titled Dignity and Respect Psychoactive Medications, dated January 2025, indicated, .The resident's medication management plan is documented in their medical record .including the resident's response to any treatment (such as .behavior flow sheets .) is essential to evaluate the ongoing effectiveness, benefits as well as risks .

Based on observation, interview, and record review, the facility failed to ensure the residents were free from unnecessary medications, for one of seven residents (Resident 7), when the use of heparin (an anticoagulant [blood thinner] solution used to prevent and treat blood clots in various medical conditions and procedures) was not evaluated for the continued use.This failure has the potential to cause Resident 7 to develop adverse reactions from unnecessary medications.Findings:On December 11, 2025, at 11:36 a.m., a concurrent observation and interview with Resident 7 was conducted. Resident 7 was observed sitting on a wheelchair in the dining room in front of the dining table waiting for lunch to be served. In a concurrent interview with Resident 7, he stated he is able to propel his wheelchair inside the facility.On December 11, 2025, at 11:40 a.m., Restorative Nursing Assistant (RNA) 2 was interviewed. RNA 2 stated she had been RNA for more than four years and have provided RNA exercises to Resident 7. RNA 2 stated Resident 7 was on ambulation program with the use of front wheel walker (FWW) five (5) times a week and the resident is able to ambulate about 150 feet with steady gait.On December 11, 2025, Resident 7's record was reviewed. Resident 7 was admitted to the facility on [DATE], with diagnoses which included wedge compression fracture of the lumbar verterbrae (a common spinal injury, usually from weak bones (osteoporosis), where the front of a lower back vertebra collapses, forming a wedge shape).A review of Resident 7's Order Summary Report, included physician's order, dated May 7, 2025, which indicated, .Heparin Sodium Injection Inject 1 (one) ml (milliliter - unit of measurement) subcutaneously (under the skin) every 12 hours for DVT (deep vein thrombosis - is a serious medical condition where a blood clot forms in a deep vein) ppx (prophylaxis - taking preventive measures (like drugs or vaccines) to stop a disease, infection, or complication before it starts, or preventing recurrence).A review of Resident 7's Minimum Data Set (MDS - a resident assessment tool), dated November 4, 2025, indicated Resident 7 required supervision in walking 50 feet with two turns.A review of Resident 7's Physical Therapy Treatment Encounter Notes, indicated the ambulation progress status on the following dates:-June 3, 2025; 20 feet gait distance using two-wheeled walker;-July 4, 2025; 90 feet gait distance using two-wheeled walker;-September 30, 2025; 150 feet gait distance using two-wheeled walker; and-October 31, 2025; 175 feet gait distance using two-wheeled walker.A review of Resident 7's physician order, dated November 20, 2025, indicated, .RNA to do ambulation using FWW QD (once a day) 5x/week as tolerated, every day shift.Further review of Resident 7's record indicated there was no documented evidence the use of heparin was evaluated for it's continued use related to DVT prophylaxis. On December 12, 2025, at 1:35 p.m., during an interview with Assistant Director of Nursing (ADON) 1, she stated that heparin was prescribed to Resident 7 on May 7, 2025, due to immobility from a wedge compression fracture. ADON 1 stated that Resident 7 is now mobile and could ambulate with the RNA and propel himself within the facility. ADON 1 stated there was no documentation indicating that the physician evaluated the continued use of heparin for DVT prophylaxis despite the resident's improved mobility. ADON 1 acknowledged that Resident 7's heparin use should have been reviewed given his current mobility status.A review of the facility's policy and procedure titled, Anticoagulation Clinical Protocol, dated November 2024, indicated, .The facility provides care and services consistent with current standards of practice for residents who use anticoagulants.To provide staff with guidelines to reduce the potential risks associated with the use of anticoagulants.In general, long-term subcutaneous administration of heparin in chronically bed-bound individuals is not indicated or of proven benefit for long-term DVT prophylaxis.The physician will help review the progress of individuals who are being anticoagulated.The physician will periodically identify individuals whose anticoagulants can be discontinued or reduced and will document a rationale for continuing anticoagulation over time, including the medication and current dosage.

Based on interview and record review, the facility failed to ensure a copy of the notice of transfer/discharge was provided to the State Long-Term Care Ombudsman (assists with conflict resolution and protection of resident rights) prior to the planned discharge, for three of three sampled residents (Resident 1, 2, and 3). This failure had the potential to violate the resident's rights to appeal their discharge. Findings: On June 2, 2025, at 10:30 a.m., an unannounced visit was conducted at the facility to investigate a complaint on discharges. 1. A review of the admission Record, indicated Resident 1 was admitted to the facility on [DATE], with the diagnoses which included hemiplegia and hemiparesis following Cerebral Infarction (muscle weakness or paralysis to one side of the body), metabolic encephalopathy (brain disorder), and dementia (loss of memory, language, problem solving and thinking abilities). A review of Resident 1's Progress Notes, dated May 13, 2025, at 11:21 a.m., indicated, .spoke with (Resident 1's family member) requesting for resident to discharge home this coming friday . A review of Resident 1's Progress Notes, dated May 16, 2025, at 12:33 p.m., indicated, .DC (discharge) 5/16/25 (May 16, 2025) .to home .with all remaining medications . A review of Resident 1's Notice of Transfer/Discharge, dated May 13, 2025, indicated Resident 1 was provided notification of discharge on [DATE], and discharged from the facility on May 16, 2025. Further review of Resident 1's record indicated there was no documented evidence the Ombudsman's office was provided with the notice of transfer prior to discharge of Resident 1 on May 16, 2025. 2. A review of the admission Record, indicated Resident 2 was admitted to the facility on [DATE], with diagnosis of Acute osteomyelitis of left ankle and foot (an infection of the bone in that area caused by bacteria). A review of Resident 2's Progress Notes, dated May 14, 2025, at 7:09 p.m., indicated, .spoke with (name of family member) and resident discussed discharge ordered .informed writer that (family member) will pick up at 11 am (a.m.) on Friday (May 16, 2025) . A review of the Notice of Transfer/Discharge dated May14, 2025, indicated Resident 2 was provided notification of discharge on [DATE], and discharged from the facility on May 16, 2025. Further review of Resident 2's record indicated there was no documented evidence the Ombudsman's office was provided with the notice of transfer prior to discharge of Resident 2 on May 16, 2025. 3. A review of the admission Record, dated June 2, 2025, indicated Resident 3 was admitted to the facility on [DATE], with the diagnosis of dissection of the descending thoracic aorta (the main artery in the chest tears allowing blood to flow between the layers of the aorta wall). A review of the Notice of Medicare Non-Coverage dated May 2, 2025, indicated Resident 3 services will end on May 16, 2025. Resident 3 was notified services would end on May 13, 2025. On June 3, 2025, at 10:30 a.m., during an interview with the Social Worker (SW), she stated residents were often being notified three (3) days prior to discharge. The SW stated the notice of transfer would be emailed to the Ombudsman prior to discharge. On June 3, 2025, at 10:46 a.m., during an interview with the Case Manager (CM), he stated the notice of discharge/transfer was to be provided to the residents three to four days prior to discharge. The CM stated it was explained to the residents they could appeal the discharge. The CM stated the notice of transfer/discharge forms was to be emailed to the Ombudsman. On June 3, 2025, at 3:15 p.m., during an interview with the Assistant Administrator (AA), she stated there was no excuse the notice of transfer/discharge was not sent to the Ombudsman, it is usually emailed to her the emails came back. The AA stated the assigned Ombudsman was out of the office and they were unsure who was covering for the Ombudsman while out of office. The AA stated the notice of proposed transfer should have been provided to the Ombudsman office. A review of the facility's policy and procedure titled Notice Requirements Before Transfer or Discharges, dated March 2023, indicated, .the notice of transfer or discharge and Ombudsman notification .for facility initiated transfer or discharge of a resident, the facility shall notify the resident and the residents representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand .the facility shall send a copy of the notice of transfer or discharge to the representative of the Office of the State Long Term Care (LTC) Ombudsman before or as close as possible to the actual time of a facility -initiated transfer or discharge .evidence that the notice was sent to the Ombudsman should be present in the medical record .the facility follows the process for ombudsman notification in accordance with their state . A review of the facility's policy and procedure titled Transfer and Discharge, dated January 2025, indicated, .the resident and or their representative shall receive an explanation of the right to appeal the transfer or discharge including the name, address mailing and email, and phone number of the representative of the Office of the State Long-Term Care ombudsman, and the name, mailing and email addresses and phone number of the state agency responsible for the protection and advocacy for residents .

Based on interview and record review, the facility failed to ensure monitoring for one of three sampled residents (Resident 1), of the following: 1. Behavior of anxiety (feeling of fear, dread, and uneasiness); 2. Psychotic behavior (refers to the observable actions, thoughts, and expression of a person experiencing psychosis [mental state or condition itself, describing a range of symptoms including those that manifest as psychotic behavior]); and 3. Side effects for use of psychotropic medications (drugs that affect the brain and nervous system, primarily used to treat mental health conditions). This failure had the potential for unnecessary medication use. Findings: On April 4, 2025, at 9:10 a.m., an unannounced visit was conducted at the facility. A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE], under general in-patient hospice (a short-term, crisis-like level of care for hospice patients who need more intensive symptom management) care with diagnoses which included dementia (a loss of thinking, remembering, and reasoning skills), Parkinson's disease (a movement disorder of the nervous system that worsens over time) and uncontrolled behaviors, danger to self and others. A review of Resident 1's History and Physical Examination, dated March 19, 2025, indicated Resident 1 does not have the capacity to understand and make decisions. A review of Resident 1's Order Summary Report, dated April 4, 2025, indicated the following medications were ordered on March 19, 2025: a. .Lorazepam Oral Concentrate 2 MG/ML (Lorazepam- psychotropic medication) Give 1 ml by mouth every 4 hours for Anxiety, restlessness, agitation, SOB (shortness of breath) .; b. .Quetiapine Fumarate Oral Tablet 50 MG (Quetiapine Fumarate- psychotropic medication) Give 1 tablet by mouth in the morning for Psychosis M/B Unprovoked Physical Behavior for 15 Days .; c. .Quetiapine Fumarate Oral Tablet 100 MG (Quetiapine Fumarate) Give 1 tablet by mouth in the afternoon for Psychosis MB Unprovoked Physical Behavior for 15 Days . There was no documented evidence that monitoring for the targeted behaviors of anxiety and psychosis and side effects from use of lorazepam and quetiapine fumarate was initiated before March 21, 2025 (two days after admission). On April 4, 2025, at 4:09 p.m., during a concurrent record review of Resident 1's medical record and an interview with Registered Nurse (RN) 1, RN 1 stated there was no monitoring of behaviors of anxiety and side effects. RN 1 stated behavior of anxiety and side effects from lorazepam use should have been monitored. On April 8, 2025, at 10:17 a.m., during a concurrent record review of Resident 1's medical record and an interview with the Assistant Director of Nursing (ADON), the ADON stated the monitoring for behavior and side effects of lorazepam and quetiapine fumarate should have been monitored on March 19, 2025. On April 8, 2025, at 1:05 p.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1, LVN stated she did not recall Resident 1. LVN 1 stated she just started to be trained on the floor and to admissions, in March 2025 and Resident 1's physician's orders were the first one she had done. LVN 1 stated physician order for monitoring of side effects of psychotropic medication use and behaviors for anxiety and psychosis should have been obtained. On April 8, 2025, at 1:33 p.m., during an interview, the Director of Nursing (DON) stated she expected the nurses to obtain orders for monitoring behaviors and medication side effects when residents are on psychotropic medications. A review of the facility's policy and procedure titled DIGNITY AND RESPECT PSYCHOACTIVE MEDICATIONS, dated January 2025 indicated, .Facility staff will monitor for adverse side effects associated with the use of psychotropic medications .

Based on interview and record review, the facility failed to notify Resident 3 ' s Responsible Person (RP- person designated as being responsible for another person's medical and/or financial decisions) as well as other emergency contacts, of Resident 3 ' s change of condition (COC) and subsequent transfer to the general acute care hospital (GACH) on January 17, 2025. This resulted in the RP and emergency contacts being uninformed and unaware of Resident 3 ' s COC and transfer to the GACH. Findings: On January 29, 2025, at 9:37 a.m., Resident 3's RP was interviewed via telephone. The RP stated in the morning of January 17, 2025, family member (FM) 1 visited Resident 3 but did not stay long since Resident 3 had a cough. The RP stated in the afternoon of January 17, 2025, the facility called and notified her that Resident 3 ' s blood pressure (BP) was low and they were going to start intravenous (IV- into the vein) fluid hydration, and may possibly do an X-ray, after which the RP were to receive another update. The RP stated neither she nor her family members (FMs) received any notification from the facility thereafter. The RP stated the following morning (Saturday, January 18, 2025), FM 1 visited Resident 3 at the facility but did not find Resident 3 in the room. The RP stated FM 1 proceeded to the nurses ' station and asked where Resident 3 was, and was informed by the staff that Resident 3 was at the GACH, at a hospital where Resident 3 did not regularly receive prior care. The RP stated Resident 3 was transferred to the GACH due to low BP and low oxygen. The RP stated when they reached the GACH, Resident 3 was already admitted in the Intensive Care Unit, and was unable to communicate with them. The RP stated on Sunday, January 19, 2025, Resident 3 passed away. The RP stated she and the FMs felt they were robbed of precious time they could have spent with Resident 3, if they have been notified sooner of Resident 3 ' s change of condition and transfer to the GACH. A review of the facility ' s transfer and discharge list indicated Resident 3 was discharged from the facility on January 17, 2025. A review of Resident 3 ' s record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included acute congestive heart failure (heart muscle is weakened and cannot pump blood efficiently enough to meet the body's needs), atrial fibrillation (irregular heart rate and rhythm), and chronic kidney disease. A review of the facility document titled, SBAR (Situation, Background, Appearance Recommendation- a clinical assessment and communication tool): Change of Condition, dated January 17, 2025, 6:49 p.m., completed by Licensed Vocational Nurse (LVN) 1, indicated Resident 3 was sent out for hypoxia (low oxygen in the blood) and hypotension (low blood pressure), and that the RP was notified at 6:30 p.m. A review of the telephone order dated January 17, 2025, at 6:58 p.m., indicated, .Send out to (name of GACH) D/T (due to) Hypoxia and Hypotension . A review of the Progress Notes included a Family Update Note by the Director of Nursing (DON), indicating a call to the RP to .address the concern regarding the lack of family notification when the resident was transferred to the hospital on 1/17/25 at approximately 6:30 PM. (Name of RP) expressed that the family was very upset about not being informed promptly. Acknowledged her concerns and sincerely apologized, stating that there was no excuse for the communication lapse. (Name of RP) also informed (the facility [sic]) that the resident had passed away over the weekend, and staff offered deepest condolences for their loss . On January 29, 2025, at 3:59 p.m., during interview, the DON stated after investigating the incident, they found out three LVNs worked on sending Resident 3 out, and Resident 3 ' s charge nurse was LVN 1. LVN 1 assumed the other two nurses notified the RP and documented it as done, however; the RP and the FM were not notified of Resident 3's transfer to the GACH. The DON stated LVN 1 should have notified the RP and/or the emergency contacts himself, to make sure they were aware of what was happening with Resident 3. A review of the facility ' s policy and procedure titled, Notification of Changes, revised March 2023, indicated, .The facility informs the resident, the resident ' s physician, and the resident ' s representative when there is an accident resulting in injury, changes involving life threatening conditions .or transfer or discharge the resident .Guidelines: .The facility notifies .the resident representative of .A significant change in the resident ' s physical, mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications) .A decision to transfer or discharge the resident from the facility .Designated resident representative or family, as appropriate, should be notified of significant changes in the resident's health status .

Based on interview and record review, the facility failed to accurately document the Responsible Person (RP) notification of one of three residents' (Resident 3) transfer to the general acute care hospital (GACH) on January 17, 2025. This failure resulted in inaccurate documentation of events in relation to Resident 3 ' s transfer process. Findings: On January 29, 2025, at 9:37 a.m., the RP was interviewed via telephone. The RP stated in the morning of January 17, 2025, family member (FM) 1 visited Resident 3 but did not stay long since Resident 3 had a cough. The RP stated in the afternoon of January 17, 2025, the facility called and notified her that Resident 3's blood pressure (BP) was low and that they were going to start intravenous (IV- into the vein) fluid hydration, and may possibly do an X-ray, after which they were to receive another update. The RP stated neither she nor her family members (FMs) received any notification from the facility thereafter. The RP stated the following morning (Saturday, January 18, 2025), FM 1 visited Resident 3 at the facility but did not find Resident 3 in the room. FM 1 proceeded to the nurses ' station and asked where Resident 3 was. After checking Resident 3 ' s record, the staff informed FM 1 that Resident 3 was at the GACH. The RP stated Resident 3 was transferred to the GACH due to low BP and low oxygen. The RP stated when they reached the GACH, Resident 3 was already admitted in the Intensive Care Unit, and was unable to communicate with them. The RP stated on Sunday, January 19, 2025, Resident 3 passed away. The RP stated she and the FMs felt they were robbed of precious time they could have spent with Resident 3, if they have been notified sooner of Resident 3 ' s change of condition and transfer to the GACH. A review of the facility ' s transfer and discharge list indicated Resident 3 was discharged from the facility on January 17, 2025. A review of Resident 3 ' s record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included acute congestive heart failure (heart muscle is weakened and cannot pump blood efficiently enough to meet the body's needs), atrial fibrillation (irregular heart rate and rhythm), and chronic kidney disease. A review the facility document titled, SBAR (Situation, Background, Appearance Recommendation- a clinical assessment and communication tool): Change of Condition, dated January 17, 2025, 6:49 p.m., completed by Licensed Vocational Nurse (LVN) 1, indicated Resident 3 was sent out for hypoxia (low oxygen in the blood) and hypotension (low blood pressure), and that the RP was notified at 6:30 p.m. A review of the telephone order dated January 17, 2025, at 6:58 p.m., indicated, .Send out to (name of GACH) D/T (due to) Hypoxia and Hypotension . A review of the Progress Notes included a Family Update Note by the Director of Nursing (DON), indicating a call to the RP to .address the concern regarding the lack of family notification when the resident was transferred to the hospital on 1/17/25 at approximately 6:30 PM. (name of RP) expressed that the family was very upset about not being informed promptly. Acknowledged her concerns and sincerely apologized, stating that there was no excuse for the communication lapse. (name of RP) also informed that the resident had passed away over the weekend, and staff offered deepest condolences for their loss . On January 29, 2025, at 3:59 p.m., during interview, the DON stated after investigating the incident, they found out three LVNs worked on sending Resident 3 out, and Resident 3 ' s charge nurse was LVN 1. LVN 1 assumed the other two nurses notified the RP and documented it as done. However, the RP and the FM were not really informed of Resident 3's transfer to the GACH. The DON stated LVN 1 should have notified the RP and/or the emergency contacts himself, to make sure they were aware of the events.

Based on interview and record review, the facility failed to ensure pain medications were administered as ordered by the physician, for one of three residents (Resident A). This failure had the potential for Resident A's pain not be managed and affect overall health condition. Findings: On January 2, 2025, at 11:30 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. On January 2, 2025, a review of Resident A's medical record was conducted. Resident A was admitted to the facility on [DATE], with diagnoses which included atherosclerotic (a buildup of fats, cholesterol, and other substances in and on the artery walls) heart disease and polyneuropathy (a condition where multiple peripheral nerves throughout the body become damaged or malfunction). A review of Resident A's care plan, dated June 26, 2023, indicated, .Resident is at risk for pain r/t (related to) risk factors .Interventions .Administer medications as ordered . A review of Resident A's Order Summary Report, included the following physician's order: - Monitor level of pain (0-10 scale): Document pain level as follows: 0 = none, 1-3 = mild pain, 4-6 = moderate pain, 7-10 = severe pain, every shift, date order May 24, 2023; - Tramadol (a drug used for pain) tablet 50 mg every 6 (six) hours as needed for pain management Moderate pain (4-6 pain scale), date order February 27, 2024; and - Morphine Sulfate .100 MG/5ML .Give 0.50 ml by mouth every 4 (four) hours as needed for Severe pain (7-10), date order July 31, 2024, discontinued December 6, 2024; - Morphine Sulfate (a drug used to treat pain) 100 mg (milligram - a unit of measure)/5 ml (milliliter-a unit of measure), give 1 (one) ml as needed for wound treatment, may medicate prior to wound treatment, date order December 19, 2024; A review of Resident A's Medication Administration Record (MAR), for Morphine Sulfate 0.50 ml every 4 hours as needed for severe pain, for December 1 to 6, 2024, indicated morphine sulfate was administered to Resident A on December 4, 2024, at 12:20 a.m., with a pain scale of 5 (moderate pain). A review of Resident A's Medication Administration Record (MAR), for December 2024, indicated the morphine sulfate 1 ml was administered to Resident A with a pain scale of 4-6 (moderate pain) on the following dates: - December 8, 2024, at 9:09 p.m.; pain level of 4; - December 9, 2024, at 1:38 a.m.; pain level of 6; - December 9, 2024, at 10:02 a.m.; pain level of 3; - December 9, 2024, at 2:02 p.m.; pain level of 5; - December 9, 2024, at 6:30 p.m.; pain level of 3; - December 10, 2024, at 3:11 a.m., pain level of 6; - December 14, 2024, at 3:29 a.m., pain level of 5; - December 15, 2024, at 10:13 p.m.; pain level of 4; - December 18, 2024, at 9:40 p.m.; pain level of 6; and - December 19,2024, at 5:31a.m.; pain level of 4. A review of Resident A's Medication Administration Record (MAR), for December 2024, indicated the tramadol (ordered for moderate pain) was administered to Resident A with a pain scale of mild or severe pain on the following dates: - December 1, 2024, at 11:58 a.m.; pain level of 3; - December 2, 2024, at 12:05 p.m.; pain level of 3; - December 6, 2024, at 12:41 p.m.; pain level of 8; - December 8, 2024, at 11:05 a.m.; pain level of 7; - December 11, 2024, at 9:53 a.m.; pain level of 9; and - December 13, 2024, at 10:50 a.m.; pain level of 8. A review of Resident A's Hospice Nurse Progress Note Routine Visit, dated December 18, 2024, indicated, .always c/o (complain of) pain BLE (bilateral lower extremities-both legs) .pain not controlled with current medication .patient is not compliant to medication regimen .Hospice aide to provide care according to assignment .confused; sad; tearful-pt (patient) refused wound care . On January 10, 2025, at 3:30 p.m., an interview and concurrent record review was conducted with the Director of Nursing (DON). The DON reviewed Resident A's MAR for December 2024, regarding Resident A's orders for morphine sulfate and tramadol. The DON stated the morphine sulfate should have been given for severe pain, and the tramadol was to be given for moderate pain. The DON stated morphine sulfate and tramadol were not administered as ordered by the physician. A review of the facility's policy and procedure titled Pain Assessment and Management, dated March 2023, indicated, .to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs .ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management .Pain management is an interdisciplinary care process that includes .identifying and using specific strategies for different levels and sources of pain .conduct a comprehensive pain assessment upon admission to the facility .whenever there is a significant change in condition .assess the resident's pain and consequences of pain at least each shift .behavioral signs of pain .verbal expressions such as groaning, crying, screaming .resisting care, irritability, depression, decreased participation .guarding, rubbing or favoring a particular part of the body evidence of depression, anxiety .assess pain using a consistent approach and a standardized pain assessment instrument .pain management interventions shall reflect the sources, type and severity of pain .non-pharmacological interventions may be appropriate alone or in conjunction with medications .pharmacological interventions .may be prescribed to manage pain .implement the medication regimen as ordered .relevant criteria for measuring pain management .document the resident's reported level of pain with adequate detail as necessary and in accordance with the pain management program .

Based on interview and record review, the facility failed to ensure the resident receive the necessary care and treatment to prevent and treat allergic reactions, for one of four residents reviewed (Resident A) when: 1. Resident A's allergy to aspirin (medication to treat pain, fever, headache, and inflammation. It can also reduce the risk of heart attack) was not listed in the allergy list. Aspirin was administered to Resident A from June 3 to 17, 2024, and June 19 to 22, 2024 (total of 19 days); and 2. Resident A did not receive medication to treat signs and symptoms of allergic reaction. These failures resulted in Resident A to be transferred to the general acute hospital and acquired toxic epidermal necrolysis (a rare, life-threatening skin reaction, usually caused by a medication. It's a severe form of [NAME]-[NAME] syndrome [SJS- a rare, serious disorder of the skin and mucous membranes usually a reaction to medication that starts with flu-like symptoms, followed by a painful rash that spreads and blisters]). Findings: On July 18, 2024, at 9 a.m., an unannounced visit to the facility was conducted to investigate a complaint of quality of care. On July 18, 2024, at 11:05 a.m., an interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated he took care of Resident A when she developed a whole-body rash. LVN 1 stated he called the doctor, and orders were given to watch her closely and treat the rash with medicine. On July 18, 2024, at 12:25 p.m., an interview was conducted with Resident A's family member (FM). The FM stated Resident A developed allergies to the medications she was being given and she developed Stevens-Johnson Syndrome. The FM stated Resident A was being given medications she was allergic to and her skin was peeling off. The FM stated Resident A had been allergic to aspirin and penicillin (an antibiotic medicine for bacterial infections) for a long time. The FM stated when Resident A was hospitalized with difficulty breathing when the resident was young, when she took aspirin, Tussin (guaifenesin-medication for chest congestion), and penicillin (antibiotic to treat infections). The FM stated he asked the staff why Resident A was receiving aspirin when she was allergic to it. The family stated when Resident A came back from the hospital on June 17, 2024, he asked the facility, why Resident A's allergy to penicillin was not listed on her chart, it was added, and the aspirin was still missing from the allergy list. The family stated Resident A was already discharged to home and was having post-traumatic stress disorder (PTSD- having a difficult time recovering from a terrifying event) symptoms (anxiety, difficulty sleeping) from her allergic reaction experience. On July 18, 2024, a review of Resident A's medical record was conducted. Resident A's Admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included a cerebral infarct (stroke-lack of blood flow in the brain) and asthma (a disease in which the airway narrows and swells, making it difficult to breathe). A review of Resident A's previous hospital records, dated May 30, 2024 (prior to admission to the facility), indicated, .Allergies .Aspirin .Guaifenesin .Acute stroke .Aspirin once safe .Clarifies that aspirin caused a rash in the past . A review of Resident A's Admit/Readmit Assessment, dated June 2, 2024, indicated, .Allergies .Aspirin, guaiFENesin . A review of Resident A's history and physical, dated June 3, 2024, indicated the resident was allergic to aspirin and guaifenesin. A review of Resident A's care plans indicated, .Allergic to guaifenesin, penicillin .Interventions: Flag chart, medication and treatment sheets with allergy information .Inform MD (Medical Director - physician) of all allergy information when receiving new orders .Inform pharmacy of allergy information .Monitor for signs and symptoms of allergic reaction such as rash, itching. Notify MD . A review of Resident A's Order Summary Report, indicated Resident A's allergies documented were guaifenesin, penicillin, and Cipro (ciprofloxacin - antibiotic to treat infections). The document included a physician's order, dated June 2, 2024, which indicated, Aspirin 81 Oral Tablet Delayed Release 81 MG (milligram - unit of measurement) Give 1 tablet .one time a day . A review of Resident A's Medications Administration Record (MAR), for June 2024, indicated allergies to guaifenesin. The MAR indicated aspirin was administered to Resident A from June 3 to 17, 2024, and June 19 to 22, 2024 (total of 19 days). Further review of Resident A's record (progress notes, MAR, physician's order, and admission record) did not include aspirin in the allergy list since admission to the facility. A review of Resident A's Progress Notes, indicated the following: - June 6, 2024, at 6:33 p.m., indicated, .The system has identified a possible drug allergy for the following order. Aspirin 81 oral tablet delayed release 81MG Give 1 tablet by mouth one time a day . - June 3, 2024, at 1:27 p.m., indicated, .The system has identified a possible drug allergy for the following order: Aspirin 81 Oral tablet delayed release 81MG (Aspirin) . A review of Resident A's Order Summary Report, included a physician's order, dated June 18, 2024, which indicated, .Rivaroxaban (Xarelto - blood thinner) Oral Tablet Give 1 tablet by mouth two times a day for PE (pulmonary embolism - blood clot in the lungs) for 21 days . A review of Resident A's Medication Administration Record, for June 2024, indicated Xarelto was administered to Resident A on June 19 to 23, 2024 (total of 10 doses). A review of Resident A's Order Summary Report, included a physician's order, dated June 21, 2024, which indicated, .Ciprofloxacin (antibiotic medication to treat UTI (Urinary Tract Infection) tablet 500mg, one tab two times a day, for UTI for five days . A review of Resident A's Medication Administration Record, for June 2024, indicated ciprofloxacin was administered to Resident A on June 21 to 22, 2024 (three doses). A review of Resident A's Progress Notes, dated June 22, 2024, at 1:26 p.m., indicated .per son and resident she feels like her lips are burning and her tongue is red, per son she had this before 20 yrs (years) ago when she takes aspirin, also noted with generalized body rash, warm to touch .per other son she had an allergic reaction with ATB (antibiotic) for UTI (urinary tract infection) long time ago but they do not remember the name of medication, MD made aware, per MD [name of MD] continue Cipro .son and resident requested to discontinue aspirin .assessed resident, noted with red tongue and generalized rash, MD made aware .no new skin problems noted at this time .no changes in condition noted at this time .Per Dr. [name], he thinks it's the ASA (aspirin) not the Cipro caused the allergic reaction .D/C (discontinue) ASA (Aspirin) start Plavix (medication to thin the blood). Continue Cipro . A review of Resident A's Assessment Summary, dated June 22, 2024, at 3:53 p.m., indicated, .Communication for Changes in Condition .generalized body rash .red tongue, burning feeling around lips . A review of Resident A's Order Summary Report, indicated the following physician's orders to address the generalized rashes: - .Monitor skin rashes for increased spread or signs of allergy reaction to antibiotics for 14 days, ordered June 22, 2024; and - .Hydrocortisone (medicine to treat skin conditions) Cream 2.5% (percent), apply to scattered rash topically (to skin) every day shift for rashes for 14 days, cleanse with NS (normal saline-used in the medical field to clean wounds), pat dry, leave open to air . A review of Resident A's Progress Notes, indicated the following: - June 23, 2024, at 12:13 p.m., indicated, .body rash is getting worse, her tongue still red and still feeling burning around lips .son is requesting to change order for ABT (antibiotic) for UTI .No new skin problems noted at this time . - June 23, 2024, at 10:52 p.m., indicated, .Communication for Changes in Condition .tachycardia (fast heart rate), hypoxia (not enough oxygen) .BP (blood pressure-the pressure of circulating blood against the heart) 150/75 (normal range less than 120/80) .P (pulse) 118 (normal range 60 - 100) .R (respiration) 35 (normal range 12 - 18) .O2 (oxygen) 85% .room air .RN (Registered Nurse) aware pt's (patient's) son [name] visited pt and was concerned about her condition, alerted charge nurse and CNA (certified Nursing Assistant) to room to assess pt (patient) .pt noted with tachycardia 118-119 bpm (beats per minute), tachypnea (fast breathing) 35 rpm (respirations per minute) .hypoxia 85% on RA (room air) .pt put on 5L (liters-a type of measurement)/min (minute) O2 (oxygen) via nasal cannula (tubing goes into the nose and delivers oxygen), O2 sat (saturation in blood level) increased to 95-96%. Son mostly concerned about O2 sat, RR (respiratory rate), and HR (heart rate) .Dr. [name] made aware .pt has poor PO (oral) intake for several days and ATB (antibiotic) changed from Cipro to Macrobid (antibiotic to treat infection) d/t (due to) allergic rxn (reaction), MD ordered 500cc (cubic centimeter-a unit of measurement) bolus (a single dose of fluid through a vein) NS (normal saline) then NS 75cc/hr (hour) x 2 days, CBC (complete blood count-a laboratory test of blood cells in the body)/CMP (comprehensive metabolic panel-a test of blood for fluid balance and electrolytes) in AM (morning), and CXR (chest x-ray) in AM. Noted and carried out .RN started IV (intravenous - through the vein) and gave bolus, effective and symptoms relieved . - June 24, 2024, at 10:24 a.m., indicated, .MD (physician) see and assessed resident received new order to transfer to [name of hospital] for further evaluation due to allergic reaction to ATB (antibiotic) . - June 24, 2024, at 10:50 a.m., indicated, .Dr. [name] does not want to send resident via 911, MD wants a regular transport, MD explained to family . A review of Resident A's LTC (Long Term Care) Routine SNF (Skilled Nursing Facility) Visit, dated June 24, 2024, indicated, .Resident A .was treated for urinary tract infection in the [name] hospital with rocephin (antibiotic medication to treat infection) but there were no clear orders for PO (by mouth) antibiotics .repeat UA (urinalysis-a urine test) and urine culture (a lab test to check for bacteria or other germs in a urine sample) were ordered .UA was positive for urine tested .started on cipro(Ciprofloxacin) (received dose on 6/21 [June 21] am and pm, 6/22 [June 22] am) .Nursing called yesterday for rash with cipro. Generalized rash, no itching, tongue was red and some burning/cracking around the lips. Cipro was stopped. Changed to Macrobid (an antibiotic to treat infection). Received one dose last night 6/22 (June 22). Macrobid discontinued today as Urine culture showing candida (fungal infection - infection caused by yeast or molds) .patient was on Aspirin since stroke. Aspirin was stopped over the weekend and changed to Plavix by on call physician .family mentioned she had red tongue with Aspirin in the past .rash started 21st morning. It was generalized redness and no itching. Within the last 12 hours the rash is blistering and peeling. It is very painful. She is now having difficulty swallowing due to pain. She was started on IV fluids yesterday .Adverse Drug Reaction .rash worsened very rapidly. Concern of mucus membrane (lining inside organs and body) involvement along with skin blistering and peeling .urine culture showing candida. She had not been treated for it yet .send patient to [name] Emergency Department . Further review of Resident A's record (progress notes, MAR, and physician's order) did not indicate a medication was prescribed and administered to treat the resident's allergic reaction. On July 19, 2024, at 8:45 a.m., an interview was conducted with the Director of Nurses (DON). The DON stated Resident A was admitted with allergies to aspirin and guaifenesin, the admission nurse's report indicated the two medications were allergies, only the guaifenesin was put into the electronic medical record for the resident. The DON stated she did not know why the allergy for aspirin was not included in the allergy list. The DON stated the allergy list should have been reviewed closer and aspirin should have been added. The DON stated Resident A was admitted to the facility on [DATE], and was prescribed aspirin 81mg daily. The DON stated Redsident A was prescribed Cipro for five days after she returned from the hospital on June 21, 2024. The DON stated the cipro and aspirin were discontinued on June 22, 2024, after Resident A developed a body rash. On July 19, 2024, at 11:30 a.m., an interview was conducted with the Registered Nurse (RN). The RN stated a resident's medication list, on admission to the facility, should always be compared to their allergy list. The RN stated it was important to verify with the resident, if you are able to, if the resident is allergic to certain medications, what is their past reaction to the medications, and determine if it is a medication side effect or a true allergy. The RN stated the physician would need to be contacted to verify the medication list and allergies, discuss the resident's reaction to medications in the past, and determined if it is a true allergy. The RN stated it was important to educate the resident and family on medication reactions and other medications in the same class of drugs, which may result in similar symptoms. The RN stated when a resident does have an allergic reaction, stop the medication, notify the doctor, order some type of antihistamine (medication used to treat allergies) or cream to treat symptoms (rash/hives). On July 24, 2024, at 3:30 p.m., an interview was conducted with the Medical Doctor (MD). The MD stated Resident A did have aspirin listed as an allergy, when she was admitted to the facility, and upon review of her records from the hospital, it was determined the discharging provider from the hospital had prescribed her aspirin, for Resident A's stroke. The MD stated it was decided the benefits outweighed the risks, and the aspirin was continued to be given. The MD stated allergies can be more of an intolerance, and not a true allergy, when she spoke with Resident A, she was told Resident A had tingling on the tongue, and that is considered an intolerance. The MD stated Resident A had a UTI and was placed on multiple antibiotics for treatment. The MD stated she was aware Resident A had developed a rash, had tingling to her lips, and a reddened tongue, another provider was covering for her that weekend. The MD stated she was aware of the change in medication recommendations, and when the resident developed symptoms of tachycardia (a fast heart rate) and hypoxia (not enough oxygen in the body), IV (intravenous- giving a medicine or other substance through a tube inserted into a vein) fluids and oxygen were ordered. The MD stated Resident A could have been prescribed an antihistamine (medication given for allergies) to help with the allergic reaction symptoms, the on-call provider wanted to send the resident to the emergency room , however the family felt she was dehydrated and wanted the resident to receive the fluids, at the facility. The MD stated she came to see Resident A, Resident A was having an allergic reaction and the rash had advanced rapidly, the rash began to blister and open up, and Resident A was sent to the hospital. The MD stated it was protocol for staff to call the physician about allergies versus the medication orders to clarify before having medications filled from the pharmacy, she does not remember if the staff at the facility had called her about Resident A's order for aspirin. The MD concluded Resident A did develop an allergic reaction to the medications given, she is not sure if it was the aspirin or the antibiotics, which caused Stevens-Johnson Syndrome to develop. On July 29, 2024, Resident A's hospital medical records were reviewed. Resident A's ED (emergency department) to Hospital Admission, dated June 25, 2024, indicated, .Reason for visit w/ (with) Dx (diagnoses) .chief complaint: Rash .TENS (toxic epidermal necrolysis-a severe skin reaction, a life-threatening condition, causes peeling and blistering over the body, including the mouth, eyes and genitals - it is the most severe form of [NAME]-[NAME] syndrome-caused by a reaction to medications) .drug reaction .Reason for Admission to the Hospital .Pt (patient) was transferred from (name of hospital) for TENS from possibly Cipro or Xarelto .Patient previously was on ASA (aspirin) but due to history of red tongue with ASA, pt. switched to Plavix (blood thinner) on 6/23 (June 23) .On 6/21 (June 21) pt began to develop a rash around her mouth as well as intra oral lesions (lesions inside the mouth), which spread to trunk and extremities. Pt also experience with burning sensation to eyes and while urinating .Hospital Course by Problem .Toxic epidermal necrolysis .patient was transferred to (name of hospital) from (name of hospital) on 6/25/2024 (June 25, 2024) for whole-body rash suspected secondary to TEN .Dermatology (branch of medicine concerned with the diagnosis and treatment of skin disorders) suspecting patient is toxic epidermal necrolysis possibly precipitated (cause to happen suddenly, unexpectedly) by aspirin versus Augmentin (antibiotic to treat infection) .poor PO (oral) intake .due to oral pain from her toxic epidermal necrolysis .aspirin discontinued due to concerns of it precipitating her toxic epidermal necrolysis .acute skin lesions progressing to epiderml necrolysis is secondary to medications. After review of recent medications, possible culprits include antibiotics (Ceftriaxone, Cipro, Macrobid, or Amoxicillin [antibiotic used to treat infection]), ASA, XArelto .Avoided aspirin and Xarelto as they may have been culprits behind TEN/SJS . A review of Resident A's Discharge Summary, dated June 29, 2024, indicated, .Principal diagnosis: Toxic epidermal necrolysis (TEN) .please avoid aspirin, xarelto (a blood thinner), amoxicillin, ceftriaxone (medication to treat infection), macrobid, and ciprofloxacin as these may have contributed to development of your TEN .please discuss with neurology (study of the brain and nervous system) regarding alternative treatment besides aspirin .follow up with dermatology (study of the skin) for continued management of your wounds .follow up with urogynecology (study of the urinary system, bladder/kidneys, and female reproductive parts) regarding vulvovaginal (female genitals) involvement of your TEN . A review of Resident A's 'Discharge Summary, dated July 11,2024, indicated, .Hospital course by problem .Severe epidermal (layer of skin) necrolysis (destruction of dead tissue, blood cells) consistent with TEN .acute skin lesions progressing to epidermal necrolysis is secondary to medications .possible culprits include antibiotics (Ceftriaxone, Cipro, Macrobid, or Amoxicillin), ASA, Xarelto . A review of the facility's policy titled Provider Pharmacy Requirements, dated October 2012, indicated, .The provider pharmacy is responsible for rendering the required services in accordance with local, state, and federal laws and regulations .professional standard of practices .The provider pharmacy agrees to perform the following pharmaceutical (relating to medicinal drugs, or their preparation, use, or sale of drugs) services .maintain a medication profile on each resident that includes all medication dispensed and facility provided information such as resident's age, diagnoses, weight, condition, medication allergies, diet and other pertinent information .reviewing the resident's profile prior to dispensing any medication . A review of the facility's policy and procedure titled Adverse Drug Reactions, dated July 2015, indicated, .to monitor the resident's reaction to prescribed medications .this includes any allergic reaction or side effect to the medication as described in the manufacturer's information or current literature .If an adverse reaction is suspected, the first observed occurrence will be reported to the attending physician immediately .documentation of the observed reaction .monitoring of the resident during the episode will be done in accordance with physician's instruction, with all appropriate documentation done in the resident's medical record .Signs and symptoms of an allergic reaction may include .skin: irritation, redness, itching, swelling, blistering .rash .Lungs .tightness .shortness of breath .swelling or bumps on the face .lips, tongue .eyes: red, itchy, swollen, watery .pain, nausea .fatigue .upon determination of an adverse reaction, the name of the drug and the type of adverse reaction experienced will be documented on the physician's order sheet. The name of the drug will be documented on the Medication Administration Record (MAR) in the section titled 'allergies' . A review of the Lexicomp (medication reference) on July 30, 2024, for the medication aspirin, indicated adverse reactions included: Tachycardia (fast heart rate) .tachypnea (abnormally rapid breathing) .urticaria (hives) .anaphylaxis (life threatening allergic reaction) .Contraindication (a reason for a person not to receive a treatment or medication because it might be harmful) for aspirin include a known hypersensitivity (an abnormal physiological condition in which there is an undesirable and adverse immune response to an antigen [toxin]), a history of asthma, and urticaria .

Based on interview, record review, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the status of 1 (Resident #91) of 3 sampled residents reviewed for nutrition and 1 (Resident #101) of 1 sampled resident reviewed for dementia care. Specifically, the MDS assessments inaccurately indicated Resident #91's weight-loss was due to a physician-prescribed weight-loss regimen and did not reflect Resident #101's use of bed and wander/elopement alarms. Findings included: A facility policy titled, Resident Assessment, revised in 03/2023, revealed, 1. The facility conducts initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. 1. An Admission Record revealed the facility admitted Resident #91 on 10/21/2021. According to the Admission Record, the resident had a medical history that included diagnoses of liver cancer and encounter for palliative care. Resident #91's Care Plan included a focus area, revised on 10/31/2023, that indicated the resident had an unavoidable risk for weight loss due to poor intake and pressure injuries. A quarterly MDS, with an Assessment Reference Date (ARD) of 03/04/2024, revealed Resident #91 weighed 92 pounds at the time of the assessment, had lost five percent (%) or more in the last month or 10% or more in the last six months, and was not on a physician-prescribed weight-loss regimen. A quarterly MDS, with an ARD of 05/29/2024, revealed Resident #91 weighed 81 pounds, had lost 5% or more in the last month or 10% or more in the last six months, and was on a physician-prescribed weight-loss regimen. Resident #91's Order Summary Report, listing active orders as of 07/03/2024, revealed no evidence of orders for a physician-prescribed weight-loss regimen. During an interview on 07/02/2024 at 8:08 AM, MDS Coordinator #2 stated Resident #91 was on hospice and lost weight due to poor intake. During an interview on 07/02/2024 at 8:14 AM, MDS Assistant #3 stated that a prescribed weight-loss regimen required a physician's order and confirmed Resident #91 did not have a physician's order for a prescribed weight-loss regimen. MDS Assistant #3 stated Resident #91's MDS, dated [DATE], should have been coded, Yes [for weight loss] - not on prescribed weight loss regimen. During an interview on 07/02/2024 at 8:23 AM, the Director of Nursing (DON) stated Resident #91's MDS assessment should have reflected that the resident had lost weight but should not have indicated the resident was not on a prescribed weight-loss regimen. The Administrator (ADM) was interviewed on 07/02/2024 at 9:32 AM. The ADM stated Resident #91 did not have a prescribed weight-loss regimen, and the resident's weight loss was unplanned. The ADM stated Resident #91's MDS should have been coded for weight loss but should not have indicated the resident was not on a prescribed weight-loss regimen. 46565 2. An Admission Record revealed the facility admitted Resident #101 on 07/26/2022. According to the Admission Record, the resident had a medical history that included a diagnosis of dementia. Resident #101's Care Plan included a focus area, initiated on 12/16/2022, that indicated the resident was at risk for falls. An intervention initiated on 05/19/2023 indicated the resident utilized a pad alarm in their bed. Another focus area, initiated on 02/07/2023, indicated Resident #101 was at risk for injury due to wandering. An intervention initiated on 03/30/2023 indicated the resident utilized a wanderguard (a type of wandering/elopement alarm) on their wheelchair. Resident #101's Progress Notes included a Health Status Note, dated 07/17/2023 at 5:08 AM, that indicated the resident's wanderguard was in place. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/18/2023, revealed Resident #101 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated that Resident #101 wandered during four to six days of the seven-day assessment look-back period. The MDS did not reflect the resident's use of a bed alarm or wander/elopement alarm during the seven-day look-back period. Resident #101's Progress Notes included the following entries: - a Health Status Note, dated 03/29/2024 at 6:05 AM, that indicated Resident #101's bed alarm was in place and working properly; and - an IDT [interdisciplinary team] Progress Notes- Behavior Management note, dated 04/01/2024 at 2:25 PM, that indicated Resident #101 utilized a wanderguard. A quarterly MDS, with an ARD of 04/02/2024, revealed Resident #101 had a BIMS score of 3, which indicated the resident had severe cognitive impairment. The MDS did not reflect the resident's use of a bed alarm or wander/elopement alarm during the seven-day look-back period. During an interview on 07/03/2024 at 2:17 PM, the Director of Nursing (DON) stated MDS assessments needed to be accurate.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff properly donned personal protective equipment (PPE) prior to entering the room of 1 (Resident #268) of 4 residents reviewed for transmission-based precautions. Findings included: A facility policy titled, Resident Isolation-Categories of Transmission-Based Precautions, revised on 09/01/2023, revealed, III. A. Contact precautions are implemented for residents known or suspected to be infected or colonized with microorganisms that are transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. i. Examples of infections requiring Contact Precautions include, but are not limited to: a. Gastrointestinal, respiratory, skin, or wound infections or colonization with multi-drug resistant organisms (e.g. [exempli gratia, for example], MRSA [Methicillin-Resistant Staphylococcus Aureus]. The policy further revealed, gloves (clean, nonsterile) are worn when entering the room, and gown is worn for interactions that may involve contact with the resident or potentially contaminated items in the resident's environment. An Admit/Readmit Assessment revealed the facility admitted Resident #268 on 07/01/2024. The assessment revealed Resident #268 was admitted from a hospital with a diagnosis of right foot osteomyelitis. Resident #268's Order Summary Report, listing active orders as of 07/02/2024, contained an order, started on 07/02/2024 for, Contact isolation for diagnosis of: MRSA, every shift for Right foot wound. An observation on 07/02/2024 at 7:41 AM revealed a sign on Resident #268's door that specified, Contact Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Certified Nursing Assistant (CNA) #1 entered Resident #268's room without donning any PPE. During an interview on 07/02/2024 at 8:10 AM, CNA #1 stated he had delivered Resident #268's breakfast tray. CNA #1 stated he was aware Resident #268 was on contact precautions, which required staff to put on gowns and gloves before entering the room. During an interview on 07/03/2024 at 2:30 PM, the Director of Nursing (DON) stated her expectation was that staff should wear the proper PPE before entering a resident's room. During an interview on 07/03/2024 at 2:49 PM, the Administrator stated staff should don PPE prior to entering the room of a resident on contact precautions.

Based on interview and record review, the facility failed to ensure for one three residents (Resident A), an incident of verbal abuse from a Certified Nursing Assistant (CNA) towards Resident A was reported to California Department of Public Health (CDPH) within two hours. This failure resulted to a delay in the reporting and investigation of a verbal abuse and potentially placed Resident A and/or other residents at risk for further abuse. Findings: On April 10, 2024, at 10 a.m., an unannounced visit to the facility to investigate an incident of verbal abuse was conducted. On April 10, 2024, at 10:10 a.m., an interview was conducted with the Assistant Administrator (AADM). The AADM stated on March 28, 2023, at around 11:30 a.m., the Director of Staff Development (DSD) received report from CNA 1 of an alleged verbal abuse towards Resident A. The AADM stated CNA 1 reported that on March 28, 2024, between 4 a.m. to 5 a.m., she overheard CNA 2 told Resident A, Fuck you, you are a grown woman, why are you acting like this? in the hallway. The AADM stated after further investigation and confirmed by multiple staff who had worked with CNA 2 on the day of the alleged incident, CNA 2 indeed verbally abused Resident A in the hallway. The AADM stated CNA 2 was terminated. The AADM stated LVN 1 who was in charge of the unit and had knowledge of incident was also terminated due to failure to report an abuse towards Resident A. The AADM stated the alleged verbal abuse was not reported timely to the CDPH. The AADM stated any alleged abuse towards resident must be reported to CDPH within two hours from the time alleged abuse was known. On April 10, 2024, Resident A's record was reviewed. Resident A was admitted to the facility on [DATE], with diagnoses which included dementia (a disease that causes inability to remember, think, make decisions that interferes with doing everyday activities), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), psychotic disorder (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), and mood disorder. A review of Resident A's Minimum Data Set (MDS- an assessment tool) dated January 4, 2024, indicated Resident had a BIMS (Brief Interview of Mental Status) of 3 (severe cognitive impairment). A review of Resident A's Progress Notes for the following dates indicated: - March 28, 2024, at 4:30 a.m.; .Patient increasingly confused, agitated, aggressive toward staff, swinging at staff and continuously yelling hysterically help, in the hallways . - March 28, 2024, at 3:18 p.m.; .At approx. (approximately) 12 pm DON/DSD (Director of Nursing/ Director of Staff Development) received report from staff member that she overheard another staff member tell the resident Fuck you, you're a grown woman, why are you behaving this way at approx 3-4 am . On April 11, 2024, at 1:30 p.m. an interview was conducted with CNA 1. CNA 1 stated while she was in the room with another resident, she overheard Resident A in the hallway, screaming and yelling, as her normal behavior on March 28, 2024, at around 4:30 a.m. She further stated she overheard CNA 2 yelled back at Resident A and told her Shut the fuck up, you are a grown woman, why are you acting like that? CNA 1 further stated that she did not report the incident to the DSD until later that morning, at around 11:30 a.m. CNA 1 stated she was aware that all alleged abuse must be reported to the state within two hours. On April 11, 2024, at 1:32 p.m. an interview was conducted with CNA 3. CNA 3 stated while he was in another room caring for another resident, he heard commotion between Resident A and CNA 2 in the hallway on March 28, between 4 a.m. to 4:30 a.m CNA 3 remembers hearing Resident A calling CNA 2 the devil. CNA 2 stated that as he was walking in the hallway, he saw Resident A next to CNA 2 near Resident A's room. At this time, CNA 2 stated he heard CNA 2 told Resident A, Shut the fuck up. CNA 2 stated LVN 1 was there when it happened and overheard LVN 1 told CNA 2 that he could not talk to Resident A the way he did. CNA 4 stated he did not report it to anyone since he assumed LVN 1 would report it. On April 11, 2024, at 2:21 p.m., an interview was conducted with CNA 4. CNA 4 stated on March 28, 2024, at around 4:30 a.m., while she was at the Nursing Station, she overheard CNA 2 yelled at Resident A in the hallway and stated Shut the fuck up. CNA 4 stated that she did not report the incident to anyone since she thought everyone knew about it and someone would report it. A review of the facility's policy and procedure titled Abuse Prohibition and Prevention Program, dated November 2017, indicated, .The facility prohibits the use of verbal .abuse . Verbal abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents .Mandated Reporter: Any person who, in his or her professional capacity, or within the scope his or her employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, abandonment, isolation, financial abuse, or neglect .or reasonably suspects abuse shall report the known or suspected instance of abuse . Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator and/or Director of Nursing Services .The facility shall report all alleged violations and all substantiated incidents .To the state agency and to all other agencies as required .The facility shall ensure that all alleged violations involving abuse .are reported immediately, but not later than 2 hours after the allegation is made .

Based on interview and record review, the facility failed to ensure for one three residents (Resident A) was free from verbal abuse when a Certified Nursing Assistant (CNA) was witnessed to have used explicit words towards Resident A in the hallway. This failure resulted in a verbal abuse from CNA towards Resident A and had the potential to have a negative effect on the psychological, behavioral, or psychosocial outcomes to maintain or improve resident's overall well-being. Findings: On April 10, 2024, at 10 a.m., an unannounced visit to the facility to investigate an incident of verbal abuse was conducted. On April 10, 2024, at 10:10 a.m., an interview was conducted with the Assistant Administrator (AADM). The AADM stated CNA 1 reported she overheard CNA 2 told Resident A, Fuck you, you are a grown woman, why are you acting like this? in the hallway. The AADM stated the facility had completed their investigation and confirmed by multiple witnesses that CNA 1 indeed verbally abused Resident A on the alleged incident date. The AADM further stated CNA 1 was no longer working in the facility as he has been terminated. On April 10, 2024, at 11:06 a.m., Resident A was observed lying in bed, asleep. Resident A was observed calm, but easily awaken. No physical injuries noted on Resident A. On April 10, 2024, Resident A's record was reviewed. Resident A was admitted to the facility on [DATE], with diagnoses which included dementia (a disease that causes inability to remember, think, make decisions that interferes with doing everyday activities), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), psychotic disorder (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), and mood disorder. A review of Resident A's Minimum Data Set (MDS- an assessment tool), dated January 4, 2024, indicated Resident had a BIMS (Brief Interview of Mental Status) of 3 (severe cognitive impairment). A review of Resident A's Progress Notes for the following dates indicated: - March 28, 2024, at 4:30 a.m.; .Patient increasingly confused, agitated, aggressive toward staff, swinging at staff and continuously yelling hysterically help, in the hallways . - March 28, 2024, 3:18 p.m.; .At approx. (approximately) 12 pm DON/DSD (Director of Nursing/ Director of Staff Development) received report from staff member that she overheard another staff member tell the resident Fuck you, you're a grown woman, why are you behaving this way at approx 3-4 am . On April 11, 2024, at 12:40 p.m., an interview was conducted with CNA 1. CNA 1 stated while she was in the room with another resident, she overheard Resident A in the hallway, screaming and yelling, as her normal behavior on March 28, 2024, at around 4:30 a.m She further stated she overheard CNA 2 yelled back at Resident A and told her Shut the fuck up, you are a grown woman, why are you acting like that? On April 11, 2024, at 1:32 p.m. an interview was conducted with CNA 3. CNA 3 stated while he was in another room caring for another resident, he heard commotion between Resident A and CNA 2 in the hallway on March 28, between 4 a.m. to 4:30 a.m. CNA 3 stated he remembered hearing Resident A calling CNA 2 the devil. CNA 3 stated that as he was walking in the hallway, he saw Resident A next to CNA 2 near Resident A's room. At this time, CNA 3 stated he heard CNA 2 told Resident A, Shut the fuck up. On April 11, 2024, at 2:21 p.m., an interview was conducted with CNA 4. CNA 4 stated while she was at the nursing station, she overheard CNA 2 yelled at Resident A in the hallway and stated Shut the fuck up. on March 28, 2024, at around 4:30 a.m. On April 15, 2024, at 2:10 p.m., a follow up interview was conducted with the AADM. The AADM stated the incident of alleged verbal abuse on March 28, 2024, from CNA 2 towards Resident A indeed occurred and has been substantiated through their abuse investigation. The AADM stated all resident should be free from any verbal abuse from staff. A review of the facility's policy and procedure titled Abuse Prohibition and Prevention Program, dated November 2017, indicated, .The facility has policies and procedures for screening and training employees, protection of residents and for the prevention .of abuse .To provide staff guidelines to ensure protection for the health, welfare and rights of each resident residing in the facility; and to assure the facility is doing all that is within its control to prevent occurrences of abuse .PREVENTION .The facility strives to provide an environment which prohibits and prevents abuse .of resident .Supervision of staff to identify inappropriate behaviors, such as using derogatory language .The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as resident with history of aggressive behaviors .

Based on interview and record review, facility failed to ensure for one three residents (Resident A), was free from any further abuse, when Certified Nursing Assistant (CNA) was not removed from all patient care after being witnessed by other staff to have verbally abused Resident A in the hallway. This failure had the potential to placed Resident A and/or other residents at risk for further abuse. Findings: On April 10, 2024, at 10 a.m., an unannounced visit to the facility to investigate an incident of verbal abuse was conducted. On April 10, 2024, at 10:10 a.m., an interview was conducted with the Assistant Administrator (AADM). The AADM stated the Director of Staff Development (DSD) received report from CNA 1 of an alleged verbal abuse towards Resident A on March 28, 2023, at around 11:30 a.m. The AADM stated CNA 1 reported she overheard CNA 2 told Resident A, Fuck you, you are a grown woman, why are you acting like this? in the hallway on March 28, 2024, between 4 a.m. to 5 a.m. The AADM stated after further investigation and confirmed by multiple staff who had worked with CNA 2 on the day of the alleged incident, CNA 2 indeed verbally abused Resident A in the hallway. The AADM stated Licensed Vocational Nurse (LVN) 1 did not follow protocol of removing CNA 2 immediately from the facility from the time abuse was known. The AADM stated CNA 2 remained in the facility for about an hour after he verbally abused Resident A in the hallway. On April 10, 2024, Resident A's record was reviewed. Resident A was admitted to the facility on [DATE], with diagnoses which included dementia (a disease that causes inability to remember, think, make decisions that interferes with doing everyday activities), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), psychotic disorder (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), and mood disorder. A review of Resident A's Minimum Data Set (MDS- an assessment tool) dated January 4, 2024, indicated Resident had a BIMS (Brief Interview of Mental Status) of 3 (severe cognitive impairment). A review of Resident A's Progress Notes for the following dates indicated: -March 28, 2024, at 4:30 a.m. - .Patient increasingly confused, agitated, aggressive toward staff, swinging at staff and continuously yelling hysterically help, in the hallways . - March 28, 2024, 3:18 p.m. - .At approx. (approximately) 12 pm DON/DSD (Director of Nursing/ Director of Staff Development) received report from staff member that she overheard another staff member tell the resident Fuck you, you're a grown woman, why are you behaving this way at approx 3-4 am . On April 10, 2024, a review of the facility document titled Employee Timesheet, for CNA 2 indicated, CNA 2 did not clock out from work until 5:59 a.m. (approximately 2 hours later from the time CNA 2 was witnessed to have verbally abuse Resident A) on March 28, 2024. On April 11, 2024, at 1:30 p.m. an interview was conducted with CNA 1. CNA 1 stated on March 28, 2024, at around 4:30 a.m., while she was in the room with another resident, she overheard Resident A in the hallway, screaming and yelling, as her normal behavior. Then she overheard CNA 2 yelled back at Resident A and told her Shut the fuck up, you are a grown woman, why are you acting like that? On April 11, 2024, at 1:32 p.m. an interview was conducted with CNA 3. CNA 3 stated while he was in another room caring for another resident, he heard commotion between Resident A and CNA 2 in the hallway on March 28, between 4 a.m. to 4:30 a.m. CNA 3 stated he remembered hearing Resident A calling CNA 2 the devil. CNA 2 stated as he was walking in the hallway, he saw Resident A next to CNA 2 near Resident A's room. He further stated at this time, CNA 2 stated he heard CNA 2 told Resident A, Shut the fuck up. CNA 2 stated LVN 1 was there when it happened and overheard LVN 1 told CNA 2 he could not talk to Resident A the way he did. CNA 3 further stated LVN 1 did not remove CNA 2 immediately from the facility after he was observed to have verbally abuse Resident A in the hallway. On April 11, 2024, at 2:21 p.m., an interview was conducted with CNA 4. CNA 4 stated while she was at the nursing station, she overheard CNA 2 yelled at Resident A in the hallway and stated Shut the fuck up. on March 28, 2024, at around 4:30 a.m. A review of the facility's policy and procedure titled Abuse Prohibition and Prevention Program, dated November 2017, indicated, .The facility has policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse .To provide staff guidelines to ensure protection for the health, welfare and rights of each resident residing in the facility; and to assure the facility is doing all that is within its control to prevent occurrences of abuse .PREVENTION .The facility strives to provide an environment which prohibits and prevents abuse .of resident .Supervision of staff to identify inappropriate behaviors, such as using derogatory language .The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as resident with history of aggressive behaviors .PROTECTION .The facility will provide protection of residents from harm during an investigation including, but not limited to .Suspension of facility personnel involved in the suspected or actual abuse allegation

Based on interview and record review, the facility failed to provide appropriate care and treatment services to prevent recurrent urinary tract infection (UTI- an infection in any part of the urinary system which include the kidneys, ureters, bladder, and urethra) to a resident with an indwelling catheter (IC - a flexible tube passed into the bladder to allow urine to drain), for one of three residents reviewed (Resident A). This failure resulted in Resident A to have recurrent episodes of UTIs on [DATE], [DATE], [DATE], [DATE], and [DATE]. In addition, Resident A was transferred to the acute hospital on [DATE], due to a change of condition secondary to UTI and Resident A expired after three days at the acute hospital due to sepsis (bacteria spread through blood). Findings: On [DATE], at 10:05 a.m., an unannounced visit to the facility was conducted to investigate a complaint related to quality of care. On [DATE], Resident A's record was reviewed. Resident A was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss/cognitive impairment) and benign prostatic hyperplasia (enlarged prostate). A review of Resident A's History and Physical, dated [DATE], indicated Resident A did not have an IC upon admission. A review of Resident A's Minimum Data Set (MDS - an assessment tool), dated [DATE], indicated Resident A had periods of continence (able to control urge to urinate) and incontinence (unable to control urge to urinate) and did not have an indwelling catheter. A review of Resident A's Progress Notes, dated [DATE], at 5:03 p.m., indicated, .Resident has swollen testes .more confused .abdominal distention bladder scan (a device used to measure volume of urine in the bladder) is at 434cc (cc/ml - milliliter; unit of measurement) .Per (name of physician), obtain urine sample, cbc (Complete Blood Count - laboratory test to measure blood counts), cmp (Complete Metabolic Panel - laboratory test to check electrolyte levels) .repeat bladder scan at ,d+[DATE] pm (7 p.m. to 8 p.m.) If more than 500cc retention, will need foley . A review of Resident A's Order Summary Report, included a physician's order, dated [DATE], which indicated, .(name of doctor) wants resident to consult with Urologist (a doctor who specializes with diseases of the male and female urinary tract system) Asap (as soon as possible) for swollen testes, urinary retention (difficulty urinating and completely emptying the bladder), and thick, cloudy, and odorous urine . A review of Resident A's laboratory result, dated [DATE], indicated urinalysis was not completed as urine specimen was not received, and needed to recollect. There was no documented evidence if another urine specimen was collected for urinalysis conducted on or after [DATE]. A review of Resident A's physician order, dated [DATE], indicated, .Cipro (antibiotic medication used to treat bacterial infection) Oral Tablet 500 mg (milligram- unit of measurement) give by mouth every 24 hours for UTI infection until [DATE] ([DATE]) . A review of Resident A's physician's order, dated [DATE], indicated, .Indwelling catheter .to drainage bag due to diagnosis of retention . There was no documented evidence care plans were initiated related to the use of antibiotic on [DATE], and the use of indwelling catheter due to urinary retention on [DATE]. A review of Resident A's physician's order, dated [DATE], indicated a urology consult was scheduled on [DATE], at 2:50 p.m. In further review of Resident A's clinical record, there was no documented evidence the urology appointment scheduled on [DATE], was conducted as ordered by the physician. A review of Resident A's SBAR:Change of Condition, dated [DATE], indicated Resident A was noted with increased lethargy (tiredness), cloudy and concentrated urine, and poor food intake. A review of Resident A's physician order, dated [DATE], indicated request for laboratory including urinalysis with culture and sensitivity (UA w/ C & S) stat (immediately) due to change of condition of increased lethargy and abnormal changes in urine status. A review of Resident A's laboratory results, dated [DATE], indicated a urinalysis was completed, with the following results: - Color: dark yellow; - Character: turbid - WBCs (White Blood Cell): >200 (normal: none) In further review of Resident A's clinical record, there was no documented evidence the UA w/ C & S laboratory result was referred to the physician for appropriate treatment for UTI. A review of Resident A's physician's order, dated [DATE], indicated, .Urology consult appt (appointment): (name of doctor). Date of appointment [DATE] (34 days after the order for stat urology consult order on [DATE]) . A review of Resident A's urology consult notes, dated [DATE], indicated, .being seen for a chief complaint of Swollen Testicles .He is in poor physical condition and his clothes are quite stained. He is with a caregiver has no understanding of why the patient has a catheter how often the catheter is changed. The patient has an odor indicating clear infection with very turbid urine draining his catheter . The urologist recommended the following for Resident A: - Bactrim DS (antibiotic for UTI) twice daily for seven days; - Change IC every four weeks; and - Renal and bladder ultrasound. Refer to the facility physician and report any abnormalities to the urologist. A review of Resident A's physician's order, dated [DATE], indicated, Bactrim DS Oral Tablet ,d+[DATE] mg .give 1 (one) tablet by mouth two times a day for UTI for 7 (seven) days . The physician's order for antibiotic was started on [DATE] (8 days after the onset of Resident A's change of condition on [DATE]). In further review of Resident A's clinical record, there was no documented evidence a renal and bladder ultrasound were conducted as recommended by the urologist on [DATE]. A review of Resident A's care plan, dated [DATE], indicated, .The Resident has an indwelling catheter .At risk of UTI Urinary Retention .Goals .The resident will have minimized risk for complications from indwelling catheter with interventions .Notify physician/responsible party, as needed, regarding urinary status changes .Observe resident for changes in mental or functional status .Observe urine odor, color, clarity and amount as needed . A review of Resident A's physician's order, dated [DATE], indicated, .Macrobid (medication used to treat UTI) Oral Capsule 100 mg .Give by mouth two times a day for UTI for 10 days . A review of Resident A's physician's order, dated [DATE], indicated, UA with culture .to r/o (rule out) UTI . A review of Resident A's laboratory result, dated [DATE], indicated, .Urinalysis w/ C&S .Urine culture result: ESBL (Extended Spectrum Beta-Lactamase - bacteria usually resistance to many antibiotics) POSITIVE Escherichia coli (a type of bacteria that normally lives in your intestines) isolated. Colony count > 100,000 . A review of Resident A's physician's order, dated [DATE], indicated, .Ertapenem Sodium (medication to treat bacterial infection) .use 1 gm (gram- unit of measurement) intravenously (medication via the veins) at bedtime for ESBL for seven days. A review of Resident A's Progress Notes, indicated the changes of condition on Resident A: - [DATE], at 6:14 a.m., .resident pulled out his f/c (foley catheter) and noted with redness to his .penis and scrotum .re-inserted f/c .; - [DATE], at 2:50 p.m., .Most of the time resident appeared to be restless and confused .; - [DATE], at 2:24 a.m., .Resident received alert and noted to be restless in bed, trying to get out of bed .agitated and aggressive when trying to make him comfortable . ; - [DATE], at 3:08 a.m., .Resident receiving bladder scans for F/C removal .MD (physician) was messaged for 450cc bladder retention, awaiting response .; - [DATE]:13 p.m., .Patient has abdominal distention and scanned with 600ml of cloudy, foul smelling, deep concentrated urine. Foley catheter is reinsertion (sic) and PCP (physician) is notified of findings. Urine sample is collected .; and - [DATE], at 3:11 p.m., .Resident with increased confusion, fatigue, cloudy urine with increased sediment. Foul smelling urine, low grade fever of 100.2, HR (heart rate) of 104, (BP) blood pressure of ,d+[DATE] .did not eaten breakfast or lunch .UA (urinalysis) order carried out STAT (immediately) .; A review of Resident A's urinalysis results, dated [DATE], indicated, .Collected: [DATE] ([DATE]) 1141 (11:41 a.m.) .Received: [DATE] 1915 (7:15 p.m.) .urine screen .color .yellow .character .turbid .WBCs .>200 (normal - none) .RBCs (red blood cells) XXX,d+[DATE] (normal - none) .bacteria .1+ (normal - none) . In further review of Resident A's clinical record, there was no documented evidence the urinalysis result was referred to the physician when it was received on [DATE], at 7:15 p.m. A review of Resident A's Progress Notes, dated [DATE], at 1:14 p.m., indicated, .Macrobid Oral Capsule 100 mg .give one capsule by mouth two times a day for UTI for 10 days . The physician order was documented as obtained 18 hours after the urinalysis result was reported to the facility on [DATE], at 7:15 p.m. There was no documented evidence Macrobid was administered to Resident A after it was ordered by the physician on [DATE]. A review of Resident A's Progress Notes, dated [DATE], at 10:36 p.m., indicated, .Resident not responsive, increase in HR (heart rate) .coughing without able to expectorate .vital signs were as follows BP (blood pressure) ,d+[DATE], P (pulse) 128 (normal rate 60 - 100), Resp (respiratory - breathing) rate 22 .Dr (doctor) called and recommended to transport to (name of hospital) . In further review of Resident A's clinal record, the resident had IC from [DATE], to [DATE]. There was no documented evidence the facility implemented interventions for Resident A to return to prior urinary status of continence and for the resident not to use an IC if not necessary such as trial removal of IC. There was no documented evidence the facility conducted an IDT (Interdisciplinary Team - a group of healthcare professionals) meeting to address Resident A's recurrent episodes of UTI on [DATE], [DATE], [DATE], [DATE], and [DATE]. There was no documented evidence the urology recommendation for Resident A to have a renal and bladder ultrasound was conducted since [DATE]. There was no documented evidence a follow up urology consult was scheduled after [DATE], to address Resident A's recurrent UTI secondary to IC use. There was no documented evidence the frequent use of antibiotics by Resident A to treat UTI was reviewed during the facility's Antibiotic Stewardship Program (ASP - a program developed to improve the treatment of infections while decreasing the chances of adverse effects with the use of antibiotics). There was no documented evidence a plan of care was developed to address recurrent episodes of UTI. A review of Resident A's hospital records titled, Expiration Summary, dated [DATE], indicated, .Admitting Diagnosis: septic shock (life-threatening condition caused by a severe infection which requires immediate attention) .Discharge Diagnosis: Septic shock . Patient was brought into the emergency room in septic shock. He has history of .chronic foley catheter. He was started on IV antibiotics .On the morning of [DATE], patient was unresponsive, pupil was fixed and dilated. No pulse. He was pronounced at 6:15 AM (sic) . On [DATE], at 11 a.m., a concurrent interview and record review of Resident A's clinical record was conducted with the Director of Nursing (DON). She stated Resident A was admitted to the facility on [DATE], and was not on IC. She stated the physician ordered for Resident A to be seen by the urologist as soon as possible due to swollen testes, urinary retention with thick cloudy urine, on [DATE]. She stated Resident A was prescribed Cipro for UTI on [DATE]. She stated Resident A was not seen by the urologist until [DATE], due to some issues with Resident A's paperwork. She stated IC was inserted initially for Resident A on [DATE], due to urinary retention. She stated a urinalysis results indicated urine turbid with WBC greater than 200 on [DATE]. She stated there was no documentation the abnormal urinalysis result of [DATE], was referred or reviewed by the physician. She stated the urinalysis result on [DATE], should have been referred to the physician for appropriate treatment. She stated the urologist prescribed Bactrim for UTI to Resident A during his appointment on [DATE]. She stated the recommendation for renal and bladder ultrasound was not referred to the primary physician to be carried out. She stated Resident A had repeated UTIs on [DATE], [DATE], [DATE], [DATE] and [DATE] of 2023 and was on IC. The DON was not able to provide documentation for the clinical justification for long term use of IC for Resident A. In addition, the DON was not able to provide documentation of any plan for removal of the IC for Resident A since he was started on IC on [DATE]. The DON stated there were no IDT done for Resident A to discuss repeated occurrence of UTIs and or Resident A's use of antibiotics was reviewed in the facility's antibiotic stewardship program. The DON stated the care plan for the use of the IC and risk for UTIs was started on [DATE], and was not update or revised since then. She also stated care plan was not person-centered or individualized since Resident A had repeated UTIs. She stated care plan should have been initiated on [DATE], and revised thereafter. The DON stated Resident A started to have a change of condition on [DATE], with increased confusion, poor food intake, and pulled out his IC. The DON stated a STAT urinalysis was ordered by the physician on [DATE], at 12:13 p.m., after the resident had increased confusion, fatigue, cloudy urine with sediments, and fever. She stated the Nurse Practitioner (NP) saw the resident on [DATE], at 9:32 p.m., but did not have any orders despite Resident A's condition and abnormal vital signs. The DON stated she could not find documentation the STAT urinalysis result was referred to the physician or NP when it was received on [DATE]. She stated the physician ordered antibiotic on [DATE], at 1:14 p.m. (more than 24 hours from the time of Resident A's change of condition). She stated the STAT urinalysis should have been referred to the physician or NP as soon as the result was received. The DON stated there should have been aggressive interventions to address possible cause of increased confusion and restlessness of Resident A starting on [DATE], and provide interventions to address the fever and poor food intake, such as intravenous (IV) hydration and antipyretic (medication to treat fever) on [DATE]. On [DATE], at 1:39 p.m., an interview was conducted with Nurse Practitioner (NP). He stated on the evening of [DATE], he came and assessed Resident A. He stated Resident A was in stable condition with normal vital signs. He stated Resident A had a temperature of approximately 97.8. He was aware Resident A had cloudy urine with sediments. He said there was an order for stat UA prior to him coming into the facility on [DATE]. However, he stated the UA result did not come back until [DATE] (four days after resident was discharged to the hospital). He stated he ordered for prophylactic antibiotic (Macrobid), while UA result was pending on [DATE]. He acknowledged the order for Macrobid was not carried out until the following day. He stated his expectation was to have Macrobid administered to Resident A within the same shift when he had ordered it on [DATE]. He was not able to explain the reason as to why Resident A did not get Macrobid until the following day. He also was not able to explain as to why the result for the stat UA was not received until [DATE]. He stated prior to [DATE], there was no information provided to him regarding Resident A's prior conditions (increase confusion, restlessness, and poor food intake). He stated if these conditions were communicated clearly to him from the facility staff, it could have possibly change the course of treatment for Resident A. The facility's policy and procedure titled Catheter - Care of dated [DATE], was reviewed. The policy indicated, .To prevent catheter-associated urinary tract infections while ensuring that residents are not given indwelling catheter unless is medically necessary .Residents who enter the facility without an indwelling catheter will not be catheterized, unless the resident's clinical condition demonstrates the catheterization is necessary .An indwelling catheter is not used unless there is a valid medical justification .Services are provided to restore or improve normal bladder function to the extent possible, after the removal of the catheter .A resident, with or without a catheter, receives the appropriate care and services to prevent infection to the extent possible .Update the resident's Care Plan as necessary . The facility's policy and procedure titled Change of Condition Notification, dated [DATE], was reviewed. The policy indicated, .An acute change of condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. clinically important means a deviation that, without intervention, may result in complications or death .The Facility will promptly .consult with the resident's Attending Physician .when the resident endures a significant change in their condition . The facility's policy and procedure titled Laboratory, Diagnostic and Radiology Services, dated [DATE], was reviewed. The policy indicated, .To ensure that laboratory, diagnostic and radiology services are provided to meet resident needs .the facility is responsible for the quality and timeliness of services provided by the laboratory, diagnostic or radiology provider .Any orders labeled STAT will be followed up on during same shift .the ordering practitioner will be notified of results that fall outside of clinical reference or expected normal ranges per the ordering practitioner's order .

Based on observation, interview, and record review, the facility failed to ensure home medications were destructed or disposed according to the facility's policy and procedure when: 1. Multiple Dilaudid (narcotic medication for pain) tablets were destructed together with non-narcotic medications; and 2. Multiple Zofran (medication to treat nausea) tablets and a tube of antifungal cream (medication to treat fungal skin infection) were destructed without verification of the physician orders for the medication. These failures had the potential administration error, inaccurate reconciliation, and drug diversion (illegal distribution or abuse of prescription drugs or their unintended purposes) of narcotic and non-narcotic medications. Findings: On October 20, 2023, at 9:50 a.m., an unannounced visit ws conducted at the facility to investigate a compliant on quality of care. On October 20, 2023, at 10:25 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. She stated home medications were to be given to the Registered Nurse Supervisor (RNS) for review. She stated narcotic medications needed to be disposed should be given to the Director of Nursing (DON) for medication destruction. On October 20, 2023, at 10:30 a.m., LVN 2 was interviewed. She stated narcotic medications from home should be documented and accounted for on the narcotic sheet, stored in the locked narcotics drawer until DON could retrieve it for disposal. On October 20, 2023, at 11:45 a.m., LVN 3 was interviewed. She stated if a resident would bring medications from home, the charge nurse should collect the medication, verify it according to the physician's orders, and store them in the locked medication room until the family would bring it home for safe keeping. She stated the RNS should account for the narcotic medications and document it in the narcotic count sheet and store in the locked narcotic drawer. On October 20, 2023, at 12:00 pm., the DON was interviewed. She stated Resident 1's family member had complained regarding inability to retrieve the resident's home medications. She stated upon her investigation, Resident 1's home medications (Dilaudid, Zofran, and antifungal cream) were destructed by the night shift RNS 1 and LVN 4. The DON further stated home medications should be reconciled against the physician's orders and eventually to be sent home with the family if not needed. She stated the licensed nurse was to remove non-controlled medications from the storage and destructed by the RN and LVN and complete the non-controlled disposal sheet when the resident's home medication were not ordered by the physician. She stated discontinued narcotics together with the narcotic count sheet, were to be placed into the narcotic drawer in the locked medication cart. The DON was to be notified of the unused or discontinued narcotics, after counting and verifying the accuracy of the narcotic cound sheet with the licensed nurse, then the narcotics were to be taken to the DON office and locked in a safe until the pharmacist was available for drug destruction. On October 20, 2023, a review of the facility document titled Drug Disposition Record Non-Controlled Medications, indicated 45 tablets of Dilaudid 2mg (milligram - unit of measurement) were signed by two licensed nurses as disposed or destructed on September 22, 2023. There was no documented evidence Resident 1's Dilaudid medications were accounted and documented on the narcotic count sheet. There was no documented evidence Resident 1's Zofran and antifungal cream were destructed by the licensed nurses. On October 31, 2023, at 3:30 p.m., RNS 1 was interviewed. She stated she disposed and destructed Resident 1's Zofran tablets and antifungal cream but did noy document it on the non-narcotic disposition form. A review of the facility's policy and procedure titled Medications Brought To The Facility By a Resident or Responsible Party, dated October 2012, indicated, .Medications brought into the facility by a resident or responsible party are used only upon written order by the resident's attending physician, after the contents are verified .A licensed nurse .receives medications delivered to the facility and documents delivery of the medication on the appropriate form .Verifies medications received and directions for use with the original medication order .Assures medications are incorporated into the resident's specific allocation/storage area .Medications not ordered by the resident's physician .are returned to the responsible party or designated agent. If unclaimed within [thirty] days, the medications are disposed of in accordance with facility medication destruction/disposal procedures . A review of the facility's policy and procedure titled Disposal of Medications and Medication-Related Supplies, dated June 2016, indicated, .Unused, unwanted and non-returnable medications should be removed from their storage area and secured until destroyed .Medication destruction occurs only in the presence of at least two licensed Nurses .The licensed healthcare professionals witnessing the destruction ensure that the following information is entered on the medication disposition form .Date of destruction .Resident's name .Name and strength of medication .Prescription number .Amount of medication destroyed . Signature of witnesses .The medication disposition form is kept in the facility according to facility policy . A review of the facility's policy and procedure titled Controlled Substance Disposal, revised January 2017, indicated, .All controlled substances remaining in the facility after a resident has been discharged , or the order is discontinued, are disposed of and rendered unusable .in the facility by the director of nursing or other designated Registered Nurse and the consultant pharmacist .Disposition is documented on the individual controlled substance accountability record .Form 11: CONTROLLED DRUG RECORD .

Based on observations, interviews, and record reviews, the facility failed to maintain an environment that meets professional standards for food service safety and ensure the residents' food was prepared under sanitary conditions when: 1. Unpasteurized eggs (pasteurized eggs have been gently heated to eliminate bacteria, a process that makes the eggs safe to consume if not fully cooked so that all parts of the egg do not have to be completely firm; unpasteurized eggs have not been heat treated to eliminate this bacteria), served to nine residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, and 9) were not cooked to ensure all parts of the eggs were completely firm to eliminate the risk of Salmonella infection (usually caused by eating raw or undercooked meat poultry or eggs and can be life-threatening in older adults where complications can be dangerous). This failure to cook unpasteurized eggs so that all parts of the eggs were completely firm when serving to residents had the potential to result in serious harm to these nine residents who were part of the highly susceptible population; 2. The kitchen areas were not maintained free from litter and food debris when the hot food preparation area floors had a significant amount of litter, grime and old food debris accumulation. This failure to keep the floors in the hot food preparation areas free of litter and food debris had the potential to result in pest attraction, infestation and contamination by pests of the food for 121 Residents who ate the food prepared and served in the facility; 3. The food preparation equipment and storage tubs containing clean utensils were not clean and free from food residue and crumbs; This failure to maintain food preparation equipment and storage tubs free from food residue and crumbs had the potential to result in pest attraction, infestation, and food contamination. 4. The food preparation sink located in the hot food preparation area did not maintain an air gap (an unobstructed vertical space between the water outlet or drain pipe and the flood level of a fixture or rim of the floor sink to prevent backflow of sewage water) to prevent a potential unsanitary situation in the event of a backflow into the sink. This had the potential to contaminate the sink and the food if there were a negative pressure event; 5. Resident food was expired or past the use-by date for service to a highly susceptible population: a. Two one-gallon size containers of Caesar salad dressing in the refrigerator had use-by dates of [DATE]; This failure had the potential to result in food borne illness from residents consuming the expired dressing b. Four 46-ounce cartons of thickened flavored water had use-by dates of [DATE] were stored in the kitchen; This failure had the potential for the flavored thickened water to be of poor quality; 6. Resident food held in the freezer and the dry storage area were not covered to prevent pest harborage and freezer burn (a condition that occurs when frozen food has been damaged due to air reaching the food generally caused by food not being securely wrapped) when: a. Plastic containers of graham cracker crumbs, egg noodles, white rice, brown rice and red and yellow onions were stored with the lids to the plastic containers ajar, not sealed; b. Cheesecake mix and yellow cake mix bags had been opened and were not sealed; c. A plastic bag of bread and a plastic bag of bagels were left open and not sealed; d. A box of frozen dinner rolls, stored in the freezer, was not covered and open to the freezer air; These failures had the potential to attract and harbor pests or result in a poor quality food due to freezer burn; 7. The handwashing sink in the kitchen took 45 - 60 seconds for the temperature of the water to reach a warm temperature. This failure had the potential to prevent dietetic service staff from effectively performing hand hygiene while working in the kitchen. Findings: 1. According to the U.S. Food and Drug Administration (FDA), Fresh eggs .may contain bacteria called Salmonella that can cause food borne illness. The FDA estimates 79,000 cases of food borne illness and 30 deaths each year are caused by eating eggs contaminated with Salmonella. Egg-associated illness caused by Salmonella is a serious public health problem and individuals may suffer mild to severe gastrointestinal (stomach and intestinal) illness such as diarrhea, fever, abdominal cramps and vomiting, as well as short term or chronic arthritis, or even death. The FDA requires that all cartons of shell eggs that have not been treated to destroy Salmonella (or pasteurized) to carry the safe handling statement: Safe handling instructions, to prevent illness from bacteria, keep eggs refrigerated, cook yolks until yolks are firm and cook foods containing eggs thoroughly. According to the Centers for Disease Control (CDC), to avoid Salmonella, you should never eat raw or lightly cooked (runny whites or yolks) eggs. Cooking reduces the number of Salmonella bacteria present in an egg. However, a lightly cooked egg with a runny white or yolk still possess a greater risk than a thoroughly cooked egg. Lightly cooked egg whites and yolks have both caused outbreaks of Salmonella infections. Although anyone can get a Salmonella infection, older adults, infants and people with impaired immune systems are at increased risk for serious illness. In these people, a relatively small number of Salmonella bacteria can cause severe illness. According to the 2017 FDA Food Code, although foodborne illness can be severe or even fatal, milder cases are often not detected through routine surveillance. According to the Food Code, eggs are still a major source of Salmonella infections, causing outbreaks when they are combined or undercooked, so special precautions need to be in place with those most susceptible to foodborne illness. The Food Code defines a highly susceptible population as persons who are more likely than other people in the general population to experience foodborne disease because they: 1. have compromised immune system .or are older adults; and 2. obtaining food at a facility that provides services such as custodial care, health care, or assisted living .hospital or nursing home . During a tour of the facility's kitchen and concurrent interview with the Dietary Manager (DM) on [DATE], at 10:23 AM, a box of shell eggs was observed in the walk-in refrigerator. Upon further observation, the box which indicated that it originally contained 15 dozen shell eggs, did not indicate the eggs were pasteurized. The box contained approximately 3 dozen (of the original 15 dozen) shell eggs that did not have the stamped letter P on them (pasteurized eggs would be distinguishable from unpasteurized eggs by a red P stamped on the shell). During a concurrent interview, the DM verified that the shell eggs were not pasteurized, and also stated that the facility did not have any shell or liquid pasteurized eggs at the time of the interview. The DM further pointed to a label on the box of shell eggs that stated CA SEFS Compliant (California Shell Egg Food Safety Compliant) stating that the eggs were okay to serve because of this designation. According to the California Department of Food and Drug (CDFA), the CA SEFS Compliant designation is required for all shell eggs sold in the California. According to the CA SEFS Compliant program, this statement on a container of shell eggs means that the eggs have gone through added measures to reduce the risk of Salmonella contamination, however, does not eliminate Salmonella like pasteurized eggs do. During a review of the facility's food purchase invoices and concurrent interview with the DM on [DATE], at 3:38 PM, the DM verified that the last time shell eggs were delivered was on [DATE]. A review of the food purchase invoice, dated [DATE], indicated these shell eggs were not pasteurized. The DM verified they were not pasteurized and stated these were the same shell eggs in the walk-in refrigerator observed earlier in the day. Further review of the facility's food purchase invoices indicated a case (15 dozen) of unpasteurized eggs was also delivered on [DATE]. The DM verified this invoice. On [DATE], at 8:41 AM, during an observation in the kitchen and concurrent interview with Cook 1, he stated that he regularly made fried eggs for multiple residents. He stated these residents liked their eggs over easy or sunny side up (both styles have runny yolks). When asked which eggs he used to cook the fried eggs, Cook 1 pointed to a carton of (name of brand) eggs and stated the DM had purchased them at the store and the DM told Cook 1 these eggs were pasteurized. Cook 1 reviewed the label and carton of the (name of brand) eggs and could not find where it indicated the eggs were pasteurized. There was the egg brand's red stamp on the remaining four eggs in the carton. Cook 1 stated he recalled cooking the eggs for Residents 1, 2, 3, 4, and 9 for breakfast that morning, and he was unable to remember all the residents that he had cooked fried eggs for. a.) During an observation and concurrent interview with Resident 7 in her room, on [DATE], at 8:50 AM, Resident 7's breakfast tray included two fried eggs with runny yolks. Resident 7 stated that she got fried eggs with runny yolks every day. In a concurrent interview with Licensed Vocational Nurse (LVN) 1, who was assisting Resident 7 to set up the meal tray, LVN 1 stated Resident 7 always gets eggs like this for breakfast, pointing to Resident 7's runny yolk eggs. A review of the medical record for Resident 7 indicated Resident 7 was [AGE] years old, admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease ([CONDITION(S)] - a chronic lung disease that causes obstructive airflow from the lungs and difficulty breathing), chronic kidney disease (long-term impairment of kidney function), malignant neoplasm (a cancerous tumor) of kidney and meets the definition of a member of a highly susceptible population. Resident 7's MDS (Minimum Data Set, a comprehensive assessment tool completed by the facility) indicated the resident had a BIMS score (Brief Interview for Mental Status score) of 11, indicating moderate cognitive impairment. b.) During an observation and concurrent interview with Resident 4 in her room, on [DATE], at 8:58 AM, Resident 4's plate contained mostly runny yolk eggs with the white part of the eggs pushed off her plate. Resident 4 stated that she liked her eggs over easy and stated that she gets two eggs every day. Resident 4 further stated that she would cut the whites off and only ate the runny yolks. A review of the medical record for Resident 4 indicated Resident 4 was [AGE] years old, admitted to the facility on [DATE], with diagnoses including facial bone fractures (broken bones), Type 2 diabetes mellitus (an impairment in the way the body regulates and uses sugar as a fuel and is a long-term condition), [CONDITION(S)] (a condition of not enough healthy red blood cells to carry adequate oxygen to the body's tissues), hypertensive heart disease (high blood pressure) and met the definition of a member of a highly susceptible population. Resident 4's MDS indicated the resident had a BIMS score of 12, indicating moderate cognitive impairment. c.) During an observation and concurrent interview with Resident 5 in her room, on [DATE], at 9 AM, Resident 5's plate contained 2 fried eggs. Resident 5 stated that she got the fried eggs every morning and she liked her yolks runny. A review of the medical record for Resident 5 indicated Resident 5 was [AGE] years old, admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease, Type 2 diabetes mellitus, heart failure (when heart does not pump blood as well as it should), and met the definition of a member of a highly susceptible population. Resident 5's MDS indicated a BIMS score of 15, indicating intact cognitive status. d.) During an observation and concurrent interview with Resident 9 in her room, on [DATE], at 9:05 AM, Resident 9's tray was not present. Resident 9 stated that she had an egg for breakfast with a runny yolk like she did every morning. A review of the medical record for Resident 9 indicated Resident 9 was [AGE] years old, admitted to the facility on [DATE], with diagnoses including congestive heart failure, chronic kidney disease, Type 2 diabetes mellitus, and met the definition of a member of a highly susceptible population. Resident 9's MDS indicated the resident had a BIMS score of 15, indicating intact cognitive status. During an interview with the DM on [DATE], at 9:10 AM, the DM stated that he purchased the (name of brand) eggs at the store and a store clerk told him they were pasteurized. The DM was unable to explain why he relied on the store clerk and thought the (name of brand) eggs were pasteurized when they did not have the P stamped on them. An Immediate Jeopardy situation was declared on [DATE], at 10:58 AM, in the presence of the Administrator (Admin), the Assistant Administrator (Asst. Admin.) and the Director of Nursing (DON) due to the facility's failure to ensure residents' non-pasteurized eggs were cooked until all parts of the eggs were completely firm to eliminate the risk of Salmonella infection and the potential serious complications which could result from such an infection in a highly susceptible population. A review of the meal tray tickets (menu of served items for each resident) for Residents 1, 2, 3, 6, and 8 indicated that all five residents were served undercooked eggs for breakfast on [DATE]. During a concurrent interview with the DM on [DATE], at 2:30 PM, the DM stated these residents were the residents (Residents 1 through 9) who had indicated their preference was for over easy, over medium and sunny side up eggs (all with runny yolks). He stated that the cooks made these styles of eggs daily. The DM also verified that the facility last received pasteurized shell eggs on [DATE], and the last shell eggs received on [DATE], were not pasteurized eggs. e.) A review of the medical record for Resident 8 indicated Resident 8 was [AGE] years old, admitted to the facility on [DATE], with diagnoses including end stage renal disease requiring hemodialysis (kidney failure which required treatment of the blood to remove the toxic build-up of substances normally filtered by functional kidneys), [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] of the liver (a late stage scarring of the liver caused by many forms of liver disease), and a pressure ulcer (also known as bedsore) on the lower back. Resident 8 met the definition of a member of a highly susceptible population. f.) A review of the medical record for Resident 1 indicated Resident 1 was [AGE] years old, admitted to the facility on [DATE], with diagnoses including congestive heart failure, history of a heart attack, and gastrointestinal hemorrhage (bleed in the stomach or intestines). Resident 1 met the definition of a highly susceptible population. g.) A review of medical record for Resident 2 indicated Resident 2 was [AGE] years old, admitted to the facility on [DATE], with diagnoses including congestive heart failure, hypertension, chronic kidney disease, stroke (occurs when the blood supply to part of the brain is interrupted or reduced), Type 2 diabetes mellitus and [CONDITION(S)]. Resident 2 met the definition of a member of a highly susceptible population. h.) A review of the medical record for Resident 3 indicated Resident 3 was [AGE] years old, admitted to the facility on [DATE], with diagnoses including heart failure, [CONDITION(S)] (a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues), pressure ulcer on the heel, [CONDITION(S)] (an infection or swelling in the bone) and Type 2 diabetes mellitus. Resident 3 met the definition of a member of a highly susceptible population. i.) A review of the medical record for Resident 6 indicated Resident 6 was [AGE] years old, admitted to the facility on [DATE], with diagnoses including end stage kidney disease dependent on hemodialysis, [CONDITION(S)], Type 2 diabetes mellitus, congestive heart failure and [CONDITION(S)]. Resident 6 met the definition of a member of a highly susceptible population. During an interview with the Program Manager for the CA SEFS Compliant program, on [DATE], at 4 PM, the Program Manager stated that the program did not maintain data on individual cases of Salmonella infections from CA SEFS Compliant eggs. Therefore, the Program Manager was not able to state if the risk of Salmonella infections in a highly susceptible population was less when served undercooked CA SEFS Compliant eggs. The Program Manager further stated that the requirement remained that undercooked eggs served to this population should be pasteurized. 2. During a tour of the kitchen and concurrent interview with the Dietary Manager, on [DATE], at 11:05 AM, the hot food preparation floor area was observed to have an accumulation of grime, old food debris and litter around the steamer, stove, handwashing sink, and preparation tables. The DM verified that the floors were not clean. He stated that the floors should be swept and mopped each night and it did not look as though it had been. During an interview with the DM on [DATE], at 1:30 PM, the DM stated that he had in-serviced the dietetic staff in May, June, and [DATE] on cleaning logs, cleaning equipment and cleaning the cook's area. The DM could not explain why the kitchen floor was not clean despite these in-services. The DM verified that there was no cleaning log for sweeping and mopping the floor in the cook's area. Instead, he stated that duty was on the job task list for the D4 Diet Aid position. A review of the dietetic service job duties document titled, D4 PM Diet Aid 12:00 - 8:00 (PM) (undated), indicated it was the responsibility of this position to sweep and mop the kitchen once dinner trayline was complete. A review of the facility's In-Service Time-in Sheet, dated [DATE], indicated an in-service titled, Cleanliness of Kitchen, Upkeep Logs with a description of the in-service stating, Staff will keep kitchen neat, logs will be filled out daily. A review of the facility's In-Service Time-in Sheet, dated [DATE], indicated an in-service titled, How to read cleaning logs with a description of the in-service stating, Staff will be shown proper cleaning techniques, staff will be shown what each cleaning duty consists of. The length of the in-service stated, 10 minutes. Five of the department's 10 staff signed the sign-in sheet. A review of the facility's In-Service Time-in Sheet, dated [DATE] indicated an in-service titled, Temperature, Cleaning and Hot Holding with a description of the in-service stating, Staff will record temp[eratures] of food. Plates will not be pre-prepped. Cleaning of cook's area. No other description of these in-services was provided. According to the 2017 FDA Food Code, physical facilities shall be cleaned as often as necessary to keep them clean. 3. During a tour of the kitchen on [DATE], between 10:54 AM and 11:16 AM, the following equipment was noted to have food residual accumulations and were not clean: a.) Meat slicer was covered with a plastic bag and when removed had a crusty food residual on the underside and the upper side of the blade; b.) Food mixer was stored with a black sticky residual on the bottom of the motor housing; c.) The microwave handle used to open it had a crusty residual; d.) Two steamtable pans stored in the clean area contained food residual; and e.) Two large tubs used to store serving utensils had an accumulation of crumbs inside where the clean scoops, ladles, and spatulas were stored. During a concurrent interview with the DM, he verified the above soiled equipment and tubs. The DM stated that the bag covering the meat slicer was supposed to indicate that it had been cleaned. The DM further stated that all of the equipment and tubs should be clean. A review of the facility's policy titled, Microwave Oven - Operation and Cleaning, revised [DATE], indicated, The dietary staff will operate the microwave oven according to the manufacturer's guidelines. The microwave will be cleaned after each use. A review of the facility's policy titled, Mixer - Operation and Cleaning, revised [DATE], indicated, The dietary staff will operate the mixer according to the manufacturer's guidelines. The microwave will be cleaned after each use. A review of the facility's policy titled, Meat Slicer-Operation and Cleaning, revised [DATE], indicated, The dietary staff will operate the meat slicer according to the manufacturer's guidelines. The meat slicer will be cleaned after each use. According to the 2017 FDA Food Code, .equipment food-contact surfaces and utensils shall be clean to sight and touch. (b) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (c) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. 4. During a tour of the kitchen and concurrent interview with the DM on [DATE], at 11:06 AM, the food preparation sink in the hot food preparation area was observed to have a drainpipe from the sink to the floor sink/drain which did not maintain an air gap. The drainpipe also had a plastic bag tied around it. During a concurrent interview with the DM, he stated that the drainpipe kept falling down in the floor sink and the plastic bag was used to keep it from falling. The DM verified the air gap was not maintained. According to the 2017 FDA Food Code, an air gap between the drainpipe and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the drain pipe and may not be less than one inch. 5a.) During an observation in the walk-in refrigerator in the kitchen and concurrent interview with the DM, on [DATE], at 10:33 AM, two one-gallon containers of Caesar salad dressing were noted to have a use-by date of [DATE]. The DM verified the use-by date on the containers and stated that the use-by date sticker was not placed on the salad dressings by the facility. The DM further stated, We would look, smell and taste the product to check if it is okay. 5b.) During an observation in the dry storage in the kitchen, on [DATE], at 10:05 AM, two 46-ounce flavored thickened water were observed with use-by dates of [DATE]. In addition, during a subsequent observation in the walk-in refrigerator the same day ([DATE]), at 10:23 AM, two more 46-ounce containers of the same flavored thickened water were noted with the same use-by dates of [DATE]. During concurrent interviews with the DM, he verified the use-by dates and the containers of liquid were past their use-by dates. During an interview with the Registered Dietitian (RD) on [DATE], at 10:36 AM, the RD stated that the facility does not have a policy on use-by, best by date or expiration dates so that they would not get a deficiency for not following their policy. The RD stated, however, in the case of best by dates they usually have until the end of the month that is indicated on the best by date. She was unable to state how the dietetic staff knew when to discard a product past its best-by, use-by or expiration dates since there is no written guidance to the staff. 6. During a tour of the kitchen on [DATE], between 10:10 and 10:54 AM, in the dry storage area was observed large plastic containers with red lids all ajar (not sealed) of graham cracker crumbs, egg noodles, white rice and brown rice. Also in the dry storage was an opened bag of dry cheesecake mix partially covered with plastic wrap but not sealed. In the cold food preparation area, a plastic container of red and yellow onions was stored with the lid only partially covering the container. On the bread rack in the cold food preparation area one loaf of bread and one bag of 2 bagels were both left open to the air. In the walk-in freezer, a box of frozen dinner rolls was left open to the freezer air. During concurrent interviews with the DM, he stated the plastic containers with the red lids in the dry storage were difficult to close because the containers had been run through the dishwasher. He verified that the containers were not sealed for this reason. The DM also verified the bags of bread, bagels, cheesecake mix and yellow cake mix were not closed or sealed shut and stated that they should be sealed. In the freezer, the DM stated that the cardboard box that contained the frozen rolls should be sealed, and he verified that it was not sealed. A review of the facility's policy titled, Food Storage, revised [DATE], indicated, Dry Storage Guidelines Any open products should be placed in storage containers with tight fitting lids. It further stated, Frozen Meat/Poultry and Food Guidelines Foods should be stored in their original containers if designed for freezing. Food to be frozen should be stored in airtight containers or wrapped in heavy-duty aluminum foil or special laminated papers. 7. According to the 2017 US FDA Food code, Food employees shall use the following cleaning procedure in the order stated to clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands and arms: (1) Rinse under clean, running warm water; (2) Apply an amount of cleaning compound recommended by the cleaning compound manufacturer; (3) Rub together vigorously for at least 10 to 15 seconds while: (a) Paying particular attention to removing soil from underneath the fingernails during the cleaning procedure, and (b) Creating friction on the surfaces of the hands and arms or surrogate prosthetic devices for hands and arms, finger tips, and areas between the fingers; (4) Thoroughly rinse under clean, running warm water; and (5) Immediately follow the cleaning procedure with thorough drying .(without) re-contaminating their hands . Soap is important for the effect in removing soil from the hands and a warm water temperature is important in achieving the maximum effect of the soap. During a tour of the kitchen and concurrent interview with the DM on [DATE], between 10:00 and 11:00 AM, the handwashing sink outside of the DM's office took more than 60 seconds to reach the temperature of at least 100 °F. The DM stated the sink takes a while to get hot. The handwashing sink in the hot food preparation area also took more than 60 seconds to reach at least 100 °F. The water pressure in the cook's area sink was very low with water only trickling out. The DM verified the observation and stated he had soaked the sink water outlet with a chemical mineral deposit remover to remove mineral build-up, but the water continued to trickle out. The DM stated he needed to have the maintenance director look at it. During an interview with the Maintenance Director on [DATE], at 11:54 AM, the Maintenance Director stated all 3 handwashing sinks in the kitchen had low water pressure which caused the hot water temperature to rise too slowly.