Every finding on record at The Win Post-Acute

Based on interview and record review, the facility failed to ensure care and services in accordance with professional standard of practice for one of two residents (Resident 1) when nursing staff failed to follow up an order for a medication.This failure had the potential for negative health outcomes related to not receiving prescribed medication as ordered.Findings:Review of Resident 1's admission Record indicated he was admitted to the facility on [DATE] with diagnoses including benign prostatic hyperplasia (BPH, enlargement of the prostate gland [part of the male reproductive system], type II diabetes mellitus (high levels of sugar in the blood), wedge compression fracture of first lumbar vertebra (collapse of the bone in the spine).Review of Resident 1's physician's order, dated 11/11/25, indicated Finasteride 5 milligrams (mg, unit of measurement) tablet to give 1 tablet by mouth one time a day for BPH.Review of Resident 1's Medication Administration Record (MAR), indicated the medication Finasteride was not given on 11/12/25 and 11/13/25.Review of Resident 1's EMAR (Electronic Medication Administration Record) Administration Note, dated 11/13/25, indicated Finasteride 5 mg tablet awaiting supply.During a concurrent interview and record review with the Director of Nursing (DON), on 3/16/26 at 10:45 a.m., the DON confirmed the Finasteride medication was not given. The DON also confirmed there was no shortage or inadequate supply of the medication. The DON stated nursing staff documented the medication was in order. The DON also stated the nursing staff should have followed up with the pharmacy. The DON confirmed there was no documentation that nursing staff followed up on the medication with pharmacy.Review of the facility's Policy and Procedure (P&P), titled Medication Shortages/Unavailable Medications, dated 12/1/07, indicated The facility nurse should call Pharmacy to determine the status of the order.If the next available delivery causes delay or missed dose in the resident's medication schedule, Facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose. If the medication is not available in the Emergency Medication Supply, Facility staff should notify Pharmacy and arrange for an emergency delivery.When a missed dose is unavoidable, Facility nurse should document the missed dose and the explanation for such missed dose on the MAR or TAR and in the nurse's notes per Facility policy.

Based on interview and record review, the facility failed to report an allegation of abuse for one of three sampled residents (Resident 1). This failure had the potential to delay abuse investigations and compromise Resident 1's safety.Review of Resident 1's medical record indicated he was admitted on [DATE] and had the diagnosis of spinal stenosis (the space inside the bones of the spine gets too small), anxiety disorder (a mental health condition), difficulty in walking, and muscle weakness.Review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 5/1/25, indicated his Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 (BIMS score of 13-15 indicates cognitively intact).During a telephone interview with Resident 1 on 6/3/25, at 12:01 p.m., he stated that he was assaulted by his co-resident and did not feel safe in the facility. Resident 1 stated that his co-resident came to him in the middle of the night and touched his belongings, like bed sheets on 2/20/25. Resident 1 further stated that he reported the assault to the Social Service Director (SSD), but he did not report to the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities).Review of Resident 1's Nursing Progress Notes, dated 2/20/25 at 6:05 a.m., indicated that at around 4:30 a.m., resident yelling & busting the call light multiple times. Resident yelling to the staff to move the roommate immediately/right now. Resident c/o (complain of) roommate smelly, noisy & kept getting up & going to his side.Review of Resident 1's Social Service Progress Notes, dated 2/20/25 at 8:48 p.m., indicated that Resident refusing to have new roommate placed in room. Resident stated it is due to the roommate he received on 2/19/25 not going well. Resident's main concern is having a roommate who is able to get out of bed and come to his side of the room.Review of Resident 1's medical record on 7/16/25 revealed there was no documentation for the allegation of assault which reported by Resident 1.During an interview with the SSD on 6/3/25 at 2:10 p.m., he stated Resident 1 reported that he was assaulted by his roommate on 2/20/25. The SSD stated Resident 1 reported that his roommate came to him and grabbed his covers, like a blanket; Resident 1 denied any physical contact from his roommate. The SSD further stated that he investigated and concluded Resident 1's report was not an allegation of abuse.Review of the SSD's Investigation provided by the SSD on 6/3/25 indicated Incident: Resident 1 reported he was assaulted by his roommate. Asked resident to elaborate on what he meant by assaulted ‘he stated his old roommate was grabbing at his covers.' Asked resident if he was hit or if other resident made physical contact with him, he replied ‘no'.During an interview with the SSD on 6/3/25 at 3:09 p.m., he stated he reported his investigation to the Director of Nursing (DON).During an interview with the DON on 6/3/25 at 3:15 p.m., she confirmed that she received the SSD's Investigation about Resident 1's report. The DON stated that she and the SSD concluded that Resident 1's report was not an allegation of abuse after the investigation performed by the SSD. The DON stated Resident 1's report was not reported to the California Department of Public Health (CDPH) or Ombudsman.During an interview with the DON on 7/16/25 at 10:50 a.m., she stated that the SSD clarified the meaning of the assault reported by Resident 1; Resident 1 stated the meaning of the assault was his roommate grabbed his sheet; Resident 1 was alert and oriented, he was able to define the meaning of the assault. The DON stated she and the SSD concluded that Resident 1's report was not an allegation of abuse.Review of the facility's policy and procedure (P&P) titled Alleged or Suspected Abuse and Crime Reporting, revised 10/2022, indicated, definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Alleged violation is a situation or occurrence that is observed or reported .During an interview and the facility's policy titled Alleged or Suspected Abuse and Crime Reporting review with the DON on 7/16/25 at 11 a.m., she acknowledged the definitions of abuse and alleged violation.During an interview and record review with the DON on 7/16/25 at 11:10 a.m., she confirmed there was no documentation of Resident 1's allegation of assault. The DON stated there was no documentation about Resident 1's report in his chart because Resident 1's report was a complaint not an allegation of abuse. The DON further stated Resident 1's report was discussed during the facility morning meeting without documentation, also the SSD's investigation was internal investigation.During an interview with the Administrator (ADM) on 7/16/25 at 11:30 a.m., he stated he was not aware of Resident 1's allegation of assault on 2/20/25; the SSD's investigation was not reported to him. The ADM stated it was reported during the facility's morning meeting that Resident 1 complained about his roommate pulling his sheets. The ADM stated he was the facility's abuse coordinator and would report to the outside agency if he was aware of the allegation of assault reported by Resident 1.During a review of the facility's policy and procedure (P&P) titled Alleged or Suspected Abuse and Crime Reporting, revised 10/2022, the P&P indicated, 8. Reporting/response: It is the responsibility of all employees to immediately report to the facility administrator, and to other officials in accordance with federal and state law, any incident of suspected or alleged abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

Based on interview and record review, the facility failed to identify the lack of annual performance reviews for Certified Nursing Assistants (CNAs) in their Quality Assurance Performance Improvement Plan (QAPI- a plan developed by the facility with the goal of improving conditions in the facility) when monitoring of employee files was not documented as reviewed for regulatory compliance, per the QAPI monitoring plan. As a result, the facility did not identify 40 of 69 CNAs employeed by the facility did not have a documented annual performance review. (see F730). Findings: During a review of the facility's QAPI Plan, updated 2017, QAPI plan indicated, Quality Surveillance Data.Education/In-Service Tracking, Responsible for Review/reporting to Committee Director of Staff Development, Action Plan(s) required for: Federal/State required in-services not completed per regulations, personnel files audits that result in negative findings. QAPI Plan indicated, Random personnel file reviews should occur quarterly to determine compliance with training and documentation requirements as well as mandatory hiring criteria and license verification. Results of random audits should be reviewed by the Executive Director with training summary and audit findings reported to the QA&A [QAPI] Committee for review and process improvement. During an interview on 5/9/25, at 9:23 a.m., with the Administrator in Training (AIT), the AIT stated, he does not have documentation of the DSD having performed random audits of personnel files. AIT stated the facility was not aware CNA annual performance reviews were not being completed.

Based on interview and record review, the facility failed to ensure 40 out of 69 Certified Nursing Assistants (CNAs) who have worked at the facility for over one year were reviewed annually for a performance review per federal regulation. This failure resulted in the facility being unaware of 40 CNA's performance through the prior year. This failure also had the potential for CNA's performance to be below the standard or practice for patient care. Findings: During a review of CNA I's employee file, undated, employee file indicated, no annual performance review was documented. CNA I's hire date was 9/29/2021 During a review of CNA J's employee file, undated, employee file indicated, no annual performance review was documented. CNA J's hire date was 1/12/2017. During an interview on 5/07/25, at 1:18 p.m., with the Director of Staff Development (DSD), the DSD stated, she took over the position of DSD as interim for the last two weeks. DSD stated, I do not know what the prior DSD's process was, but we looked in her desk and did not find any annual performance reviews for the CNAs. During an interview on 5/7/25, at 1:28 p.m., with the Director of Nursing (DON), the DON stated, we do not see any performance reviews for CNA I, or CNA J. The DON stated, she would get a list of the current CNAs who have not had a performance review. The DON also stated, the CNAs are supposed to have a performance review annually. During a concurrent interview and record review on 5/8/25, at 3:17 p.m., with the DON, the list of CNAs who have not a performance review was reviewed. The list indicated, 40 CNAs out of 69 di not have their annual performance review. The DON stated, this list is all the CNAs who have worked for over one year at least, and they have not had an annual performance review.

Based on observation, interview and record review, the facility failed to ensure staff were implementing infection prevention practices when: 1. One of four Certified Nursing Assistances (CNA) failed to perform hand hygiene between residents during dining; 2. Resident 309's intravenous (IV, to deliver a medication into a vein) tubing tip left uncapped when not in use. During an observation on 05/06/25 at 12:53 p.m., Certified Nursing Assistant (CNA) F, was in the dining room sitting between Resident 5 and Resident 44 feeding them both lunch without cleaning her hands between Residents. During an interview on 05/06/25 at 3:07 p.m., CNA F stated, She washes hands prior to feeding the residents but does not clean hands between residents when feeding two residents at the same time. Review of the facility's policy and procedure titled Hand Hygiene, dated 5/29/24 indicated, Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table .Between resident contacts. Review of the facility's policy and procedure titled Infection Prevention and Control Program, dated 2/5/25 indicated, All staff are responsible for following all policies and procedures related to the program. 50135 Review of Resident 309 's clinical record indicated Resident 309 was admitted on [DATE] with diagnoses including post digestive system (a group of organs in the body that break down food into its simplest forms) surgery care, severe protein-calorie malnutrition, and status post gastrostomy (GT tube, a surgical opening into the stomach for the administration of nutrition and medications). Review of the Order Summary Report for Resident 309 indicated a physician order dated 5/4/25 for 0.45% sodium chloride (low salt fluid) intravenous sodium solution. Use intravenously every shift for IV hydration (provides fluid to the body when food by mouth is insufficient or not possible. During a concurrent observation and interview on 5/7/25 at 9:55 a.m. with Licensed Vocational Nurse D (LVN D) inside Resident 309's room, LVN D confirmed the tip of the IV tubing was left uncapped and exposed to air while not in use. LVN D stated, It should not be like that. LVN D also stated, It should have a small cap on the end to prevent infection. Review of the facility's policy and procedure titled, Infection Prevention and Control Program, dated 2/5/25 indicated, All staff are responsible for following all policies and procedures related to the program.

Based on interview and record review, the facility failed to ensure one of 35 sampled residents (Resident 34) was free from inappropriate and unnecessary medication use when the medication Midodrine HCI (to treat low blood pressure) was given outside of the ordered parameters. This failure had the potential for causing harm to Resident 34's health and well-being. Findings: During review of Resident 34's medication administration record (provides a comprehensive, organized record of each medication administered to a patient) (MAR), dated May 2025, the MAR indicated Resident 34 received Midodrine HCI 5 milligrams (a unit of measure) (Mg) on 5/8/25 when the blood pressure (refers to the force of circulating blood against the walls of blood vessels. Blood pressure is measured in two values: systolic [highest pressure during a heartbeat] and diastolic [lowest pressure between heartbeats]) was 126/68. During review of Resident 34's orders dated 3/4/25, the order indicated Midodrine HCl oral tablet 5 MG, one tablet by mouth three times a day for hypotension, hold for SBP (systolic blood pressure) greater than 120 mmHg. During review of Resident 34's MAR dated March 2025 and April 2025, the MAR for March 2025 indicated Midodrine HCl was given five times when SBP was above 120 (3/6/25, 3/8/25, 3/9/25, 3/15/25 and 3/25/25). The MAR for April 2025 indicated Midodrine HCl was given eight times when SBP was above 120 (4/1/25, 4/5/25, 4/15/25 two times, 4/17/25, 4/19/25, and 4/27/25 two times). During a concurrent interview and record review on 5/8/25 at 2:00 p.m. with Licensed Vocational Nurse (LVN) K, Resident 34's orders and MAR for March, April and May 2025 were reviewed. LVN K stated the order indicated to hold for SBP greater than 120 mmHg. LVN K confirmed Resident 34 should not have received medication when the SBP was greater than 120 mmHG on the 14 incidents reviewed. Review of the facility's policy and procedure titled, Medication Administration, dated 4/9/25, indicated Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician 's prescribed parameters.

Based on interview and record review, the facility failed to ensure accurate accountability of controlled medication (medication with high potential for abuse and addiction) when random controlled medication use audit for three of twelve residents (Residents 93, 3 and 87) did not reconcile when: 1. The medication was documented on the Medication Administration Record (MAR, used to document medications taken by each individual) to indicate they were administered to Resident 93 but was not signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications). 2. The medication was signed out of the CDR but not documented on the MAR for Resident 87 and Resident 3. The failure resulted in inaccurate accountability and had the potential for misuse or diversion of controlled medications. Findings: 1. The Controlled Drug Record (CDR) for twelve residents receiving controlled medications were requested for review during the survey. A review of Resident 93's clinical record indicated she had a Physician order for Hydrocodone-Acetaminophen (Norco, a controlled medication for pain) 10-325 milligrams (mg, unit of measurement) 1 tablet every 4 hours for pain, dated 4/24/25. During a concurrent interview and record review on 5/5/25 at 7:48 a.m., with Registered Nurse (RN) H, RN H stated she gave the medication at 12:15 a.m. but forgot to sign the CDR. During an interview on 5/6/25 at 2:16 p.m., with the Director of Nursing (DON), the DON stated that the narcotic sheet, which is the CDR, should be signed as soon as the medication was given and signed in the MAR. 2. A review of Resident 3's clinical record indicated she had a Physician order for Norco 5-325 mg 1 tablet every 6 hours as needed for severe pain, dated 4/17/25. During a concurrent interview and record review on 5/6/25 at 2:32 p.m., with the DON, a review of Resident 3's CDR for Norco and the 4/2025 MAR reflected the nursing staff removed the medication from the locked controlled medication compartment in the medication cart and signed out of the CDR on 4/18/25 at 9:35 a.m., but did not document the respective administration on the MAR. The DON acknowledged that the controlled medication was not accounted for in the MAR. A review of Resident 87's clinical record indicated she had a Physician order for Oxycodone Hydrochloride (a controlled medication for pain) 5 mg per 5 milliliter (ml, unit of measurement) give 2.5 ml every 6 hours as needed for severe pain., dated 4/5/25. During a concurrent interview and record review on 5/6/25 at 2:39 p.m., with the DON, a review of Resident 87's CDR for Oxycodone and the 4/2025 MAR reflected the nursing staff removed the medication from the locked controlled medication compartment in the medication cart and signed out of the CDR on 4/15/25 at 10:15 p.m., but did not document the respective administration on the MAR. The DON acknowledged that the controlled medication was not accounted for in the MAR. A review of the facility's Medication Administration policy and procedure (P&P), dated 4/9/25, indicated Policy Explanation and Compliance Guidelines .21. If medication is a controlled substance, sign narcotic book. A review of the facility's General Dose Preparation and Medication Administration P&P, dated 11/15/24, indicated 5.5 Document the administration of controlled substances in accordance with applicable law .6. After medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 6.1 Document necessary medication administration/treatment information .on appropriate forms .

Based on observation, interview and record review the facility failed to follow professional standards of practice for oxygen administration for three of nine residents receiving oxygen therapy in the facility when: 1. Resident 20 was administered the wrong dose of oxygen. 2. Resident 49 was administered oxygen without a doctor's order. 3. Resident 16 was administered the wrong dose of oxygen. These failures had the potential to negatively affect Resident 20's, Resident 49's, and Resident 16's health. Findings: 1. During a concurrent observation and interview on 5/5/25, at 1:17 p.m., with Registered Nurse (RN) A, in Resident 20's room, Resident 20 was observed wearing a nasal cannula (plastic tubing which supplies oxygen from a machine). RN A stated, she saw Resident 20s oxygen set to between 2.5 and 3 liters (measure of oxygen give to patient per minute). RN A stated, she will lower it, the order is for 2 liters for Resident 20, it should be at 2 liters per the doctor's order. During a review of Resident 20's Order Summary Report dated 5/8/25 indicated, Resident 20 had an order for Oxygen at 2 LPM [liters per minute] via nasal cannula. During a review of Resident 20's Care Plan dated 10/10/24, Care Plan indicated, The resident has oxygen therapy r/t [related to] COPD [Chronic Obstructive Pulmonary Disease: a group of lung diseases that cause ongoing breathing problems].Interventions.Give medications as ordered by physician. 2. During a concurrent interview and record review on 5/5/25, at 1:15p.m, with RN A, Resident 49's Physician Orders was reviewed. The orders indicated, no order for oxygen. RN A stated, there is no order for oxygen, I will call the Doctor and ask for one, we have to have an order for oxygen. During a concurrent observation and interview on 5/5/25, at 1:25 p.m., with RN A, in Resident 49's room. Resident 49 was observed receiving oxygen through a nasal cannula. RN A stated, the oxygen is set to 4 liters. During a review of the facility's Policy & Procedure (P&P) titled, Oxygen Administration, dated, 2014, the P&P indicated, Purpose to administer oxygen to the resident when insufficient oxygen is being carried but the blood to the tissues.Procedure 1. Check physician's order for liter flow and method of administration. 50135 3. Review of Resident 16's Admission Record indicated Resident 16 was admitted to the facility with diagnoses including spinal cord injury (damage to the bundle of nerves that sends and receives signals from the brain), diabetes mellitus (a condition which affects the way the body processes blood sugar), chronic kidney disease, myelofibrosis (chronic blood cancer that causes bone marrow[the soft matter inside the bones] scarring, making it difficult to produce normal blood cells) and anemia (low levels of healthy red blood cells to carry oxygen throughout the body). During an observation on 5/5/25 at 9:23 a.m., Resident 16 was sitting up in bed receiving oxygen through a nasal cannula. Resident 16's oxygen concentrator (machine used to deliver oxygen) was set at 4 LPM. Review of Resident 16's Physician Order Summary Report, dated 8/25/2024, indicated an order of oxygen at 2/LPM. Review of Resident 16's Care Plan Report dated 8/23/2024, indicated, The resident has altered respiratory by difficulty of breathing and has low oxygen level, with an intervention to, Administer oxygen as ordered. During a concurrent observation and interview with LVN B on 5/6/25 at 2:03 p.m., inside Resident 16's room, LVN B confirmed Resident 16's oxygen was administered at 4LPM. LVN B stated Resident 16's oxygen flow rate should have been at 2 LPM. During an interview on 5/6/25 at 2:15 p.m., with the Director of Nursing (DON), the DON stated the oxygen order should always be followed. During a review of the facility's Policy & Procedure (P&P) titled, Oxygen Administration, dated, 2014, the P&P indicated, Purpose to administer oxygen to the resident when insufficient oxygen is being carried but the blood to the tissues.Procedure 1. Check physician's order for liter flow and method of administration.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person centered care plan for one of eight residents with the potential for skin problems when the facility failed to develop and implement Resident 49's care plan for preventative foot care. This failure had the potential for Resident 49's feet to deteriorate clinically. Findings: During an interview on 5/5/25 at 9:05 a.m., with Confidential Friend (CF) G, CF G stated, they saw Resident 49's feet and believes her care plan needs to be adjusted, because her toe nails are long and they need to do something about them. CF G stated, Resident 49 had fungal infections in her feet, in the past and if they don't keep them clean it will happen again. During an observation on 5/6/25, at 8:21 a.m., in Resident 49's room, Resident 49's feet were noted to have skin buildup to both feet, with thickened, discolored and longer than average toe nails. During a record review of Resident 49's medical diagnoses list, dated 5/6/25, the list indicated, Resident 49 was diagnosed with Type 2 Diabetes Mellitus(a chronic disease where the body can't produce enough insulin or can't use the insulin effectively). During a review of Diabetic Foot Care an article by the National Institute of Health, dated 2023, article indicated, Patients with diabetes are at increased risk for foot ulceration secondary to neuropathy [nerve pain], microvascular disease[damage to inner walls of small blood vessels], and [changes to anatomy]. During a review of Resident 49's Care Plan dated 5/6/25, it indicated no care plan for preventive foot care was created. During a review of Resident 49's Order Summary List dated 5/6/25 indicated, no orders to be seen by Podiatrist for cutting of toe nails or preventive foot care. During an interview on 5/6/28, at 9:58 a.m., with the Director of Nursing (DON), the DON stated, she does not see a care plan for Resident 49 regarding preventive foot care. The DON also stated, if a resident is at risk of an issue, then they need a care plan for it. During a review of the facility's Policy & Procedure (P&P) titled, Care Plan, Comprehensive, dated 2008, the P&P indicated, It is the policy of the facility to develop, in conjunction with the resident and/or representative, the Comprehensive Resident Care Plan. The care plan is directed toward achieving and maintaining optimal status of health, functional ability, a quality of life.

Based on interview and record review, the facility failed to revise the care plan for two of 15 residents (Resident 34 & 74) when there was no evidence the facility reviewed or revised the care plan with new recommendations to prevent the Resident from falling again. This failure had the potential to result in further falls and/or injury. Findings: 1. During a review of Resident 34's Fall Report Incident dated 2/21/25, it indicated Resident 34 had a fall on 2/21/25 at 4:30 p.m. During a review of Resident 34's care plans, dated 11/25/24 last revision, indicated no care plan following the 2/21/25 fall or revisions to the previous care plan. During an interview on 5/8/25 at 1:31 p.m. with the Director of Nursing (DON), she stated, the care plan was not updated after the fall. Review of the facility's policy and procedure titled, Fall Prevention and Response, dated 8/2023, indicated Facility will monitor effectiveness of planned fall prevention interventions no less often than quarterly and modify interventions when necessary, such as following a significant COC or fall accident. Review of the facility's policy and procedure titled, Care plan, Comprehensive, dated 2008, indicated It is reviewed and revised by the Interdisciplinary Team quarterly, following completion of the MDS assessment, and following assessment for significant change. Review of the facility's policy and procedure titled, Fall Risk assessment dated [DATE], indicated Monitor the effectiveness of the care plan interventions, and modify the interventions as necessary, in accordance with current standards of practice. 46939 2. During a review of Resident 74's Fall Report Incident dated 1/12/25, indicated Resident 74 had a fall on 1/12/25 at around 7:40 a.m. During a review of Resident 74's care plan dated 5/8/25, it indicated, no care plan for Resident 74's fall on 1/12/25. During an interview on 5/8/25, at 3:47 p.m., with Director of Nursing (DON), DON stated, they did not update the care plan for Resident 74's fall on 1/12/25. During a review of the facility's policy & procedure (P&P) titled, Care Plan, Comprehensive dated 2008, the P&P indicated, It is the policy of the facility to develop, in conjunction with the resident and/or representative, the Comprehensive Resident Care Plan.It is completed.following assessment for significant change.

Based on observation, interview and record review, the facility failed to ensure services were provided to prevent and/or heal pressure ulcers (damage to the skin or underlying tissue as a result of prolonged pressure) for one of eight sampled residents (Resident 308) with pressureulcers when staff did not follow physician's order for heel protectors (device applied to the feet to minimize pressure on the heels). This failure had the potential to result in worsening of resdient 308's pressure ulcers. Findings: Review of Resident 308's clinical record indicated he was admitted on [DATE] with diagnoses including heart failure (a condition in which the heart doesn't pump blood as well as it should), pancytopenia (abnormally low amounts of all three types of blood cells, red, white and platelets), encephalopathy (disease that affects brain function), and muscle weakness. Review of Resident 308's clinical record indicated a physician order for right and left heel skin barrier film as needed every shift for pressure ulcers. Further review of Resident 308's clinical record indicated a physician order dated 4/26/25, to apply protective boots every evening and night shift for protection while in bed every shift, and on 5/7/25 an order to apply protective boots to both feet every shift. Review of Resident 308's Skin and Wound Evaluation dated 4/25/25 indicated Resident 308's skin was fragile and at risk for skin breakdown. Review of Resident 308s Braden Scale for Predicting Pressure Score Risk dated 4/24/25 indicated a score of 17 (At Risk 15-18), and potential problem with friction and shear (gradual breakdown of the skin from constant rubbing against something and forces that cause body tissues or parts to move in opposite directions) due to weak movement or requiring assistance and skin sliding to some extent against sheets or other devices. Review of Resident 308's Care Plan Report dated 4/25/25 indicated Resident 308 had a new impairment to skin integrity with interventions including, Treatment per order. During observations on 5/5/25 at 9:26 a.m., 5/6/25 at 8:30 a.m., and 5/8/25 at 4:10 p.m., Resident 308 was lying in bed and was not wearing heal protectors on both feet. During a concurrent observation, interview and record review on 5/6/25 at 9:18 a.m., with Licensed Vocational Nurse C (LVN C) during wound care for Resident 308, LVN C stated Resident 308 had stage 1 pressure ulcers to the heels of both feet. LVN C confirmed there was a physician order for bilateral heel protective boots and stated Resident 308 was not wearing any heel protective boots while in bed. During a concurrent observation and interview on 5/6/25 at 2:15 p.m., with Certified Nursing Assistant E (CNA E), CNA E confirmed Resident 308 was not wearing bilateral heel protector boots while in bed. CNA E looked for Resident 308's heel protectors inside the room, inside the closet and in each of Resident 308's drawers. CNA E stated the boots could not be found. During a concurrent interview and record review on 5/8/2023 at 3:30 p.m., with the Director of Nursing (DON), the DON reviewed Resident 308's Order Summary Report and care plan. The DON confirmed the physician's order for bilateral heel protectors on 4/26/2025 and 5/7/25, and stated the heel protector boots must be somewhere in Resident 308's room and should be on his feet while he's in bed. Review of the facility's policy and procedure titled, Pressure Injury Prevention and Management, revised 12/03/2024, indicated, This facility is committed to the prevention of avoidable pressure injuries . and to provide treatment and services to heal the pressure ulcers/injury, prevent infection and the development of additional pressure ulcers/injuries. Basic or routine care interventions could include but are not limited to: .i. Redistribute pressure (such as repositioning, protecting and or offloading heels, etc.); .iv. Provide non-irritating surfaces .

Based on observation, interview and record review, the facility failed to ensure expired medication was removed in one of three medication carts (med cart AA)) when a bottle of Mirtazapine (used to treat depression [a mood disorder characterized by persistent sadness and a loss of interest in activities]) 15 milligrams (mg, unit of measurement) with expiration date of [DATE] was identified. The failure had the potential for residents to receive medications with reduced potency. Findings: During an inspection of the med cart AA and interview with Licensed Vocational Nurse (LVN) B on [DATE] at 12:08 p.m., a bottle of Mirtazapine was found in the medication cart that expired on [DATE]. LVN B confirmed that the medication has expired and should have been removed. During an interview on [DATE] at 2:20 p.m., with the Director of Nursing (DON), the DON stated the expired medication should have been removed from the medication cart. During a review of the facility's Disposal/Destruction of Expired or Discontinued Medication policy and procedure (P&P), dated [DATE], indicated Facility should place all discontinued or outdated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction. During a review of the facility's Labeling of Medications and Biologicals P&P, dated [DATE], indicated All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. During a review of the facility's Medication Storage P&P, dated [DATE], indicated Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels .

Based on observations and interviews, the facility failed to ensure all multiple-resident bedrooms provided at least 80 square feet per resident for 9 of 60 rooms observed. This failure had the potential for Residents in rooms #301, #302, #303, #304, #305, #309, #311, #312, and #314 to have less space available for daily care and assistance. Findings: During observations from 5/5/25 to 5/9/2025 in rooms #301, #302, #303, #304, #305, #309, #311, #312, and #314., each room was a two-resident room and measured 13 feet by 11 feet, resulting in a total square footage of 143 square feet, or 71.5 square feet per resident. During the observation, residents reported they had plenty of space and did not have concerns with the size of their rooms. During an interview on 5/5/25 at 8 am with the Administrator, the Administrator, stated social services asks the residents or their families each quarter if there were any problems with the room size and none had been reported. The Administrator indicated the smaller room size did not inhibit resident care, and the facility has a room waiver.

Based on interview and record review, one of two sampled residents (Resident 1) was not free from physical abuse when Resident 1 was found in bed with multiple bruises to the face and arms, swelling on the bridge of the nose and right eyebrow, a cut on the lower lip, blood in the mouth, on the lips, and on the fingers, and chipped teeth. Resident 1 passed away, and the immediate cause of death was documented as, Blunt force injury [injury caused by forceful impact from an object without sharp edges or points] of head complicating hypertensive [having high blood pressure] and atherosclerotic cardiovascular disease [heart disease involving plaque buildup in the arteries]. Findings: Review of Resident 1's medical record indicated Resident 1 was admitted to the facility on [DATE], and had diagnoses including osteomyelitis (inflammation of bone or bone marrow, usually caused by infection), chronic obstructive pulmonary disease (COPD, a disease that causes obstructed airflow from the lungs), severe protein-calorie malnutrition (significant fat loss and muscle wasting), muscle weakness, paroxysmal atrial fibrillation (a type of irregular heart rate), stage 4 pressure ulcer (an injury resulting from prolonged pressure that involves full thickness tissue loss with exposed bone, tendon or muscle), congestive heart failure (a condition in which the heart cannot pump blood well enough to provide a normal supply to the body), osteoporosis (a condition that causes the bones to become brittle and fragile), and osteoarthritis (degeneration of the joints that causes pain and stiffness). Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated [DATE], indicated Resident 1 had a brief interview for mental status (BIMS) score of 3 (a score of 0 to 7 indicates severe cognitive impairment [problems with how a person thinks, learn, use judgment and make decisions]). The MDS indicated Resident 1 required substantial/maximal assistance (staff does more than half the effort) for rolling left and right in bed. The MDS also indicated Resident 1 was dependent (staff does all of the effort) for moving from a lying to sitting position in bed and moving from a sitting to lying position in bed. The MDS further indicated Resident 1 refused to move from a sitting to standing position and refused to transfer to and from her bed to a chair or wheelchair. Review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a tool used to communicate information to the resident's doctor), dated [DATE], indicated Resident 1 was involved in an incident of alleged physical abuse. The SBAR indicated, Found bruises on the resident's nose bridge, left and right cheek, left forehead, and chin. Also noted that the resident's front upper teeth were chipped and there is dried blood on the lower lip. There is also swelling on the bridge of the nose. The SBAR also indicated Resident 1 had, extensive bruising on face and arms. Blood in mouth and on lips and fingers. The SBAR also indicated Resident 1 has bruising on the right side of the face, bruising on the lips, swelling on the right eyebrow area. The SBAR further indicated, The resident has a multiple discoloration and swelling on her face, chipped upper front teeth and cut on the lower lip. During an interview with certified nursing assistant (CNA) A on [DATE], at 2:13 p.m., CNA A stated when she started work at 3:00 p.m. on [DATE], Resident 1 was in bed sleeping. CNA A stated she later provided care to Resident 1 at 6:30 p.m., at which time the resident did not have any injuries. CNA A stated the next time she saw Resident 1, at around 8:30 p.m. or 9:30 p.m., she saw bruises on Resident 1's face and blood on Resident 1's lips. CNA A stated she did not know of anyone who saw what happened to Resident 1. She stated Resident 1 was not able to get out of bed, and Resident 1 did not have any behaviors of self-harm. During an interview with registered nurse (RN) B on [DATE], at 3:17 p.m., RN B stated on [DATE], she and RN C were informed by RN D that Resident 1 had injuries to her face. RN B stated when staff asked Resident 1 what happened, the resident stated she did not know. RN B stated Resident 1 did not have behaviors of self-harm, and it was unlikely that Resident 1 inflicted the injuries on herself. RN B stated staff had determined Resident 1 did not fall out of bed, as the resident was dependent with care and would not have been able to get up and get herself back into bed after a fall. During an interview with RN C on [DATE], at 3:32 p.m., RN C stated on [DATE], at around 9:45 p.m., she was notified of Resident 1's injuries. RN C stated she went to the resident's room and saw Resident 1 in bed with bruises and swelling on her face, chipped teeth, and a cut on the inside of her lower lip. RN C stated Resident 1 did not remember what happened. RN C stated it was not likely that Resident 1 fell and got herself back into bed. During an interview with RN D on [DATE], at 3:49 p.m., RN D stated on [DATE], she initially saw Resident 1 at around 3:00 p.m. or 4:00 p.m., and Resident 1 did not have injuries at that time. RN D stated she gave medications to Resident 1 between 5:30 p.m. and 6:00 p.m. and the resident still had no injuries. RN D stated CNA A informed her of Resident 1's injuries at around 9:30 p.m. RN D stated she went into Resident 1's room and saw bruising and swelling on Resident 1's face, a chipped tooth, and a cut with dried blood on her lip. RN D stated she did not think Resident 1 would have been able to get herself back into bed if she fell . She also stated she did not think Resident 1 caused the injuries herself, as Resident 1 did not have behaviors of hitting or harming herself. Review of the facility's undated investigation summary indicated that on [DATE], CNA A went into Resident 1's room and noted Resident 1 had, multiple bruises and swelling on her face, chipped front teeth and cut on lower lip. The investigation summary further indicated Resident 1 was sent to the acute hospital for further evaluation. Review of Resident 1's Emergency Department Attending Physician Note, dated [DATE], indicated Resident 1 was brought in by ambulance after Resident 1 was assaulted at her nursing facility. The note indicated, Yesterday evening patient was assaulted between the hours of 9 and 11. The note further indicated, Patient is more altered than normal today. She has not been talking at all today and usually she can have a conversation. She has bruising to the right side of her face and a chipped tooth. Review of Resident 1's Medicine History and Physical from the acute hospital, dated [DATE], indicated, Noted abrasions on left side of face, bruising around the lips with chipped tooth. The Medicine History and Physical indicated diagnostic imaging showed Resident 1 had, Mild right malar soft tissue swelling [mild swelling in the right facial cheek area]. Review of Resident 1's Physician Discharge Summary from the acute hospital, dated [DATE], indicated Resident 1 was declared deceased (dead) at 4:06 p.m. The Physician Discharge Summary further indicated Resident 1's family requested an autopsy (examination to determine the cause of death) and the coroner (an official who investigates violent, sudden, or suspicious deaths) was notified. Resident 1's Certificate of Death, issued [DATE], was reviewed. The first page of the certificate indicated Resident 1's immediate cause of death was Pending. The second page of the certificate contained a Physician/Coroner's Amendment that indicated Resident 1's immediate cause of death was, Blunt force injury of head complicating hypertensive and atherosclerotic cardiovascular disease. The Physician/Coroner's Amendment indicated Resident 1's injury occurred on [DATE] at [facility address] and indicated, Bedbound subject found in bed with facial trauma in a shared room at a skilled nursing facility. The Physician/Coroner's Amendment further indicated Resident 1's manner of death was, Homicide [the killing of one person by another]. The facility's policy titled Alleged or Suspected Abuse and Crime Reporting, revised ,d+[DATE], indicated each resident has the right to be free from abuse.

Based on observations, interviews, and facility policy review, the facility failed to ensure 2 of 6 medication carts on 1 of 4 halls were not left unlocked and unattended. Findings included: Review of a facility policy titled, Medication Storage in the Facility, updated in August 2019, revealed, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The policy further indicated, Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. An observation on 02/07/2024 at 6:16 AM revealed there were two unlocked medication carts on the 100-Hall. Cart 1A was located between room [ROOM NUMBER] and room [ROOM NUMBER], and Cart 1B was located between room [ROOM NUMBER] and the Director of Nursing's (DON's) office. Both carts contained multiple over the counter (OTC) medications, prescription medications, medical supplies, nutritional supplements, bleach wipes, alcohol wipes, and drug disposal solution. On 02/07/2024 at 6:25 AM, Registered Nurse (RN) #1 was observed exiting room [ROOM NUMBER]. She walked past Cart 1B and did not lock it. She stated that she was responsible for both medication carts. RN #1 confirmed she left the medication carts unlocked and stated that she usually kept them locked. She indicated that if medication carts were left unlocked and unattended, residents or visitors could open them and get anything out of them, including items that may be contraindicated for use. During an interview on 02/08/2024 at 2:01 PM, the DON stated all medication carts were supposed to be locked if not attended. She further stated if the carts were open and unattended, a resident could remove something from the carts. During an interview on 02/08/2024 at 2:23 PM, the Administrator said the medication carts should be locked so that residents could not access the contents.

Based on observations and interviews, the facility failed to ensure all multiple-resident bedrooms provided at least 80 square feet per resident for 9 of 60 rooms observed. Findings included: During observations on 02/08/2024 from 2:05 PM to 2:12 PM, Maintenance Supervisor (MS) #4 measured Rooms #301, #302, #303, #304, #305, #309, #311, #312, and #314. Each room was a two-resident room and measured 13 feet by 11 feet, resulting in a total square footage of 143 square feet, or 71.5 square feet per resident. During the observation, residents reported they had plenty of space and did not have concerns with the size of their rooms. During an interview on 02/08/2024 at 2:26 PM, Certified Nursing Assistant (CNA) #5 indicated she had plenty of space in the rooms to get her work done. During an interview on 02/08/2024 at 2:32 PM, CNA #6 indicated there was plenty of space in the rooms, and she had no problems. During an interview on 02/08/2024 at 2:54 PM, the Director of Nursing (DON) stated the required room space was 80 square feet per resident. The DON further stated the rooms had enough space to provide care to the residents. During an interview on 02/08/2024 at 2:56 PM, the Administrator stated there was no facility policy addressing square footage per room. The Administrator stated there should be 80 square feet per resident. The Administrator indicated there had been no complaints about the room sizes. The Administrator further stated social services asked the residents or their families each quarter if there were any problems with the room size and none had been reported. The Administrator indicated the smaller room size did not inhibit resident care.

Based on interview and record review the facility failed to ensure medically-related social services was provided for one of three sampled residents who lost their dentures (Resident 1). There was no documentation of the dentures being lost, no social services documentation of a discussion with a family member regarding how to proceed to replace the loss and no policy addressing under what circumstance the facility was responsible. This failure placed the resident at risk for weight loss, oral discomfort, and general well-being. Findings: Review of Resident 1's Inventory of Personal Effects form, signed on 1/7/23 indicated the resident had one lower denture. During an interview on 7/31/23 at 3:30 p.m., the director of social services (SSD) recalled Resident 1's lower dentures was lost, and he informed a family member the insurance will not cover the cost of the replacement unless the remainder of the resident ' s lower teeth were extracted. The family member then stated to the SSD she did not want the resident to go through the process and to leave things as it was. The SSD confirmed there was no documentation in the medical record of this conversation. Further review of Resident 1's record, the record did not indicate the resident lost his denture and how to address the lost. During an interview on 8/16/23 at 1:30 p.m., the director of nurses stated there should be but she could not find a denture loss policy. Review of the Social Service Responsibilities, dated November 2016, indicated a duty to make appropriate dental referrals.

Based on interview and record review the facility failed to follow standards of care in obtaining and implementing physician's orders for the treatment and monitoring of skin tears (separation or tear in the skin commonly resulting from bumping or moving) for one of three sampled residents (Resident 1). Resident 1 sustained skin tears and physician's orders for treatment were not obtained and carried out. This failure resulted in the lacked of consistent monitoring of the wound status and had the potential for the skin tears to not optimally heal. Findings: Review of Resident 1's Change in Condition Evaluation, dated 5/3/23 at 4:09 p.m., indicated the resident had a new skin tear to his left elbow and a message was sent to the physician. Review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool that addresses and plans care of a resident's condition) form, dated 5/31/23 at 6 p.m., indicated a staff from an ambulance company reported the resident had sustained a skin tear and a primary care provider recommended treatment. During an interview on 9/12/23 at 5:23 p.m., the director of nurses (DON) who reviewed the record stated there should have been but there were no physician orders obtained for the treatment and monitoring of the above noted skin tears. Review of the Skin Integrity policy, dated August 2014, indicated residents identified to be at risk for skin breakdown was to have a routine assessment implemented to maintain and/or improve skin integrity to actively manage skin integrity issue. Review of the Physician Orders policy, dated August 2017, indicated it was the practice of the facility to process physician orders.

Based on the interview and record review, the facility failed to follow their policy and procedure when a medication administration was not documented for one of three sampled residents (Resident 1). This failure could affect the determination of the quality of care rendered to the resident. Findings: Review of Resident 1's clinical record, dated April 2023, indicated Resident 1 was admitted on [DATE] and had diagnoses including age-related osteoporosis ( a condition in which bones become weak and brittle) without current pathological fracture. During a review of Resident 1's physician order (PO) dated 4/4/23, the PO indicated, Abaloparatide (a medication used in the management and treatment of osteoporosis) Subcutaneous solution pen-injector 3120 MCG/1.56ml inject 80 Microgram (mcg) subcutaneously at bedtime for osteoporosis. During a concurrent interview and record review on 5/24/23 at 1:40 p.m., with Registered Nurse A (RN A), Resident 1's Medication Administration Record (MAR), dated March 2023 was reviewed. The MAR indicated, on 3/26/23, for the 9:00 p.m. administration time, there were no licensed staff initials in the box for Resident 1's Abaloparatide 80 mcg, to demonstrate the medication was administered. RN A stated there was no documentation on the MAR dated 3/26/23 that indicated Resident 1 received the Abaloparatide 80 mcg at 9:00 p.m. The RN A further stated, I administered the Abaloparatide 80mcg at 9:00 p.m. but forgot to document, and I should have documented immediately after administering the medication. During an interview with the Director of Nursing (DON) on 5/24/23 at 2:59 p.m., the DON stated medication that was administered should be documented in a timely manner. During a review of the facility's policy and procedure (P&P) titled LTC Health Information Practice and Documentation Guideline, the P&P indicated the facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible and systematically organized.

Based on interview and record review, the facility failed to follow their policy and procedure when the treatment administration record (TAR) was not documented by the licensed nurse after providing wound treatments for one of one resident (Resident 1). This failure could affect the determination of quality of care rendered to the resident. Findings: Review of Resident 1 ' s clinical record indicated he was readmitted to the facility on [DATE] with diagnoses including left leg atherosclerosis of native arteries of extremities with gangrene (diseases of the circulatory system), peripheral vascular disease (PVD, a slow and progressive circulation disorder) severe sepsis (an infection that caused an organ damage), squamous cell carcinoma of skin (skin cancer that affects the middle and outer layers of the skin). Review of Resident 1 ' s July 2022 TAR indicated the following: Day shift left leg gangrene (dead tissue caused by an infection or lack of blood flow) treatment were not initialed/electronically signed on 7/2, 7/3, 7/4, 7/9 to 7/11, 7/13, 7/14, 7/16, 7/17, 7/19, 7/21, and 7/23. Day shift right first toe, left foot; left heel and left lateral treatment were not initialed/electronically signed on 7/2; 7/3; 7/4; 7/9 to 7/11; 7/13; 7/14; 7/16; 7/17; 7/19; 7/21; and 7/23. Day shift sacrum buttocks were not initialed/electronically signed on 7/4, 7/11, and 7/13. During a telephone interview with the treatment nurse (TN) on 12/6/22 at 10:37 a.m., the TN reviewed the TAR and confirmed the above record review. The TN further stated he might have missed signing the TAR. During a telephone interview with licensed vocational nurse A (LVN A) on 12/13/22 at 1:09 p.m., LVN A reviewed Resident 1 ' s July 2022 TAR and confirmed the above record review. LVN A further stated, we probably forgot to sign the TAR. During another telephone interview with LVN A on 12/13/22 at 3:25 p.m., LVN A stated, the TAR should have been signed after treatments were provided to Resident 1 to make sure the treatments were done. During an interview with the director of nursing (DON) on 12/16/22 at 10:10 a.m., the DON stated nurses should have documented when a treatment was provided to Resident 1. At 10:39 a.m., the DON confirmed there were no late entries in the TAR progress notes regarding Resident 1 ' s treatments. Review of the facility ' s policy, LTC Health Information Practice and Documentation Guidelines dated August 2001 indicated, .a treatment that can be delivered any time during a shift, could have a block of time identified on the treatment record with staff signing that they delivered the treatment during that shift.

Based on observation, interview, and record review, the facility failed to implement their written abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) policy for one of 24 sampled residents (Resident 14) when certified nursing assistant A (CNA A) continued to provide direct care for activities of daily living (ADLs, such as bed mobility, transfer, dressing, toileting, bathing, personal hygiene, locomotion on unit, and locomotion off unit), had interactions with Resident 14 during weights monitoring and assistance with social dining after an abuse incident investigation when Resident 14 alleged CNA A committed verbal abuse. These failures resulted in Resident 14's emotional distress and social isolation. Findings: Review of Resident 14's undated face sheet indicated she was admitted on [DATE], with diagnoses of diabetes (increase in blood sugar), hemiplegia (paralysis of one side of the body), muscle weakness, and hypertension (increase blood pressure). Review of Resident 14's minimum data set (MDS, an assessment tool) dated 3/23/21, indicated she had a brief interview for mental status (BIMS, cognitive status) score of 15 (a score of 15 means cognitively intact), required staff assistance for bed mobility, transfer, dressing, eating, toilet, bathing, locomotion on unit, locomotion off unit, and personal hygiene. Review of Resident 14's situation, background, assessment, recommendation (SBAR, a way for health care professionals to communicate effectively with one another, and allows for important information to be transferred accurately) dated 12/3/2020, indicated Resident 14 had an allegation of verbal abuse against CNA A, which occurred approximately 11/19/2020 at 11:00 a.m. CNA A called her gordita (Spanish word for fat person per the resident) and Resident 14 identified this incident as a stressor due to her inability to sleep. The goal was to make sure the resident would be safe and free from harm. Review of Resident 14's undated abuse incident investigation related to verbal abuse, Resident 14 was not able to provide the exact date but mentioned the incident occurred around 11/27/2020. Resident 14 did not want CNA A to come back to her room and she did not want to interact with CNA A. CNA A and her supervisor were made aware that she cannot provide any direct care to Resident 14 or her roommate. Facility staff ensured Resident 14's preferences continued and were accommodated. During an observation and interview with Resident 14 on 6/7/21 at 9:20 a.m., Resident 14 was lying in bed and tearful. Resident 14 stated CNA A told her she was so big and the incident happened in 2020. Resident 14 stated CNA A should not come to her room and CNA A was assigned to provide direct care to her. Resident 14 stated CNA A comes to her room and she did not want to see her. Resident 14 stated she felt terrified and scared when she saw CNA A in her room and Resident 14 cried. Resident 14 stated she just wants to stay in her room. Review of the CNAs' assignment sheet indicated on 6/4/21 and 6/5/21, CNA A was assigned to provide direct care to Resident 14. During an interview with CNA A on 6/11/21 at 7:57 a.m., CNA A stated she was assigned to work all stations as both a CNA and RNA (Restorative Nursing Aide). CNA A confirmed she was assigned to provide direct care to Resident 14 on 6/4/21, 6/5/21, and sometimes she was assigned to weigh Resident 14. CNA A also stated she served Resident 14's food on 6/6/21 in the social dining area. CNA A also added Resident 14 requested to go back to her room after being served her food. During an interview with the social service assistant (SSA) on 6/11/21 at 10:25 a.m., she stated Resident 14 was alert, oriented, cooperative, and could make decisions. The SSA confirmed she was aware of the verbal abuse incident reported on 12/3/2020 regarding Resident 14 and CNA A. SSA stated CNA A should not be assigned to Resident 14 and should have no interactions with Resident 14 to prevent emotional distress to the resident. The SSA also stated the nursing staff should have monitored and checked CNA A was no longer assigned to Resident 14. The SSA stated Resident 14 could have emotional distress and psychological distress when CNA A was assigned to her. During an interview with the director of staff development (DSD) on 6/11/21 at 1:40 p.m., she confirmed CNA A was assigned to weigh Resident 14 and sometimes assigned in social dining to assist Resident 14. The DSD stated Resident 14's preference related to not wanting CNA A to provide direct care to her should have been monitored, and discussed during the interdisciplinary meeting (IDT, improve communication technique). The DSD also stated Resident 14 was on the social dining area on 6/6/21 with CNA A, and Resident 14 wanted to return to her room because she did not want to interact with CNA A. During an interview with registered nurse C (RN C) on 6/11/21 at 2:17 p.m., she stated she was the assigned charge nurse for 6/4/21 and assigned CNA A to provide direct care for Resident 14. RN C confirmed she did not know not to assign CNA A to provide direct care to Resident 14. During an interview with the director of nursing (DON) on 6/11/21at 3:34 p.m., the DON stated CNA A should not have been assigned or interacted with Resident 14 on 6/4/21, and 6/5/21. The DON stated Resident 14's preference related to not wanting CNA A to provide direct care to her should have been monitored and implemented to prevent future abuse. DON confirmed there was no facility staff who monitored and checked the CNA A's schedule. Review of the facility's 2016 policy, Abuse Prevention, Interventions, Investigation & Crime reporting policy, indicated the facility is responsible for assuring resident safety by prohibiting verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.

Based on interview and record review, the facility failed to ensure one of two residents (Resident 1) was free from significant medication errors when a student nurse, without the supervision of the instructor, administered Resident 2's ten (10) medications to Resident 1. This failure resulted in Resident 1 experiencing lethargy (deep unresponsiveness), dizziness, and [MEDICAL CONDITION] (low blood pressure), had to be admitted to an acute care hospital with transfer to the intensive care unit (ICU), and a stay in the hospital for seven (7) days for [MEDICAL CONDITION] due to the accidental administration of three medications that used to treat high blood pressure: [MEDICATION NAME], and [MEDICATION NAME] while she had low blood pressure diagnosis. Findings: Review of Resident 1's Admission Record indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. blood as well as it should), end stage [MEDICAL CONDITION] (the kidneys are no longer able to work as they should to meet the body's needs), and dependence on [MEDICAL TREATMENT] (the blood is put through a filter outside the body, cleaned, and then returned to the body). Review of the facility's Medication Regimen Report of Incident, dated 9/17/19, indicated on 9/17/19 at 8:50 a.m., a student nurse did not check the name outside of Resident 1's room, did not identify Resident 1, and administered to Resident 1 medications that did not belong to Resident 1. Review of the student nurse's Incident Report Summary indicated on 9/17/19 at around 8:30 a.m. to 9 a.m. after dispensing medications for Resident 2 along with two other classmates and her instructor, the student nurse went ahead to Resident 1's room and gave Resident 1 the medications for Resident 2. Resident 1 took all the medications that the student nurse gave her except the nose sprays. Resident 1 refused the nose sprays. Review of the instructor's Written Statement indicated on 9/17/19 at around 8:30 a.m. after preparing all medications for Resident 2, which were at least three blood pressure medications, the student nurse left to go to the resident room to administer the medications without her instructor's supervision. About 10 minutes later, the student nurse told her that she accidentally gave the medications for Resident 2 to Resident 1. During an interview with the director of nursing (DON) on 10/26/2020 at 1:20 p.m., she stated the student nurse administered 10 wrong medications to Resident 1, and the 10 medications belonged to Resident 2. Review of the facility's Medication Error report and Resident 2's 9/2019 Medication Administration Record [REDACTED]. Resident 1 was given Resident 2's 10 medications including three medications for high blood pressure. Resident 1 had low blood pressure [DIAGNOSES REDACTED]. Review of Resident 1's Progress Notes, dated 9/17/19 at 1:56 p.m., indicated Resident 1's blood pressure was 99/58 at 10 a.m., 82/52 at 11 a.m., 99/66 at 11:30 a.m., 83/45 at 11:45 a.m., and around 12 p.m. Resident 1's blood pressure dropped to 77/41. Review of Resident 1's Change of Condition (COC) 911 Transfer, dated 9/17/19, indicated she was sent to the hospital via 911 for low blood pressure, dizziness, and right abdominal quadrant pain. During an interview with Resident 1 on 10/26/2020 at 12:40 p.m., she stated last year a student nurse gave her eight or nine wrong medications and it made her dizzy, and she had nausea, and she had to stay in the hospital for more than five (5) days. Review of the first hospital's Emergency Department (ED) Provider Notes, dated 9/17/19, indicated Resident 1 presented with [MEDICAL CONDITION]. Her systolic blood pressure (SBP, indicates how much pressure the blood is exerting against the artery wall when the heart beats) was in the 80s. Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: Shock. Resident 1 was given intravenous fluid (IVF, liquids are given straight into a vein through a drip) and started on Dopamin (blood pressure support, it can treat symptoms of shock by improving blood flow) and [MEDICATION NAME] (used to treat life-threatening low blood pressure). Review of the first hospital's Discharge Summary, dated 9/18/19, indicated Resident 1 was transferred to the second hospital's ICU with critical condition. Review of the second hospital's ICU Admission History and Physical, dated 9/19/19, indicated Resident 1 presented with low blood pressure and lethargy. Review of the second hospital's Discharge Summary, dated 9/25/19, indicated the principal [DIAGNOSES REDACTED]. Review of the agreement between the facility known as Clinical Site and the nursing school, Clinical Educational Agreement, effective as of 3/1/17, indicated Clinical Site shall retain ultimate responsibility for patient care and services.