Every finding on record at Villa Mesa Care Center

Based on observation, interview, and record review, the facility failed to ensure care and monitoring were maintained for two of two sampled residents (Resident 23 and 4) reviewed for pressure ulcers (injury to skin and underlying tissues that develop because of prolonged pressure, shear (skin tissues slide in opposite directions when sticks to a surface), or friction) when: 1. For Resident 23, there was no documented evidence of wound treatments for Left Iliac Crest (thick, curved bony ridge at the very top of the hip bone), PI (Pressure Injury), change in condition, physician orders for January 7, 2026 through January 16, 2026, IDT meeting (Interdisciplinary Team meeting - a meeting where different professionals come together to discuss a patient's care) and care plan, to address Resident 23's unstageable (when the base of the wound is covered by a layer of dead tissue and it is not possible to determine the stage (classifying wounds)) PI prior to January 21, 2026.2. Resident 4's moisture associated skin damage (MASD- a condition caused by repeated exposure to bodily secretions such as urine resulting in skin breakdown) had no documented evidence of assessments, monitoring, treatments, and interventions.These failures resulted in Resident 23's worsening pressure injury being undetected and Resident 4 MASD left unaddressed, placing both residents at higher risk for infection, development of new pressure ulcers, and delayed wound healing. 1.During a record review of Resident 23's admission Record (contains demographic and medical information), it indicated, Resident 23 was admitted to the facility on [DATE], with diagnoses which included, Parkinson's disease with dyskinesia (a progressive disorder that affects the nervous system, causing involuntary, jerky, or writhing movements) dysphagia (difficulty swallowing), dementia (a condition characterized by the decline mental ability, affecting memory, thinking and language interfering with daily life), heart failure (a condition in which the heart muscle is too weak or stiff to effectively pump enough oxygen). During an observation and interview on January 20, 2026, at 4:00 PM, in Resident 23's room, with Treatment Nurse 1 and 2 (TX 1 and TX 2), Resident 23 was lying on bed with the eyes open. TX 1 and TX 2 positioned Resident 23 to his right side. There was a brown dressing covering his left iliac crest area (top, outer edge of the left hip bone), undated. TX 1 stated, we don't date the dressing when we do treatments, and proceeded to remove the dressing from Resident 23's left iliac crest area. An open wound with black colored edges appeared dry with yellow color slough (a yellowish, soft, stringy, or creamy dead tissue found in wounds) in the center of the wound, was noted. TX 1 stated, Resident 23's wound was unstageable with yellow slough in the center and eschar (a thick, dry, black or brown layer of dead tissue that forms over deep wounds or pressure ulcers). TX 1 and TX 2 stated they were not sure when the last wound treatment was rendered. TX 1 further stated Resident 23's wound treatment was not done today (January 20, 2026). During a record review of facility provided document for Resident 23's titled, physician's orders, a verbal order dated December 31, 2025, it indicated (Treatment) Left Iliac Crest, PI (Pressure Injury). Cleanse with NS (normal saline - a solution of water with dissolved salts) pat dry apply [name of brand] oint (ointment) and cover w/DD (dry dressing). As needed, may change dressing if soiled /dislodged, every day shift for wound care 14 days. During a record review of Resident 23's physician's orders, dated January 16, 2026, it indicated (Treatment) Left Iliac Crest, PI. Cleanse with NSS (normal saline solution) pat dry apply small amount of skin barrier (cream to protect the skin) cover with DD X (times) 21 days every day shift for wound management, for 21 days. During a record review of Resident 23's Skin Observation Tool-V2, the following skin assessments were reviewed: December 31, 2025, indicated, 2. Notes. L (left) ILIAC CREST PRESUURE INJURY: DTI (Deep Tissue Injury - soft tissues under intact or broken skin are damaged often appearing as a maroon or purple discoloration) DARK DEEP DISCOLORATION, SKIN INTACT. Signed by TX 2 on December 31, 2025. January 7, 2026, indicated, 2. Notes: .L ILIAC CREST PRESSURE INJURY: DTI Deep Tissue Injury - the area often appears as purple or maroon localized, intact skin, or a blood-filled blister) DARK DEEP DISCLORATION, SKIN INTACT. Signed by TX 2 on January 20, 2026. January 13, 2026, indicated, 2. Notes: .L ILIAC CREST PRESSURE INJURY: DTI DARK DEEP DISCLORATION, SKIN INTACT. The document was not signed by staff. January 20, 2026, indicated, 2. Notes: .L ILIAC CREST PRESSURE INJURY: UNSTAGEABLE. 90% S (slough), 10% G (granulation – healthy tissue), MILD SEROUS EXUDATE (a thin, clear to pale yellow, watery fluid that leaks from wounds), PERIWOUND (the skin and tissue immediately surrounding a wound) W/DRY EXUDATE. PERIWOUND W/MILD ERYTHEMA (skin redness). admitted WOUND DTI NOW UNSTAGEABLE DUE TO SLOUGH PRESENT TO WOUND BED (base of the wound). TX (treatment): [name of brand] + DD (dry dressing) DAILY. SIGNED 01/20/2026 (January 20, 2026). During a record review of Resident 23's Braden scale assessment (tool used to predict the risk for developing pressure ulcers, categorized as: score of 19–23 (No risk), 15–18 (Mild risk), 13–14 (Moderate risk), 10–12 (High risk), and less than 9 (Severe risk)), dated December 31, 2025, it indicated, Resident 23 was at high risk for pressure sore development due to constant moisture, chairfast, immobility and poor nutrition, with a BRADEN score of 9 (severe risk). During a concurrent interview and record review on January 20, 2026, at 4:28 PM, with interim Director of Nursing (DON) and TX 2. DON and TX 2 reviewed Resident 23's Treatment Administration Record (TAR - a legal document used to document the specific treatments and medications administered to a resident), for the month of January 2026. The TAR indicated, a treatment order for January, (Treatment) Left Iliac Crest, PI (Pressure Injury). Cleanse with NS (normal saline) pat dry apply [name of brand] oint (ointment) and cover w/DD (dry dressing) every day shift for wound care for 14 days. Start date 01/01/2026 (January 1, 2026) D/C (discontinue) date 01/06/2026 (January 6, 2026). The treatment order was initiated again on January 17, 2026. The DON stated there was no treatment order for January 7 through January 16, 2026, he was not sure why. DON further stated, he was not sure why Resident 23's TAR had missing initials that indicated wound treatment was done, on January 7, 2026, through January 16, 2026. DON stated, he will find out. TX 2 stated, treatment for Left Iliac Crest, PI was done on January 17, 18, and 19. TX2 stated, she (TX2) did the treatment on January 17, 2026, but did not write wound description. TX 2 further stated she does not document description of the wound every time she renders residents' treatments and only checks the box indicating she did the treatment, with her initials. The DON further stated, we only do skin assessment and wound description document weekly, and after each wound treatment, the treatment nurse only write the initials to show treatment was done for that date. During a concurrent interview and record review on January 21, 2026, at 11:40 AM, with Assistant Director of Nursing (ADON) and TX 1. ADON and TX1 reviewed Resident 23's TAR for the month of January 2026. The TAR indicated, (Treatment) Left Iliac Crest, PI (Pressure Injury). Cleanse with NS (normal saline) pat dry apply [name of brand] oint (ointment) and cover w/DD (dry dressing) every day shift for wound care for 14 days. Start date 01/01/2026 (January 1, 2026) D/C (discontinued) date 01/06/2026 (January 6, 2026). The ADON stated the order started on January 17, 2026. TX1 stated she did not know why there was no treatment rendered from January 7, 2026, to January16, 2026. In addition, ADON and TX 1 could not provide documented evidence that Resident 23's care plan, change of condition and IDT notes that address unstageable left Iliac Crest wound, was initiated before January 20, 2026. TX 1 acknowledged there was no care plan, change of condition documented, and IDT to address Resident 23's Left iliac Crest unstageable wound. During a concurrent interview and record review on January 21, 2026, at 11:45 AM, with ADON and TX 1, the ADON and TX 1 reviewed the facility's policy and procedures (P&P) titled, Wound Care/Skin Management, revised October 2010, the P&P indicated . Steps in the procedure.13. Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initials, time, and date and apply to dressing. Documentation. The following information should be recorded in the resident's medical record. 6. All assessment data (i.e., wound bed color, size, drainage, description of skin impairment, etc.) obtained when inspecting the wound/skin. TX 1 stated, she (TX 1) does not write the description of wounds during daily treatment, only weekly, and documented on the Skin Observation Tool-V2. TX 1 further stated, We don't date the dressing on the wound. The ADON stated, if the policy stated, the wound dressing should be dated. ADON further stated, I thought we only have to do skin assessment once a week. ADON acknowledged the policy. During a concurrent interview and record review on January 23, 2026, at 9:38 AM, with the Administrator (ADMIN) and DON, the ADMIN and DON reviewed the facility policy and procedures (P&P) titled, Wound Care/Skin Management, revised October 2010. The P&P indicated, . Steps in the procedure.13. Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initials, time, and date and apply to dressing. Documentation. The following information should be recorded in the resident's medical record. 6. All assessment data (i.e., wound bed color, size, drainage, description of skin impairment, etc.) obtained when inspecting the wound/skin. The DON acknowledged the policy and stated it had not been followed. ADMIN stated staff should be following the facility policy. The DON acknowledged there were no documented treatments for January 7, 2026, through January 16, 2026, and there was no change in Resident 23's condition, IDT meeting notes and care plan documentation before January 20, 2026. The DON further stated that treatment nurses are responsible for renewing treatment orders and informed the physician about residents' wounds change in condition. 2. During a review of Resident's 4 admission Records (contains demographic and medical information) it indicated, Resident 4 was admitted to the facility on [DATE], with diagnoses which included pressure ulcer of sacral region (at the bottom of the spine), stage 4 (a wound involving full-thickness tissue loss where skin, fat, and deeper tissues are gone, exposing underlying muscle, tendon, or bone), sepsis (a life threatening medical emergency caused by the body's extreme response to an infection), and neuromuscular dysfunction of bladder (a dysfunction of the bladder muscle resulting in an inability to properly store or empty urine). During a review of Resident's 4's clinical records, the Physician Note (contains history and physical information), dated September 24, 2025, it indicated Resident 4 does not have capacity to make and understand medical decisions. During a review of Resident's 4 Braden scale for predicting pressure sore risk (a tool used to assess a patient's risk of developing pressure injuries (bedsores)), dated August 28, 2025, it indicated Resident 4 was at a high risk for developing pressure sore with a score of 11 out of 18 (range for high risk is 10-12). During a concurrent observation and interview on January 22, 2026, at 9:54 AM, with the wound treatment nurse (TX 1) and a Certified Nursing Assistant (CNA 2), Resident 4 was lying in bed. The TX 1 and CNA 2 turned Resident 4 to his left side. Resident 4 had a wound vacuum (tool used to suction drainage from a wound) attached to his sacral region (tailbone). On the left buttock was a foam dressing, the TX 1 removed the dressing and revealed a pink tinged skin wound with dark bruising around the edges. The TX 1 stated it was an MASD and there were wound care orders in place. During a review of Resident 4's clinical records, the document titled Section M-Skin Conditions (resident assessment instrument that gathers information regarding a resident's skin integrity), dated November 28, 2025, the section M-skin conditions indicated . M1040: Other ulcers, Wounds, and Skin Problems. H. Moisture Associated Skin Damage (MASD) (e.g., incontinence-associated dermatitis - (IAD - skin damage, caused by prolonged exposure to urine, feces, or both), perspiration, drainage) was checked. During a review of Resident 4's clinical records, the document Section GG-Functional Abilities- OBRA (Omnibus Budget Reconciliation Act of 1987 - It requires to conduct comprehensive assessments for all residents to ensure quality of care, focusing on resident safety, rights, and proper placement)/Interim, dated November 28, 2025, section GG-functional abilities indicated Resident 4 is dependent on toileting hygiene and transfers. During a review of Resident 4's Skin Observation Tool-V2 dated December 31, 2025, there was no documentation of Resident 4's MASD on the left buttock. During a review of Resident 4's Skin Observation Tool-V2 dated January 07, 2026, there was no documentation of Resident 4's MASD on the left buttock. During a review of Resident 4's Skin Observation Tool-V2 dated January 12, 2026, there was no documentation of Resident 4's MASD on the left buttock. During a review of Resident 4's Skin Observation Tool-V2 dated January 13, 2026, there was no documentation of Resident 4's MASD on the left buttock. During a concurrent interview and record review on January 23, 2026, at 9:20 AM, with the Assistant Director of Nursing (ADON), Resident 4's Change in Condition- SBAR Communication Form - Situation, Background, Assessment, Recommendation, a structured communication tool used in healthcare to quickly and clearly convey critical patient information), dated January 22, 2026, was reviewed. The SBAR communication form addressing the MASD was started on January 22, 2026. ADON acknowledged the SBAR communication form addressing MASD on Patient 4's left buttock was not initiated prior to January 22, 2026. During a concurrent interview and record review on January 23, 2026, at 9:22 AM, with the ADON, Resident 4's Treatment Administration Record (TAR- document used to record treatments administered to the residents) for the month of December 2025, and January 2026, was reviewed. The TAR indicated a treatment order for left lower buttock MASD: Cleanse w/NS (normal saline-solution used to clean wound), pat dry, apply ointment and cover w/dd (dry dressing), every day shift for wound management for 14 days. The order started on January 22, 2026. The ADON stated there was no treatment order prior to January 22, 2026. During a review of Resident 4's Care Plan dated January 22, 2026, there was no focus, goals, and interventions for Resident 4's MASD. During a review of Resident 4's Order Summary Report, dated January 22, 2026, indicated there was no treatment order for Resident 4's MASD on the left buttock. During a follow-up interview on January 23, 2026, at 11:49 AM, with TX 1, TX 1 stated there was no treatment order addressing Resident 4's MASD on the left buttock, prior to January 22, 2026. TX 1 further stated a change of condition and care plan was created on January 22, 2026. During a concurrent interview and record review on January 23, 2026, at 4:17 PM, with the ADON, the facility's policy and procedure (P&P) titled, Wound Care/Skin Management, revised October 2010, was reviewed. The P&P indicated, .Preparation. 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the patient. The ADON stated the P&P was not followed. During a concurrent interview and record review on January 23, 2026, at 4:19 PM with the ADON, the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, revised February 2021, was reviewed. The P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. 2. A significant change of condition is a major decline or improvement in the resident's status. 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 6. Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments. The ADON stated the P&P was not followed. During a concurrent interview and record review on January 23, 2026, at 4:21 PM with the ADON, the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised March 2022 was reviewed. The P&P indicated, .Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. The ADON stated the P&P was not followed.

Based on observation, interview, and record review, the facility failed to ensure accurate records of controlled medications (narcotic medications that are controlled by the government because it may be abused or cause addiction) were maintained in accordance with their own policy and procedure for one of three Medication Carts (Medication Cart B).This failure had the potential to result in inaccurate count of narcotic drugs and drug diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by the staff in a highly vulnerable population of 93 residents.During a concurrent observation, interview, and record review, on January 1, 2026, at 7:30 AM with a Licensed Vocational Nurse (LVN 3), at Medication Cart B, Medication Cart B's 8-hour Controlled Drugs-Count Record (8 HR CDCR- mandatory, real-time log tracking high-risk medication inventory [Schedules II-V] to prevent theft or misuse), dated January 1, 2026, through January 22, 2026, was reviewed. LVN 3 stated two licensed nurses verify the log during shift change. The 8 HR CDCR indicated there were missing signatures for the following dates:On January 1, 2026, morning shift (7:00 AM -3:00 PM) oncoming nurse.On January 1, 2026, evening shift (3:00 PM to 11:00 PM) off going nurse.On January 3, 2026, evening shift (3:00 to 11:00 PM) oncoming nurse.On January 3, 2026, night shift (11:00 PM to 7:00 AM) off going nurse.On January 4, 2026, morning shift (7:00 AM-3:00 PM) oncoming nurse.On January 4, 2026, evening shift (3:00 PM to 11:00 PM) off going nurse and oncoming nurse.On January 4, 2026, night shift (11:00 PM to 7:00 AM) off going nurse.On January 5, 2026, morning shift (7:00 AM-3:00 PM) oncoming nurse.On January 6, 2026, morning shift (7:00 AM-3:00 PM) oncoming nurse.On January 6, 2026, evening shift (3:00 PM to 11:00 PM) off going nurse.On January 8, 2026, evening shift (3:00 PM to 11:00 PM) oncoming nurse.On January 8, 2026, night shift (11:00 PM to 7:00 AM) off going nurse.On January 11, 2026, evening shift (3:00 PM to 11:00 PM) oncoming nurse.On January 11, 2026, night shift (11:00 PM to 7:00 AM) off going nurse.On January 17, 2026, evening shift (3:00 PM to 11:00 PM) oncoming nurse.On January 17, 2026, nightshift (11:00 PM to 7:00 AM) off going nurse.LVN 3 confirmed the 17 missing signatures in the 8 HR CDCR. LVN 3 stated it was important to do a shift narcotic count so there are no discrepancies.During a concurrent interview and record review on January 23, 2026, at 10:46 AM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Controlled Medication Storage, dated April 2019 was reviewed. The P & P indicated, .At each shift change, a physical inventory of all controlled medications shall be conducted by two licensed nurses and is documented on the controlled substances accountability record. The DON stated the facility did not follow the policy. The DON further stated it was important to do shift to shift narcotic count, to ensure count is accurate, and making each staff accountable for their carts.

Based on observation, interview, and record review, the facility failed to ensure its intravenous (IV) therapy (a method of giving fluids or medications directly into a vein through a small tube) policy and procedures was followed for one of eight sampled residents (Resident 61) when Resident 61's IV dressing (the bandage place over the IV site to protect it) on the right arm was not labeled to indicate the date when it was changed.This failure prevents staff from properly monitoring the IV site, increasing the risk of infection and infiltration (where fluid leaks into the surrounding tissue causing pain or damage).During a review of Resident 61's admission Record (clinical record with demographic information), the admission Record indicated, Resident 61 was admitted to the facility on [DATE], with diagnoses which included, dysphagia (difficulty swallowing) and dementia (impaired memory, judgment, and ability to understand or communicate needs).During an observation on January 20, 2026, at 11:21 AM, in Resident 61's room, Resident 61 was observed lying on her back with head of the bed slightly elevated. Resident 61 was awake, on the right side of the resident's bed. There was an IV bag of 0.9% Normal Saline ( a solution used for intravenous hydration) infusing at a rate of 60 mL (mL- unit of fluid measurement) per hour, Resident 61 had a peripheral (a short, flexible, small-gauge tube inserted through the skin into a peripheral vein) IV catheter (a short, flexible plastic tube placed into a small vein in the arm, hand, or foot to deliver fluids, medications, blood, or nutrition) inserted in the right arm. The IV insertion site was unlabeled. There were no staff initials and date and time of insertion to indicate or when the dressing was applied. During a concurrent observation and interview on January 20, 2026, at 11:31 AM, with the Director of Nurses, DON, inside Resident 61's room, the DON confirmed the IV site dressing should be labeled with the date, time and initials so staff can identify when the IV was inserted and when the dressing was changed. During an interview on January 20, 2026, at 11:36 AM, with Registered Nurse (RN 1), RN 1 stated the IV dressing was not labeled and IV with dressing should include the date it was applied, time, and staff initials for infection control purposes, and to allow staff to track when the IV and dressing need to be changed. During a review of Resident 61' Physician Orders dated January 19, 2026 at 7:00 AM indicated, Sodium Chloride Intravenous Solution 0.9% (Sodium Chloride) use 60 mg/ml Intravenously every shift for dehydration start date January 19, 2026 at 07:00 AM.During a concurrent interview and record review on January 21, 2026, at 5:12 PM, with the ADON, the facility's policy and procedure (P&P) titled Peripheral and Midline IV Dressing Changes, revised March 2022, was reviewed. The P&P indicated, General Guidelines. 4. Change the dressing if it becomes damp, loosened or visible soiled and: . a. at least every 7 days for TSM (Transparent semi-permeable membrane - a thin, clear, adhesive film that allows oxygen and water vapor to pass through while blocking bacteria and liquids) dressing. Steps in the Procedure. 9. Place new dressing (TSM or gauze) over insertion site. Label dressing with the date and time of dressing change, and initials. The ADON stated the policy was not followed.

Based on observation, interview, and record review, the facility failed to ensure nutritional status was monitored for one of eight sampled residents (Resident 47) reviewed for weight loss, when Resident 47's weight loss was not addressed from November 6, 2025, through January 19, 2026.This failure had the potential to result in delayed treatment, increased risk for unmet nutritional needs, further weight loss, decline in function status, and compromised overall health and well-being.During a review of Resident 47's admission Record (clinical record with demographic information), the admission Record indicated Resident 47 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction with right - sided hemiplegia (a stroke that caused weakness on the right side of the body), epilepsy (convulsions) and metabolic encephalopathy (a condition affecting brain function that causes confusion, impaired thinking, and reduced ability to safety care for oneself).During a review of Resident 47's MDS (Minimum Data Set - a standardized assessment tool that measures health status in nursing homes) Section C (Cognitive (involving conscious intellectual activity) Patters, Dated, December 22, 2025, the MDS Section C indicated, Resident 47 had a BIMS (Brief Interview for Mental Status a tool used to screen how a resident is functioning cognitively) Score of 8 (a BMIS score of 8-12: moderately impaired).During a review of Resident 47's MDS Section GG - Functional Abilities, dated December 22, 2025, the MDS Section GG indicated, (GG130A - Eating) was coded as 05 - Set up or clean up assistance, indicating the resident required staff assistance to prepare and set up meals prior to eating.During an observation on January 21, 2026, at 12:35 PM, during lunch time, in Resident 47's room, with Certified Nurse Assistant (CNA 4), Resident 47 was lying in bed with the head of the bed elevated, awake. The lunch tray meal ticket indicated the following: Diet: fortified (meals enhanced with added calories and protein to support nutrition.), consistency: PU4 (Pureed foods with a smooth, uniform texture requiring no chewing), beverages: MT2 (mild thick) (Slightly thickened liquid to reduce aspiration risk), Nectar (nectar-thick liquid with pourable consistency) , 4 oz (oz - unit of measurement), whole milk, 4 oz (regular milk), water 4 oz (plain drinking water), HPN 4 oz (high-protein nutritional supplement). Resident 47 was fed by CNA 4, who was sitting within one arm's reach, and assisting the resident during the meal. During an interview on January 21, 2026, at 12:39 PM, with Certified Nursing Assistant (CNA 5), CNA 5 entered Resident 47's room and stated she was familiar with the resident and reported that residents require assistance with meals. The CNA 5 stated that Resident 47's weight are taken weekly by the Restorative Nursing Assistant (RNA - staff trained to assist with restorative care and monitoring), and that any identified weight loss is reported to the charge nurse.During a concurrent interview and record review on January 21, 2026, at 12:45 PM, with License Vocational Nurse (LVN 1), the LVN 1 reviewed Resident 47's meal percentage, in the clinical records from January 1, 2026, through January 20, 2026. The LVN 1 confirmed that the resident oral intake ranges from 50-100%. The LVN 1 stated the resident is able to feed himself with set- up assistance and that at times requires assistance.During a review of Resident 47 physician orders, dated January 14, 2026, it indicated WEEKLY WEIGHTS X (times) 4.During a concurrent interview and record review on January 21, 2026, at 12:48 PM, with LVN 1, the Resident 47's Vital Weights, dated November 6, 2025, through January 19, 2026, were reviewed. The LVN 1 confirmed that there were no weights recorded on from November 11, 2025, through January 4, 2026. LVN 1 stated that weights are obtained weekly for new admissions and for residents with identified weight loss, according to physicians' orders. LVN 1 further stated significant weight loss is considered a change in condition, which requires notification of the physician and responsible party, and may result in further monitoring or interventions based on physician orders. LVN 1 confined that the lack of documented weights during this period was an oversight. During a concurrent interview and record review on January 21, 2025, at 12:51 PM, the Change of Condition from November 1, 2025 - January 21, 2026, was reviewed. The LVN 1, confirmed that two change of conditions were recorded in the system: one dated November 24, 2025 related to skin tear and the second change of condition dated January 8, 2026 related to skin discoloration. LVN 1 confirmed that no change of condition related to Resident 47's weight loss was documented in the system.During an interview on January 21, 2026, at 4:38 PM, the Registered Dietitian (RD), the RD acknowledged that review of Resident 47's weight history showed an approximately 11 pounds weight loss from November 2025, through December 2025, at the time the RD completed the December 15, 2025, assessment. The RD further acknowledged she was not aware of the weight loss at the time of her assessment.During a review of Resident 47's Vital Weight dated January 21, 2026, at 4:44 PM, the following was indicated: November 6, 2025: 147 Lbs (pounds), (wheelchair)December 1, 2025: 138 Lbs (mechanical lift); (weight was entered on January 21, 2026, and the entry data was confirmed with the DON)December 8, 2025 - January 4, 2026 (No weights were recorded during this periodJanuary 5, 2026: 133 Lbs (Mechanical lift) (used to safely obtain in resident's weight when unable to stand)January 12, 2026: 135 Lbs. (mechanical lift)January 19, 2026: 136 Lbs. (mechanical lift)During an interview on January 22, 2026, at 11:32 AM, with the Restorative Nursing Assistant (RNA 1), the RNA 1 stated weights are documented on paper logs and submitted to the Director of Staff development. The RNA 1 further stated residents with weight loss may be provided nourishments, fortified shakes, assisted dining and one to one feeding assistance, and are monitor weekly.During a concurrent interview and record review on January 22, 2026, at 11:38 AM, with the Director of Staff Development, DSD the Resident 47's January Monthly Weights, dated January 1, 2026, and the Weekly Weights dated January 21, 2026, was reviewed. The monthly weighs for Resident 47's indicated,November 2025: 147 Lbs.December 2025: 138 Lbs.During the concurrent interview and record review on January 22, 2026 at 11:42 AM with the DSD confirmed that December monthly weights dated December 1, 2025 was not recorded in the electronic system at the time, that the weight was obtained and recorded on January 21, 2026. The weekly weights dated January 21, 2026, the Resident 47's weights indicated the following:January 19, 2026: 136 Lbs.January 12, 2026: 135 LbsJanuary 5, 2026 : No weight recorded.December 29, 2025: No weight recorded.December 22, 2025: No weight recorded.December 15, 2025: No weight recorded.December 8, 2025 : No weight recorded.The DSD acknowledged Resident 47's weight loss of approximately 11 pounds from November 2025 through January 2026.During a concurrent interview and record review on January 23, 2026, at 10:09 AM, with the Assistant Director for Nursing (ADON), the facility's policy and procedure (P&P) titled Nutrition (Impaired) /Unplanned Weight Loss - Clinical Protocol, Revised September 2017, was reviewed. The P&P indicated, Assessment and Recognition. 1. The nursing staff will monitor and document the weight and dietary intake of the resident in a format with permits comparisons over time. Cause identification. 2. For individuals with recent or rapid wight gain or loss (for example, more than a pound a day), the staff will review for possible fluid and electrolyte imbalance as a cause. The ADON stated that when a significant weight loss is identified, the expected process includes initiating an SBAR (Situation, Background, Assessment, Recommendation - used primarily in healthcare to quickly and effectively convey critical patient information), notifying the physician and family, placing the resident on weekly weights, completing 72 - hours monitoring, and revising the care plan. ADON further stated no weights were documented in the electronic system for the month of December until January 21, 2026, the SBAR dated January 8, 2026, was not completed until January 21, 2026, no 72 -hour monitoring documentation was completed following SBAR initiation, and the resident's care plan did not address the documented 11 - pound weight loss. The ADON acknowledged that staff did not follow the facility's Nutrition (Impaired) / Unplanned Weight Loss - Clinical Protocol.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan (a summary of a resident's health conditions, specific care needs, and current treatments) addressing identified medical needs for two of two sampled residents (Residents 11 and 14), when:1. Resident 11's care plan for intravenous (IV) therapy (a method of giving fluids or medications directly into a vein), initiated on January 12, 2026, did not address monitoring, nursing interventions, or measurable goals.2. Resident 14, admitted on hospice services (specialized care that provides physical comfort and emotional, social and spiritual support for people nearing the end of life) since June 10, 2025, did not have a comprehensive care plan addressing hospice service, including goals of care, palliative interventions, or coordination of services.These failures had the potential to result in inadequate planning, monitoring, and coordination of care, placing residents at risk for unmet medical needs, or complications related to intravenous therapy, unmanaged symptoms, and decreased quality of life consistent with resident's goals, preferences, and current clinical condition. 1. During a review of Resident 11's admission Record (contains demographic and medical information), it indicated Resident 11 was admitted to the facility on [DATE], with diagnoses which included protein-calorie malnutrition (a condition where the body does not received enough calories or protein to maintain normal body function), metabolic encephalopathy (a brain dysfunction caused by illnesses, chemical imbalances, or toxins resulting in symptoms like confusion, delirium, and coma).During an observation on January 20, 2026, at 1:18 PM, in the hallway outside room [ROOM NUMBER], Resident 11 was sitting in a Geri chair (a specialized chair designed for residents who need support with sitting, positioning and safety), with an IV (intravenous - via vein) fluid labeled 0.9% Normal Saline IV solution, (a sterile salt - water solution with the same salt concentration as the body, commonly used to provide hydration through an IV) 1000 mL (mL - unit of fluid measurement) with instructions to infuse at 50 mL per hour intravenously, continuously.During an interview on January 20, 2026, at 3:29 PM, with the License Vocational Nurse, (LVN 1), LVN 1 stated Resident 11 had poor venous access and nursing staff were unable to obtain IV access in the upper extremities due to veins repeatedly blowing. The LVN 1 further stated that the physician was notified, and an physician order was obtained authorizing placement of the IV in the lower extremity for hydration. The LVN 1 further stated that the lower extremity is uncommon and is performed only when upper - extremity access is not possible and when ordered by the physician.During a concurrent interview and record review on January 23, 2026, at 10:18 AM, with the Assistant Director of Nurses, ADON, the Physician Orders dated, January 12, 2026, at 1:22 PM was reviewed. The physician orders indicated May have IV access to lower extremity. The ADON acknowledged the order was initiated on January 12, 2026.During a concurrent interview and record review on January 23, 2026, at 10:21 AM, with the ADON, Resident 11's care plan, dated January 12, 2026, was reviewed. The care plan indicated, focus (Name of Resident 11) has poor IV access and at risk for poor tissue perfusion r/t (related to) malnutrition. The ADON confirmed that the care plan was initiated on January 12, 2026; however, the care plan was not fully completed and was reviewed on January 21, 2026. The ADON further confirmed that the care plan lacked measurable goals and did not include defined outcomes to evaluate the effectiveness of nursing interventions. The ADON stated that in nursing measurable goals and outcomes are important to guide care and to assess whether interventions are effective for the resident.During a concurrent interview and record review on January 23, 2026, with the ADON, the facility's policy and procedure (P&P) titled Goals and Objectives, Care Plans, revised April 2009, was reviewed. The P&P indicated, Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level. 3. Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment and: a. are resident oriented; b. are behaviorally stated; c. are measurable; and d. contain timetables to meet the resident's needs in accordance with the comprehensive assessment. The ADON confirmed that although the care plan for Resident 11 was initiated on January 12, 2026, the care plan lacked measurable goals and outcomes. The ADON further stated that measurable goals are important in nursing to evaluate the effectiveness of interventions and resident outcomes to address Resident 11's IV care needs. 2. During a review of Resident 14's admission Record (contains demographic and medical information), it indicated Resident 14 was admitted to the facility on [DATE], with the diagnoses which included encounter palliative care (care focused on comfort, pain relief, and quality of life rather than curing illness), dementia (a condition causing severe memory loss and inability to think communicate, or care for oneself) and protein-calorie malnutrition (not getting enough calories or nutrients, leading to weight loss, weakness, and poor healing).During a review of the Resident 14's Physician Orders, dated June 10, 2025, the physician orders indicated, Admit to (name of hospice) under RC (resident condition) DX (diagnosis): Alzheimer's Disease (a progressive brain disease that causes worsening memory loss, confusion, inability to communicate, and loss of ability to perform daily activities).During a concurrent interview and record review on January 23, 2026, at 10:26 AM, with the ADON, the ADON reviewed Resident 14's clinical records. The ADON acknowledged that no comprehensive care plan addressing hospice care was found in the electronic records. The ADON stated hospice residents are expected to have a care plan addressing the comfort measures and coordination with the hospice services.During a concurrent interview and record review on January 23, 2026, at 10:31 AM, with the ADON the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, Revised March 2022. The P&P indicated, . 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant change in Status( and no more than 21 days after admission. The ADON confirmed that this expectation was not met for the resident.

Based on interview and record review, the facility failed to accurately code the Minimum Data Set Assessment (MDS- a computerized assessment instrument) for one resident (Resident 92) reviewed for history of falls.This failure had the potential to cause inaccuracy in identifying Resident 92's care and support needs.During a review of Resident 92's clinical record, the admission Record (contains demographic and clinical data), the admission Record indicated Resident 92 was admitted to the facility on [DATE], with diagnoses which included generalized (overall body) muscle weakness, Dementia (noticeable, worsening loss of brain function, including memory, thinking, language, and judgment, that goes beyond normal aging), and adult failure to thrive (downward spiral of health and ability).During a review of Resident 92's MDS Quarterly Assessment (an assessment for a resident that must be completed every 92 days following the previous assessment), dated January 5, 2026, the MDS Quarterly Assessment under Section J titled Health Conditions indicated Resident 92 had a history of fall with injury (coded 1).During a concurrent interview and record review on January 22, 2026, at 2:25 PM, with the MDS Nurse, Resident 92's MDS Quarterly Assessment, dated January 5, 2026, was reviewed. The MDS's Quarterly Assessment under Section J titled Health Conditions indicated, Resident 92 had a history of fall with injury which was entered as 1 in J1900. The MDS Nurse stated, It [Section J-Health Conditions] was incorrectly coded as a fall. The MDS Nurse further stated, There is no history of fall with this resident in this facility. The MDS Nurse further stated, the facility was supposed to follow the Resident Assessment Instrument (RAI- instruction manual for assessing a nursing home resident's health, needs, and strengths to create a personalized care plan) manual for instructions on how to code the residents correctly in the MDS, but it was not followed.During an interview on January 23, 2026, at 10:50 AM, with the Director of Nursing (DON), the DON stated the MDS Nurse did not code Resident 92's fall correctly and should have coded it as no falls. The DON further stated, they do not have a policy, but they follow the RAI manual.During a review of the CMS's (The Centers for Medicare & Medicaid Services) RAI version 3.0 manual revised October 2025 indicated, . J1700: Fall History on Admission/Entry or Reentry (cont.)-Steps for Assessment 1. Ask the resident and family or significant other about a history of falls in the month prior to admission and in the 6 months prior to admission. 2. Review inter-facility transfer information (if the resident is being admitted from another facility) for evidence of falls. 3. Review all relevant medical records received from facilities where the resident resided during the previous 6 months; also review any other medical records received for evidence of one or more falls. Code 0, no. Code 1, yes .

Based on observation, interview, and record reviews, the facility failed to ensure one of one sampled resident (Resident 61) was provided with a dignified experience when the Infection Preventionist (IP) nurse was standing while assisting Resident 61 to eat.This failure has the potential to cause Resident 61 to feel disrespected and negatively affect their psychosocial well-being and individuality.During a review of Resident 61's admission Record (clinical record with demographic information), the admission Record indicated, Resident 61 was admitted to the facility on [DATE], with diagnoses which included, of dysphagia (difficulty swallowing), hemiplegia (paralysis on one side of the body) and dementia (impaired memory, judgment, and ability to understand or communicate needs.)During an observation on January 20, 2026, at 12:24 PM, in the dining area, the facility's Infection Preventionist (IP) nurse assisted Resident 61 with lunch. IP nurse was standing while Resident 61 was seated in a wheelchair at a dining room table. IP nurse was feeding Resident 61 with noodle soup using a spoon while remaining standing.During an interview on January 20, 2026 at 12:29 PM, with the IP nurse, the IP nurse, stated that when providing feeding assistance to a resident, staff should be seated at the resident's level for safety to help prevent aspiration (the possibility that food or liquid may enter the airway instead of the stomach during swallowing, which can cause choking, coughing or breathing problems).During a concurrent interview and record review on January 23, 2026, at 10:13 AM, with the Assistant Director of Nursing (ADON), the facility's policy and procedure (P&P) titled Assistance with Meals, revised March 2022, was reviewed. The P&P indicated, Dining Room Residents. 3. Residents who cannot feed themselves will feed with attention to safety, comfort and dignity, for example: a. not standing over resident while assisting them with meals; The ADON stated staff should not stand over residents while assisting with meals and confirmed that the staff did not follow the facility's policy.

Based on observations, interviews, and record review, the facility failed to maintain effective infection prevention and control practices (steps used to prevent the spread of germs, including proper cleaning, storage, and handling of medical equipment) for three of seven sampled residents (Residents 4, 14, and 68) when:1. For Resident 4, the urinary catheter bag (a medical bag used for collection of urine) was resting on the floor, on January 20, 2026.2. For Resident 14, an oxygen tubing (a flexible plastic tube to deliver oxygen from the oxygen concentrator to the resident) was hanging from underneath the bed and touching the floor.3. For Resident 68, a breathing treatment face mask (a medical device that covers the nose and mouth to deliver medication directly to the airways and lungs) was on top of the nightstand, uncovered and unlabeled, while not in use.These failures had the potential to result in cross contamination (when germs are spread from one person, surface, or object to another, making it easier for infections to spread) and transmission of infectious organisms due to improper storage and handling of urinary and respiratory equipment, placing Resident 4, 14, and 68 at risk for infection and harm.1. During a review of Resident's 4 clinical records the admission Record (contains demographic and medical information) indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included pressure ulcer (bed sore), sepsis (a life threatening medical emergency caused by the body's extreme response to an infection), and neuromuscular dysfunction of bladder (inability to properly store or empty urine). During a concurrent observation and interview, on January 20, 2026, at 9:50 AM, with a Certified Nursing Assistant (CNA 3), in Resident 4's room. Resident 4 was lying in his bed sleeping, his urinary catheter bag was hanging off the bed frame on the resident's left side of the bed resting on the floor. CNA 3 stated the urinary catheter should not be touching the floor. During a concurrent observation and interview, on January 20, 2026, at 9:58 AM, with a Licensed Vocational Nurse (LVN 1), in Resident 4's room. LVN 1 stated the expectations for urinary catheter is that it should have a dignity bag, should be hanging on lower level, and not touching the floor. During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on January 23, 2025, at 4:16 PM, the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, revised August 2022, was reviewed. The P&P indicated, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Infection control. 2. Be sure the catheter tubing and drainage bag are kept off the floor. The ADON stated the P&P was not followed. 2. During a review of Resident 14's admission Record (contains demographic and medical information), it indicated Resident 14 was admitted to the facility on [DATE], with the diagnoses that included dysphagia (difficulty swallowing), gastrostomy (a feeding tube, directly to the stomach) and dementia, (loss of memory, language, problem-solving, and other thinking abilities). During a concurrent observation and interview on January 20, 2026, at 10:00 AM, with the Certified Nurse Assistant, (CNA 1), in Resident 14's room, a nebulizer (a small machine that turns liquid medicine into a fine mist so a person can breathe it in through a mask or mouthpiece and helps the medicine go directly into the lungs) was on top of Resident 14's nightstand. A clear bag intended for storage of breathing treatment supplies (mask and oxygen tugging) was hanging from the nightstand. The oxygen tubing was connected to the breathing treatment mask and was downward under Resident 14's bed, touching the floor. The CNA 1 confirmed the oxygen tubing was touching the floor and stated once the oxygen tubing comes in contact with the floor, it should be discarded because it is considered contaminated. During an interview on January 20, 2026, at 10:20 AM, with the License Vocational Nurse, LVN 1, the LVN 1 acknowledged the oxygen tubing connected to a breathing treatment mask had been found touching the floor and stated, all respiratory equipment must be stored properly inside the plastic bag and should be labeled, to prevent contamination. During a review of Resident 14's Physician Orders, dated January 12, 2026, it indicated, Ipratropium-Albuterol Inhalation Solution (a combination of breathing medication that opens the airway to help the resident breathe easier) 0.5 – 2.5 (the amount of albuterol in each dose, which helps relieve wheezing and shortness of breath) (ipratropium: the amount of ipratropium in each dose, which keeps relax and open the airways) (3) MG/3ML (the total liquid volume of the medication on one dose) ipratropium-Albuterol) 1 dose inhale orally every 4 (four) hours for Congestion /SOB (shortness of breath). During a concurrent interview and record review on January 21, 2026, at 5:12 PM, with Assistant Director of Nursing (ADON), the facility's policy and procedure (P&P) titled, Departmental Respiratory Therapy – Prevention of Infection, reviewed 2011, was reviewed. The P&P indicated, Purpose. The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, among residents and staff. steps in the Procedure. Infection Control Considerations Related to Medication Nebulizer/Continuous Aerosol: .7. Store the circuit in plastic bag, marked with date and resident's name between uses. The ADON Acknowledged, the policy was not followed by staff, as equipment in contact with the floor is considered contaminated and should not be used. 3. During a review of Resident 68's admission Record, it indicated the resident was admitted to the facility on [DATE], with diagnoses which included cerebral infarction affecting the right dominant side (damage to the brain cause by a blockage of blood flow, which can result in weakness on the right side of the body), dysphagia (difficulty swallowing) and hemiplegia and hemiparesis (paralysis of weakness on one side of the body) During a concurrent observation and interview on January 20, 2026, at 10:35 AM, with the License Vocational Nurse (LVN 2), in Resident 68's room, a nebulizer (a medical device that turns liquid medication into a fine mist so it can be breathed into the lungs through a mask or mouthpiece) with an attached tubing and breathing treatment mask (a soft plastic mask place over the nose and mouth that delivers medication or oxygen into the lungs to help the person breathe easier) was located on top of Resident 68's nightstand. The nebulizer equipment was unlabeled and uncovered, improperly stored. The LVN 2 stated the nebulizer equipment, including the tubing and breathing treatment mask, should be stored inside a designated breathing treatment bag, dated and labeled, but it was not. During a concurrent interview and record review on January 21, 2026, at 5:16 PM, with ADON, the facility's policy and procedure (P&P) titled, Departmental Respiratory Therapy – Prevention of Infection, Revised 2011, was reviewed. The P&P indicated, Purpose. The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, among residents and staff. steps in the Procedure. Infection Control Considerations Related to Medication Nebulizer/Continuous Aerosol: .7. Store the circuit in plastic bag, marked with date and resident's name between uses. The ADON acknowledged the nebulizer, tubing and breathing treatment mask were found on top on the Residents 68's nightstand unlabeled and not properly stored, the ADON confirmed that the staff did not follow the policy.

Based on observation, interview, and record review, the facility failed to maintain an accurate record of Norco (a controlled medication that combines two types of drugs, acetaminophen and hydrocodone, for pain management) for one of five sample residents (Resident 4) when a Licensed Vocational Nurse (LVN1) administered Norco to Resident 4 and failed to document. This failure had the potential in delaying the recognition of possible diversion of a control medication. Findings: During a review of Resident 1 Face Sheet (contain resident demographic), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included Hemiparesis (one-sided muscle weakness), Dysphagia (difficulty swallowing), Hypertensive (high blood pressure) heart disease. A review of Resident 4's Orders, dated November 30, 2024, indicated, Norco 5-325 milligram (mg-unit dosing medication, a combination of 325 mg of acetaminophen and 5 mg of hydrocodone) was ordered to be given as needed for moderate pain (pain scale to evaluate pain level of patients). A review of the controlled drug log for Resident 4 indicated that Narco oral tablets, 5-325 mg, were administered on the following dates and times: December 1, 2024, at 09:10; December 2, 2024, at 01:50, 09:00, and 21:52; December 3, 2024, at 03:30 and 08:30; December 4, 2024, at 05:20; December 5, 2024, at 04:25 and 09:00; December 6, 2024, at 02:45 and 09:00; December 7, 2024, at 09:00; December 8, 2024, at 09:00; December 10, 2024, at 05:90; December 11, 2024, at 09:00; December 12, 2024, at 04:36 and 09:00; and December 13, 2024, at 05:30. A review of Resident 4's eMAR indicated that Narco oral tablets, 5-325 mg, were administered on the following dates and times: December 2, 2024, at 0116 hours; December 2, 2024, at 2126 hours; December 3, 2024, at 0329 hours; December 3, 2024, at 0814 hours; December 4, 2024, at 0518 hours; December 5, 2024, at 0425 hours; December 6, 2024, at 0243 hours; December 10, 2024, at 0544 hours; December 12, 2024, at 0436 hours; and December 13, 2024, at 0519 hours. During concurrent telephone interview and record review on December 17, 2024 at 11:08 AM, with the Director of Nursing (DON 1), Resident 4's eMAR and controlled drug book were reviewed. The DON 1 confirmed that on the following dates and times-December 1, 2024, at 9:00 AM; December 2, 2024, at 9:00 AM; December 5, 2024, at 9:00 AM; December 6, 2024, at 9:00 AM; December 7, 2024, at 9:00 AM; December 8, 2024, at 9:00 AM; December 11, 2024, at 9:00 AM; and December 12, 2024, at 9:00 AM-medications were documented as administered in the controlled drug book but were not recorded in the eMAR. Additionally, she emphasized that LVN1 should be aware that when administering narcotics, it is essential to sign both the eMAR and the controlled drug book. During concurrent telephone interview and record review on December 17, 2024 at 11:26 AM with LVN 1. The eMAR and controlled drug book for Resident 4 were examined. LVN 1 confirmed that she had recorded in the control book the administration of Narco to Resident 4, but did not sign the eMAR for these administrations on the following dates and times: December 1, 2024, at 0900; December 2, 2024, at 0900; December 5, 2024, at 0900; December 6, 2024, at 0900; December 7, 2024, at 0900; December 8, 2024, at 0900; December 11, 2024, at 0900; and December 12, 2024, at 0900. LVN 1 indicated that, according to policy, it is mandatory to sign the eMAR whenever medication is administered, and both the eMAR and the Narcotic Control Book must be signed for narcotics. She emphasized that failing to sign the eMAR when administering medication is unacceptable. LVN 1 further stated the fact that she didn't sign the eMAR was a coincidence. She claimed to have signed the eMAR for other medications, but she was unable to provide an explanation for why it was a coincidence that she did not sign the eMAR for narcotics alone. She acknowledged that the signatures on the eMAR are essential for verifying that medications have been administered, while the signatures in the Narcotic Control Book are necessary to ensure accurate medication counts. A review of the facility Policy & Procedure (P&P) titled, Documentation of Medication Administration indicated, .I. A nurse or certified medication aide (where applicable) documents all medications administered to each resident on the resident's medication administration record (MAR). 2. Administration of medication is documented immediately after it is given .

Based on observation, interview, and record review, the facility failed to adhere to its safety and supervision of resident ' s policy when one of three sampled residents (Resident 1) was not adequately supervised following two fall incidents within 48-hour period. This failure resulted in Resident 1 sustaining a pelvic fracture during the latest fall incident. Findings: During a review of Resident 1 ' s Progress Notes, with a date range from 9/28/2024 to 10/29/2024. The progress note indicated, Resident 1 had a witnessed fall incident on October 7, 2024, at 8:20 a.m. which occurred in the hallway. Further review of the records indicated that Resident 1 had another fall which is classified as unwitnessed (without being seen by a care professional or a resident who can accurately described the event) on October 9, 2024, at 4:30 a.m., also occurring in the hallway. During an observation on 10/28/2024, at 12:45 p.m., it was noted that the resident ' s room, which is 110 during the two recent fall incidents. This room is located far from the nurse ' s station and is not always visible from the nurse ' s view. During an interview on 10/28/2024, at 1:28 p.m., with the Assistant Administrator, (AA) 1, it was emphasized that Resident 1 was admitted as a high risk for fall, indicating the need for closer monitoring. This could have been managed by placing his room closer to the nurse ' s station. Resident 1 was in room [ROOM NUMBER] during the last two fall incidents. room [ROOM NUMBER] is located in situated in the corner and is not easily visible from the nurses ' station. AA 1 agreed that Resident 1 should have been positioned closer to the nurses ' station for better monitoring. During a review of the facility ' s policy and procedure (P&P) titled, Safety and Supervision of Residents, dated July 2017, the P&P indicated, Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident ' s assessed needs and identified hazards in the environment.

Based on interview, record review, and facility policy review, the facility failed to ensure a preadmission screening and resident review (PAASRR) screening was completed prior to admission to the facility for 3 (Residents #22, #42, and #86) of 5 sampled residents reviewed for PASARR screening. Findings included: A facility policy titled, Pre-Admission Screening Resident Review Level I, revised10/2018, specified, Policy: The State of California has adopted a process to submit Pre-Admission Screening Resident Review electronically. All facilities must complete the [PASARR] by midnight of the date of admission. The policy revealed IX. The BOM [Business Office Manager] will review the status of [PASARR] daily before Stand-Up Meeting to review if new admissions' [PASARR] have been completed. X. The BOM will report during Stand-Up Meeting the status of the [PASARR(s)]. The policy indicated, XII. The Admission Coordinator/Case Manager will ensure that the [PASARR] is part of the Admission mini packet. XIII. The facility Administrator will ensure any incomplete [PASARR(s)] are completed that day. If the person who initiated the [PASARR] is not there the following date to complete it, it must be completed by a [PASARR] Administrator. According to the policy, XV. The Medical Records Admission Audit will include [PASARR] completion. 1. An Admission Record revealed the facility admitted Resident #22 on 07/01/2024. According to the Admission Record, the resident had a medical history that included diagnoses of schizoaffective disorder, post-traumatic stress disorder (PTSD), and anxiety disorder. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/08/2024, revealed Resident #22 had Brief Interview for Mental Status (BIMS) Score of 13, which indicated the resident had intact cognition. The MDS indicated the resident had active diagnoses to include anxiety disorder, schizophrenia, and PTSD. Resident #22's Patient Care Plan: Anxiety included a problem/need statement dated 07/01/2024, that indicated the resident had behaviors of anxiety due to diagnoses of schizoaffective disorder and PTSD that manifested by rapid mood changes. Resident #22's medical record revealed no documented evidence the facility completed a Level I PASARR Screening prior to admission of the resident to the facility. During an interview on 10/01/2024 at 11:14 AM, the MDS Coordinator stated the resident's PASARR was never transferred from their previous facility, and the facility never received a PASARR for Resident #22. 2. An Admission Record revealed the facility admitted Resident #86 on 08/01/2024. According to the Admission Record, the resident had a medical history that included diagnoses of schizophrenia and anxiety disorder. An admission [NAME] Data Set (MDS), with an Assessment Reference Date (ARD) of 08/30/2024, revealed Resident #86 had Brief Interview for Mental Status (BIMS) Score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had active diagnoses to include anxiety disorder, depression, and schizophrenia. Resident #86's care plan included a problem/need statement dated 08/27/2024, that indicated the resident had schizophrenia. The care plan revealed the goal was for the resident to receive specialized services as recommended by a Level II determination evaluation report as indicated and coordinated by the interdisciplinary team. Resident #86's Preadmission Screening and Resident Review Level I Screening, dated 07/10/2024, revealed Resident #86 had diagnosis of dementia psychosis and had been prescribed Seroquel. The Level I PASARR screening revealed the resident was positive for a serious mental illness and a Level II screening was required. Resident #86's medical record revealed no evidence to indicate a Level II screening was conducted. During an interview on 10/01/2024 at 10:20 AM, the MDS Coordinator stated he did not ensure a new PASARR for Resident #86 was submitted. 37935 3. An Admission Record indicated the facility admitted Resident #42 on 08/03/2024. According to the Admission Record, the resident had a medical history that included diagnoses of paranoid schizophrenia and severe major depressive disorder with psychotic symptoms. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/07/2024, revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS revealed the resident had active diagnoses to include depression and schizophrenia. A typed document from the California Department of Health Care Services dated 08/04/2024, indicated a Level II mental health evaluation was not required due to an Exempted Hospital Discharge. According to the document, if Resident #42 remained in the nursing facility longer than 30 days, the facility must resubmit a new Level I screening on the 31st day. Resident #42's medical record revealed no documented evidence the facility submitted a new Level I screening for the resident on the 31st day after admission to the facility. During an interview on 10/02/2024 at 1:52 PM, the MDS Coordinator stated he was not aware he should resubmit a Level I screening within certain times frames. The MDS Coordinator acknowledged a Level I screening was not resubmitted for Resident #42. During an interview on10/02/2024 at 2:15 PM, the Director of Nursing (DON) stated she was not involved in the PASARR process. The DON stated she expected PASARR screenings to be completed accurately and submitted/resubmitted timely. During an interview on 10/02/2024 at 2:24 PM, the Administrator stated she was not involved in the PASARR process, but expected PASARR screenings to be completed accurately and timely.

Based on interview and record review the facility failed to report a change of condition and document in the medical records for one of four clinically compromised residents (Resident 1). This has the potential to exclude the family and responsible party of (Resident 1) to actively participate in the plan of care related to the resident's change of condition. Findings: During a review of Resident 1 ' s Face Sheet (general demographics) on October 19, 2023, the document indicated Resident 1 was admitted to the facility on [DATE], with diagnosis that included Hypertension (high blood pressure), Hyperlipidemia (high concentration of fats in blood), Hypothyroidism (low thyroid gland activity), Schizophrenia (mental illness that affect the way a person thinks, feels and behaves), Bipolar Disorder (mental illness by alternating periods of elation and depression). During a review of Resident 1 ' s Face Sheet indicated, Responsible Party, Second Contact [Name of daughter with phone number provided], Third Contact [Name of daughter with phone number provided]. During a review of Resident 1 ' s History and Physical Examination (H&P), the H&P dated February 2023, indicated, .This resident (Resident 1): .B. does NOT have the capacity to understand and make decisions. Reason: A&O x1 (Alert and oriented x 1). During a concurrent interview and record review on October 19, 2023, at 12:30 PM, with the Assistant Director of Nurse (ADON), the Physician Order dared October 11, 2023, indicated, May transfer to [Name of hospital] for Eval Due to episodes of increased confusion Decreased PO (by mouth) intake with 7 days bed hold. During a concurrent interview and record review on October 19, 2023, at 12:30 PM, with the Assistant Director of Nurse (ADON), Departmental Notes, dated October 11, 2023, by a licensed vocational nurse (LVN) indicated, .Res (Resident) pick up by arrange transportation arrange by the SSD (Social Services Director) to LADMC (Los Angeles Downtown Medical Center) for eval. Res awake, alert, no c/o (complaint of) pan noted. All needs attended well. The ADON, the ADON stated, When there is a change in condition and a transfer to the hospital, the responsible is notified of the change in condition and the transfer to the hospital. She further stated she expected the nurse to have notified the responsible party and recorded in the resident ' s medical records. During a review of the facility ' s policy and procedure (P&P), titled, Change in a Resident ' s Condition or Status, dated, May 2017, the P&P indicated, Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident ' s medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc . Policy Interpretation and Implementation . 4. Unless otherwise instructed by the resident, a nurse will notify the resident ' s representative when . d. It is necessary to transfer the resident to a hospital/treatment center.). During a review of the facility ' s policy and procedure (P&P), titled, Charting and Documentation, dated, July 2017, the P&P indicated, Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident ' s medical, physical, functional or psychosocial condition, shall be documented in the resident ' s medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident ' s condition and response to care. Policy Interpretation and Implementation . 7. Documentation of procedures and treatments will include care-specific details, including. a. The date and time the procedure/treatment was provided . f. Notification of family physician or other staff, if indicated; and g. The signature and title of the individual documenting.

Based on interview, and record review, the facility failed to document an assessment (monitor for medical changes) for one of three residents (Resident 3) after a fall. This failure had the potential for Resident 3's overall medical condition to decline and go undetected by the facility. Findings: An abbreviated survey was conducted on May 24, 2023, at 5:47 AM to investigate a complaint regarding Quality of Care. During review of Residents 3's Face sheet (general demographics), the document indicated Resident 3 was admitted to the facility on [DATE], with diagnoses to include: diabetes (body doesn't produce enough insulin) and heart failure (heart doesn't pump enough blood for your body,) During a review of the clinical record for Resident 3, the SBAR (Communication Form for changes in conditions) dated May 22, 2023, at 9:50 PM, indicated The change in condition . Resident 3 had an unwitnessed fall. Resident fell inside the room when transferring himself from one wheelchair to another wheelchair. He complained that he hit his head and complained of right hip pain. Doctor notified. Resident refused to go to the doctor. During an interview and concurrent record review of Resident 3's clinical records with Registered Nurse (RN 1), on May 24, 2023, at 6:43 AM, RN 1 stated, I didn't know resident 3 had a fall. I didn't know he fell . We are supposed to be doing neuro checks when there is an unwitnessed fall. Honestly, I don't know how we were documenting on him after a fall. There is no neuro check sheet. The documentation we do, if unwitnessed, we do neuro checks. I have not made any notes regarding Resident 3's fall. During a review of the clinical records for Resident 3 with the Director of Nursing on May 24, 2023, at 2:22 PM, the DON stated The RN didn't know resident 3 was status post fall. He should have known, and he should have been doing neuro checks for the safety of the resident and per policy. The facility could not provide documentation that RN 1 completed neuro checks and or monitoring for medical changes after Resident 3's fall. The facility policy and procedure titled Change in Residents Condition or Status dated May 2017, indicated, .8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . The facility policy and procedure titled Falls dated March 2018, indicated, .2. The nurse shall assess and document/report the following: vital signs; Neurological status; and pain .

Based on observation, interview, and record review, the facility failed to follow their policy and procedure to ensure the call lights were answered in a timely manner to provide care and services for two of three residents (Resident 1 and Resident 2). This failure had the potential to place two clinically compromised Residents (Resident 1 and Resident 2) health and safety at risk when residents were left soiled, and their activities of daily living were not met in a timely manner. Findings: 1. During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with diagnoses which includes: stroke affecting the right side, visual loss, and muscle wasting. During a review of the clinical record for Resident 1, the history and physical, dated May 18, 2023, indicated This resident: has the capacity to understand and make decisions. In an interview with Resident 1, on May 24, 2023, at 6:07 AM, Resident 1 stated, I've sat here with a wet diaper for over two hours, and nobody came in to change me. It takes forever for them to come in and answer the call light. 2. During a review of Resident 2's clinical record, the face sheet (contains demographic and medical information), indicated Resident 2 was admitted on [DATE], with diagnoses which includes: Depression and chest pain. During a review of the clinical record for Resident 2, the Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline), dated March 8, 2023, indicated, Resident 2's score was a 15, which indicated Resident 1 did not have a mental impairment. In an interview with Resident 2 on May 24, 2023, at 7:55 AM, Resident 2 stated, I put on the call light, and they didn't come until the next shift. Weekends are really bad. I had diarrhea a couple weekends ago and I had to wait and an hour and a half a couple of times. I went three times that night. During a review of the clinical records, the care plans indicated: 1. Resident 1's care plan dated May 16, 2023, indicated Resident 1 has an activity of daily living deficit (tasks of everyday life) related to a stroke. Problem: Extensive assist with toileting, and bed mobility. Plan: Have call light within reach and staff to answer promptly. 2. Resident 2's care plan dated January 6, 2023, indicated Resident 2 has an activity of daily living deficit related to morbid obesity. Problem: Extensive assist with toileting, bed mobility and hygiene. Plan: Have call light within reach and staff to answer promptly. During an interview with Director of Staff Development (DSD), on May 24, 2023, at 1:15 PM, DSD stated, Call lights should take a few minutes to answer. It may take 15 to 20 minutes. DSD stated further, it is not ok to take an hour to answer a call light. Everyone needs to be changed at the appropriate time. During an interview with the Director of Nursing on May 24, 2023, at 2:22 PM, DON stated, Call lights. It should take them 3 to 5 minutes to answer the call light. They should not be taking an hour to answer the call light. It's not good patient care. It is unacceptable. Anything could happen. The call lights are to be answered so they could assist, to meet the residents needs. The facility policy and procedure titled, Answering the Call Light dated October 2010, indicated Purpose. The purpose of this procedure is to respond to the resident's request and needs. General Guidelines .5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident .8. Answer the resident's call as soon as possible .

Based on observation, interview, and record review, the facility failed to ensure residents, staff and the public were provided a safe, functional, sanitary, and comfortable environment when the ceiling towards the back hallway from west station, was observed to be patched with plywood due to rain. This failure had the potential to result in jeopardizing the health and safety of the public, staff, and clinically compromised residents. Finding: An unannounced visit was made to the facility on [DATE], at 4:50 PM, to investigate a complaint about leakages in the facility. During an inspection of the facility on March 23, 2023, at 5:00 PM, the ceiling towards the back hallway from west station was observed to be patched with plywood. There were two yellow safety cones on the floor, Caution wet floor. During an interview with the Assistant Director of Nursing (ADON) on March 23, 2023, at 5:02 PM, the ADON confirmed the ceiling towards the back hallway from west station was leaking. The ADON stated, It was leaking during the rain yesterday, and the maintenance man put the patch until it is fixed tomorrow when it is not raining. During an interview with the Administrator (ADM) on March 23, 2023, at 5:45 PM, the ADM confirmed the ceiling towards the back hallway from west station was leaking. The ADM stated, It was happened during the rain. The patched ceiling is temporary until we can fix it when it is not raining. During a phone interview with the Maintenance Personnel, on March 27, at 2:11 PM, he confirmed the ceiling towards the back hallway from west station was leaking. The maintenance personnel further stated, I put the patch to the ceiling until we can fix the leaking. We had someone come to look at it today to fix it when it is not raining. During a review of the facility ' s policy and procedure titled, Maintenance Service, revised December 2009, indicated, maintenance service shall be provided to all areas of the building, grounds, and equipment . Maintenance Service, indicated, Maintaining the building in good repair and free from hazards . Establishing priorities in providing repair service.

Based on interview and record review the facility failed to follow their Policy when the licensed nurse failed to notify responsible party and document in medical record for one of three sampled Residents (Resident 1). This failure has the potential to exclude the family and responsible party ( RP1) of Resident 1 to actively participate in the plan of care related to the resident's room change. During a concurrent interview and record review, on 3/14/2023, at 3:42 p.m. with Assistant Director of Nursing (ADON), ADON stated that there was no documentation on Resident 1 ' s medical records regarding moving Resident 1 to a different room and no documentation of Responsible Party being notified. During a review of the facility's policy and procedure (P&P) titled, Room change/Roommate assignment, revised May 2017, the P&P indicated, Prior to changing a room or roommate assignments all parties involved in the changed/assignment (e.g., residents and their representatives (sponsors)) will be given advance notice of such change.

Based on observation, interview, and record review, the facility failed to ensure residents who are unable to carry out their activities of daily living (ADL- bathing, dressing, transfer), were provided, two baths a week for two of three sampled residents (Resident 2 and Resident 3) when: 1. Resident 2 did not receive baths on June 2, 2022, and June 6, 2022, as scheduled. 2. Resident 3 did not receive a bath on June 4, 2022, as scheduled. These failures resulted in Resident 2 and Resident 3 not receiving the necessary care to maintain good grooming and personal hygiene which created the potential for odors, poor hygiene, and embarrassment. Findings: An unannounced visit was made to the facility on [DATE], at 11:44 AM, to investigate a complaint regarding quality of care and treatment. 1.A review of Resident 2's face sheet (includes demographics) indicated, Resident 2 was readmitted to the facility on [DATE], with diagnoses of Neuropathy (nerve damage), chronic kidney disease (kidneys cannot filter blood as well as they should), and heart failure (heart is unable to pump the blood to meet the body's needs.) During an observation and concurrent interview with Resident 2, on June 7, 2022, at 12:46 PM, Resident 2 was alert, awake and was able to communicate her needs. Resident 2 stated, I don't get a shower two times a week. I don't get a bed bath either. I have not been given a bath in a week. Resident 2 confirmed that baths had not been given two times a week as scheduled. During a review of the Shower Schedule Record for Resident 2, the Shower Schedule undated, indicated, Resident 2 was scheduled to receive a bath or a shower twice a week. During a record review of the Minimum Data Set (MDS - Minimum Data Set, an assessment tool) for Resident 2, dated April 8, 2022, indicated: 1. Section C0500 BIMS (brief interview for mental status) was coded as 8, indicating moderately impaired cognition. 2. Section G Functional Status, Activities of Daily Living (ADL) Assistance. Section G120. Bathing indicated, Resident 2 needed physical help with bathing. A review of the ADL [Activities of Daily Living] flow sheet for the month of June 2022, indicated, Resident 2 had not received a shower two times a week for the month of June. ADL Flow sheet was coded as X (ADL activity itself did not occur) on June 2, 2022, and June 6, 2022. During a concurrent interview and record review with a Licensed Vocational Nurse (LVN 1), on June 7, 2022, at 1:37 PM, LVN 1 stated, Certified Nursing assistants (CNA's) are to give a shower or a bath two times a week. There is no documentation that the showers or baths were given this month to Resident 2. After reviewing Resident 2's medical records, LVN 1 further stated, there was no documented evidence of Resident 2 refusing a bath or shower for the month of June. The facility could not provide documentation to indicate Resident 2 was given a bath twice a week as scheduled. During an interview with the Assistant Director of Nursing (ADON) on June 7, 2022, at 1:52 PM, the ADON stated, The ADL flow sheet for Resident 2 states that she did not get a shower or a bath this month. Resident 2 should have received two showers this month. I don't know why Resident 2 didn't get the showers. The ADON confirmed the showers were not given twice weekly. No other documentation could be provided to indicate Resident 2 received baths twice a week for the month of June 2022 as scheduled. 2. A review of Resident 3's face sheet (includes demographics) indicated, Resident 3 was admitted to the facility on [DATE], with diagnoses of chronic obstructive disease (damages the lungs and makes it hard to breathe), depression (feeling of sadness) and anxiety (feeling of worry.) During an observation and concurrent interview with Resident 3, on June 7, 2022, at 12:54 PM, Resident 3 was alert, awake and was able to communicate her needs. Resident 3 stated, I didn't get my bath. I feel dirty. I sweat. I don't feel fresh. I am to receive a bath twice a week on Wednesday and Saturday. Resident 3 confirmed that baths had not been given two times a week as scheduled. During a review of the Shower Schedule Record for Resident 3, the Shower Schedule undated, indicated, Resident 3 was scheduled to receive a bath or a shower twice a week. During a record review of the Minimum Data Set (MDS - Minimum Data Set, an assessment tool) for Resident 3, dated March 10, 2022, indicated: 1. Section C0500 BIMS (brief interview for mental status) for Resident 2 was a 15, indicating intact cognition. 2. Section G Functional Status, Activities of Daily Living (ADL) Assistance. Section G120. Bathing indicated Resident 2 needed physical help with bathing. A review of the ADL [Activities of Daily Livin]) flow sheet for the month of June 2022, indicated, Resident 3 did not receive a shower two times a week for the month of June. During a concurrent interview and record review with a Licensed Vocational Nurse (LVN 1), on June 7, 2022, at 1:37 PM, LVN 1 stated, Certified Nursing assistants (Cna's) are to give a shower or a bath two times a week. There is no documentation that the showers or baths were given this month to Resident 3. After reviewing Resident 3's medical records, LVN 1 further stated, there was no documented evidence of Resident 3 refusing a bath or shower for the month of June. The facility could not provide documentation to indicate resident 3 was given a bath twice a week as scheduled. During an interview with the Assistant Director of Nursing (ADON) on June 7, 2022, at 1:52 PM, ADON stated, The ADL flow sheet for Resident 3 states that she did not get a shower or a bath this month. Resident 3 should have received two showers this month. I don't know why Resident 3 didn't get the showers. The ADON confirmed the showers were not given twice weekly. No other documentation could be provided to indicate Resident 3 received baths twice a week for the month of June 2022 as scheduled. The facility policy and procedure titled, Bath, Shower/Tub dated February 2018, indicated The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin . Documentation 1. The date and time the shower/tub was performed. 2. The name and title of the individual who assisted the resident with the shower/tub bath 5. If the resident refused the shower/tub bath, the reason.

Based on interview and record review the facility failed to follow their Policy and Procedure when the licensed nurse failed to notify the primary physician in regard to residents changed of condition for the one of the 3 sampled Residents (Resident 1). This failure had placed a clinically compromised Resident (Resident 1) health and safety at risk due to a 10-day delayed in treatment resulting in transferred to a higher level of care. Findings: During review of Resident 1s Admission Record (general demographics), admitted to facility on November 4, 2019, with diagnosis (DX) diabetes type II (body doesn ' t produce insulin), hypertension (high blood pressure), [CONDITION(S)] (Low blood count ), [CONDITION(S)] (nerve problem causing pain and weakness in the body), [CONDITION(S)] (inability to move the lower part of the body), [CONDITION(S)] (brittle bones), Neuromuscular Dysfunction of Bladder (a person lacks bladder control due to spinal cord or nerve problems). During concurrent interview and record review on May 19, 2022, at 11:30 AM of Resident 1 ' s Activity of Daily Living notes (ADL notes), on April 3, 2022, Certified Nurse Assistant (CNA 1) indicated, Resident stomach big and on her right side she has a ball, and she says it hurt. Notified Charge nurse (CN1). When asked CNA 1 if CN1 checked on Resident 1, CNA1 stated CN1 examined Resident 1 ' s stomach. During a review of April 3,2022 Medical Records, there was no documentation of a Change of Condition (COC), no physician notification and no documentation of abdominal assessment. During concurrent Interview and record review with the Assistant Director of Nursing (ADON) and Administrator (ADM) on May 18, 2022, at 11:45 AM, the ADON confirmed that there were no records of COC notification and No Documentation from CN1 assessment on April 3, 2022. During Record Review on May 18,2022, at 12:05 PM, Nurses Notes dated April 13,2022, at 7:55 AM by Licensed Vocational Nurse (LVN1). Records showed that COC was initiated due to hard mass located on Right side of Abdomen. Primary Physician (MD1) notified on April 13,2022, at 7:15 AM and the Responsible Party (RP). Orders received and carried out. On April 27, 2022, at 4:30 PM, R1 was sent to the hospital due to complaints of Nausea and Vomiting, Pain to Abdomen, Mass to the right-side middle of abdomen and left lower quadrant. During a review of the facility ' s policy and procedure titled, Change in a Resident ' s Condition or Status, version 2.3 (H5MAPL0118). The policy and procedure indicated, The nurse will notify the resident ' s Attending Physician or Physician on call when there has been a significant change in resident ' s physical/emotional/mental condition.

Based on interview and record review the facility failed to provide safe supervision and monitoring for one resident (Resident 1) when Resident 1 eloped from the facility and was found by his wife with his friends in the afternoon of August 4, 2022. This failure had the potential to put Resident 1 at risk for harm or injury from accident and/or heat or cold exposure. Findings: During a review of Resident 1 ' s clinical record, the face sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1 ' s MDS (Minimum Data Set-a process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) for Cognitive Patterns, dated June 23, 2022, indicated a BIMS (Brief Interview for Mental Status) score of 12 (score of 8 to 12 indicated moderate impairment). During an interview on August 05, 2022, at 10:06 AM, with the Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated, Resident 1 is alert, oriented with episodes of confusion. During a review of Resident 1 ' s Departmental Notes (DN) dated August 4, 2022, at 4:51 PM, the DN indicated, AT 1:24 PM 8-4-22 RESIDENT NOTED TO NOT BE IN THE FACILITY. CODE 10 FOR ELOPEMENT WAS ANNOUNCED, ALL STAFF IMPLEMENTED SEARCH PROTOCOL. ELOPEMENT WAS REPORTED TO UPLAND PD [Police Department]- AT 1:30 PM. RESIDENT ' S WIFE WAS NOTIFIED ABOUT ELOPEMENT AT 1:35 PM. AT 2:08 PM WIFE LOCATED RESIDENT AND NOTIFIED THE FACILITY THAT RESIDENT WILL NOT BE RETURNING. During a review of the DN dated August 4, 2022, at 2:47 PM, DN indicated, SS [Social Services] spoke to resident ' s wife (name redacted) in regards to resident leaving facility without letting the facility know. Wife states that she is not going to bring the patient back into the facility and resident does not want to come back. Wife states res. [resident] wants to stay on the streets and will not be taking him with her either. During a phone interview on August 18, 2022, at 10:59 AM, with the Administrator (ADM), ADM stated the facility ' s Central Supply Staff (CSS) went to see Resident 1 on August 4, 2022 at the location given by the wife. CSS saw Resident 1 with two male individuals. Resident 1 refused to go back to the facility with CSS. Resident 1 signed the Against Medical Advice (AMA) form on August 4, 2022. During a review of the facility ' s 5-day Investigative Summary Report (ISR) dated August 9, 2022, the ISR indicated, .Follow-up report/conclusion: Resident more than likely left during the time that the receptionist was attending to the distraught family member during the time between 11:00 am-11:30 am. During an interview on August 23, 2022, at 11:06 AM, with the Receptionist (R) 1, R 1 stated, she was responsible for monitoring whoever enters and leaves the facility from the main entrance door. R 1 also stated she left the front desk around 11:00 AM without asking another staff to cover her post while attending to a family member. R 1 further stated it was not acceptable to leave the front desk without coverage because no one would monitor who comes in and goes out of the facility. During a concurrent interview and record review on August 23, 2022, at 11:14 AM, with R 1, the Receptionist Job Description, indicated, GENERAL JOB FUNCTION: Other- Promotes/protects resident rights .Complies with facility safety program .Promotes a safe environment for residents, visitors, and staff at all times . R 1 stated she did not ensure resident ' s safety when she left the front desk without coverage. During an interview on August 23, 2022, at 11:25 AM, with the Director of Nursing (DON), DON stated, residents leaving the facility undetected by staff was not acceptable. DON further stated it was the facility ' s responsibility to monitor residents at all times. During a concurrent interview and record review on August 23, 2022, at 12:00 PM, with the Administrator (ADM), the facility ' s Policy and Procedure (P&P) on Resident Rights, revised December 2016, indicated Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to: .c. be free from abuse, neglect ., .exploitation; . ADM stated, the facility ' s P&P was not followed because Resident 1 ' s safety was not ensured when R 1 left the front desk without coverage.

This requirement was NOT MET as evidenced by: Based on observation, interview, and record review, the facility failed to provide a safe environment with adequate monitoring and supervision for a resident (Resident 1) with impaired cognition (ability to think). Resident 1 eloped (leaving a facility without observation or knowledge of departure) from the facility for more than one hour and was found by staff about half a mile away on a busy road. This failure had the potential to cause Resident 1 the risk to suffer from heat and cold exposure, dehydration, medical complications, drowning, or being struck by a motor vehicle. Findings: An unannounced visit was conducted on April 22, 2022, at 1:47 PM, to investigate a facility reported incident regarding an elopement of a resident (Resident 1). During a concurrent observation and interview on April 22, 2022, at 2:33 PM, with Resident 1, a wander guard bracelet (bracelet worn by residents that will trigger alarms on monitored doors to prevent wander-prone residents leaving unattended) was noted on Resident 1's left wrist. Resident 1 was alert, however he was constantly fidgeting and talked quickly and erratically, jumping rapidly between ideas and thoughts throughout the interview. He was unsteady while walking from the bed to the bathroom and back to bed. Resident 1 stated he walked out through the middle of the front door yesterday without being noticed by the receptionist at the front desk. A review of Resident 1's clinical records indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses that include toxic [CONDITION(S)] ([CONDITION(S)] caused by toxic exposure), alcohol dependence with withdrawal [CONDITION(S)] (a severe type of withdrawal from alcohol), [CONDITION(S)] disorder (a mental disorder characterized by abnormal thought processes and an unstable mood), anxiety disorder (mental illness that causes constant and overwhelming anxiety and fear), and [CONDITION(S)] disorder (a sudden, uncontrolled electrical disturbance in the brain). A review of Resident 1's Departmental Notes, dated April 21, 2022, at 5:04 PM, indicated, Resident was noted to not be in the facility. His last known time was 1345 (1:45 PM). Emergency procedure initiated at 1438 (2:38 PM) and staff searched the surrounding area. He was located at 1500 (3:00 PM). During an interview on April 22, 2022, at 3:24 PM, with Licensed Vocational Nurse (LVN) 1, in the conference room, LVN 1 stated on April 21, 2022, at 1:45 PM, she went to give Resident 1 his afternoon medications and noticed he was not in his room or bathroom. She looked down the hallways outside his room and the enclosed patio where he is usually hanging out and could not find him, so she initiated a code (term used in hospitals to describe an emergency situation) for elopement. She stated that Resident 1 was assessed as a high risk for eloping based on information gathered upon admission endorsement from another facility or from family. A review of Resident 1's Patient Care Plan: Elopement, dated April 9, 2022 (one day after admission), indicated interventions to include, Assist in re-orientation to room/facility. Frequent visual checks. Monitor behavior and mood patterns QS (every shift). Keep a hazard free environment. Notify MD any significant changes noted. Encourage activities of residents choice and preference. During a concurrent interview and record review on April 22, 2022, at 4:09 PM, with the Director of Nursing (DON), Resident 1's Elopement Risk Assessment, dated April 9, 2022 (one day after admission) was reviewed. The assessment indicated Resident 1 was cognitively impaired with poor decision-making skills, had a history of leaving facility without informing staff, had verbally expressed the desire to go home, had been recently admitted (within past 30 days) and not accepting of situation, and family/responsible party had voiced concerns that would indicate the resident may have wandering tendencies or try to leave. The Elopement Risk Assessment, indicated a total score of 12 (total score above 10 represents high risk for eloping). Summary of the assessment indicated Resident 1 to be at risk for elopement at this time as evidenced by attempting to leave facility. The DON stated, when a resident is high risk for eloping, the resident should have an identification bracelet, photograph on wander list, and staff to be aware of resident's wander risk. During a follow up telephone interview on April 28, 2022, at 2:23 PM, with DON, she stated she got in her car and found him on a busy road approximately half a mile from the facility. During a follow-up telephone interview on April 29, 2022, at 10:11 AM, with the DON, she stated residents are assessed upon admission and if found to be high risk, they receive 72-hour monitoring and then IDT (interdisciplinary team = group of healthcare professionals from different fields who work together to manage the needs of the patient) will determine if they are to remain as high risk. If a resident lacks the capacity to understand the facility's rules on leaving the premises, then those residents will receive monitoring continuously thereafter. She further stated if the resident is exit-seeking, has attempted to leave the facility, or has eloped, then they would request a physician order for a wander guard bracelet. During a telephone interview on June 2, 2022, at 10:07 AM, with Certified Nursing Assistant (CNA) 1, she stated she was assigned to Resident 1 when he eloped. She was not aware that Resident 1 was at risk for elopement. CNA 1 stated that prior to the elopement, Resident 1 was eating lunch in his room and told her his family was going to take him home that day. She stated she thought he was just confused and notified LVN who told her that he always says that. CNA 1 stated she continued picking up lunch trays in her other rooms and that is when she heard he had eloped. During a telephone interview on May 13, 2022, at 10:08 AM, with Receptionist 1 (was working on the date and time Resident 1 eloped), she stated her responsibilities include ensuring residents who are at risk of eloping do not get out of the facility premises. She stated she did not see Resident 1 leaving the facility, there were more than 12 nursing students wearing white scrubs going in and out the main entrance and it was really busy at that time. She stated residents are supposed to wear an identification bracelet, but some will remove it. She tends to know the residents who would most likely leave and does not necessarily look at the orange elopement binder. During a review of the facility's policy and procedure (P&P) titled, Wandering and Elopements, revised 2019, the P&P indicated, If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. During a follow up interview on May 17, 2022, at 1:28 PM, with Administrator (ADM) in their office, ADM stated they do not have P&Ps relating to risk of elopement/wandering, supervision, or neglect.

F 755 Based on interview and record review, the facility failed to ensure: I. For 10 of 11 sampled residents (Resident 1, 2, 4, 5, 6, 7, 8, 9, 10, and Resident 11) that they received their scheduled medications as ordered, and that the licensed nursing staff documented the administration or reason for not administering a medication as per facility policy and procedure. This failure resulted in 10 residents not receiving their scheduled medications as prescribed by the physician, which had the potential for health conditions to worsen or not be resolved due to incomplete dosing as prescribed in a universe of 93 residents. II. The facility's policy and procedure titled Discarding and Destroying Medications, dated October 2014 was not followed for 81 of 99 residents when the facility disposed of medications without documenting the name of the dispensing pharmacy, a obtaining a cosignature, nor indicating a method of disposition. This failure had the potential for the inadvertent access and exposure of medications that can result in harm or death. Findings: I 1. A review of Resident 1's face sheet (a record that provides the demographic data) indicated he was admitted to the facility initially on April 30, 2018, and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's physician orders [REDACTED]. a. February 6, 2020, the physician ordered one gram (gm - a unit of measurement) every day for seven days for a urinary tract infection. b. February 6, 2020, the physician changed the order to be started at 0.5 gm IM on February 7, 2020 every 12 hours for seven days. c. February 10, 2020 the physician changed the order to one gram IM twice a day for five days, then discontinued the order on February 12, 2020 A review of Resident 1's Electronic Medication Administration Record [REDACTED]. During an interview on February 21, 2020, at 1:56 PM, with the Director of Medical Record (MRD), she stated the medications administrations were documented on a paper MAR. During an interview with Registered Nurse Supervisor (RNS) 1, on February 21, 2020, at 1:20 PM, she stated the medications administrations were documented on a paper MAR. During a concurrent interview and record review on March 2, 2020, at 12:09 PM, with the MRD, she reviewed the paper MAR for Resident 1, for the month of February 2020. The MRD verified that there was no documented evidence in the paper MAR indicated [REDACTED] 2. A review of Resident 2's face sheet indicated Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 2's physician orders [REDACTED]. a. [MEDICATION NAME] (a [MEDICAL CONDITION] medication) 500 mg (mg - milligram a unit of measurement) tablet by gastric tube (a tube to the stomach) two times a day b. [MEDICATION NAME] (a [MEDICAL CONDITION] medication-affects mental state) 50 mg tablet by mouth two times a day c. [MEDICATION NAME] (a [MEDICAL CONDITION] and pain medication) 100 mg capsule by gastric tube three times a day d. [MEDICATION NAME] (a medication to treat heartburn and increased stomach acid) 150 mg tablet by gastric tube two times a day e. [MEDICATION NAME] (a medication that lowers blood pressure) 25 mg tablet by gastric tube each day. Hold if SBP (Systolic blood pressure (pressure exerted on the blood vessels when the heart contracts)) <100 or HR (heart rate) <60. f. [MEDICATION NAME] (a medication that affects the [MEDICAL CONDITION]) 88 mcg (micrograms-a unit of measure) tablet by gastric tube each day. g. [MEDICATION NAME] (a medication that lowers cholesterol) 20 mg tablet by gastric tube each day at bedtime A review of Resident 2's e-MAR for the month of February 2020, indicated Resident 2 neither received all doses of the scheduled medications, nor was there documentation indicating the reason for omission. The random omitted doses of medication from the e-MAR for the month of February 2020 are as follows: a. [MEDICATION NAME] 500 mg tablet - Five of 58 scheduled doses b. Tablet [MEDICATION NAME] 50 mg tablet - Five of 43 scheduled doses c. Capsule [MEDICATION NAME] 100 mg - Ten of 87 scheduled doses d. Tablet [MEDICATION NAME] 150 mg - Four of 58 scheduled doses e. Tablet [MEDICATION NAME] 25 mg - Ten of 29 scheduled doses f. Tablet [MEDICATION NAME] 88 mcg - Six of 29 scheduled doses g. Tablet [MEDICATION NAME] 20 mg - Four of 29 scheduled doses During an interview and concurrent record review with the Director of Nurses (DON), on February 18, 2020, at 1:04 PM, she reviewed the record of missing documentation and blank spaces on the e-MAR . She could not explain why there was missing documentation. During a concurrent interview and record review on February 18, 2020, at 1:25 PM, with the RNS 1, and the Licensed Vocational Nurse (LVN 1) at the west nursing station. RNS 1 and LVN 1 were unable to explain why there was missing documentation on the e-MAR, or whether the resident had received the prescribed medications. During an interview with LVN 2, on February 21, 2020, at 11:18 AM, she stated if there was any issue with the e-MAR, the staff are required to document on the paper MAR. LVN 1 verbalized there had been some days the computer wasn't working, so paper MARs had been used. During a concurrent interview and record review with the MRD and Medical Records Assistant (MRA) on March 2, 2020 at 1:56 PM, the MRD stated when computer documentation is not accessible, the staff were required to document in the paper MAR. The MRD reviewed the paper MAR binder for the month of February and verified no medication administration was documented on the paper MAR. The MRD further stated If it (medication administration) is not documented it (medication) is not given. A review of the facility's medication destruction log dated February 15, 2020, indicated the facility disposed of 14 doses of [MEDICATION NAME] capsule 100 mg that were prescribed to Resident 2 and filled on December 23, 2019. 3. A review of Resident 4's face sheet indicated Resident 4 was initially admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 4's physician orders [REDACTED]. a. Tablet [MEDICATION NAME] (medication that lowers blood pressure) 50 mg one tablet daily orally for high blood pressure (B.P.), hold if SBP (Systolic blood pressure is less than) <110, or HR (heart rate is less than) <60, with a start date of October 2019. b. Tablet [MEDICATION NAME] (medication that lowers blood pressure) 2.5 mg daily orally for high blood pressure with a start date of October 2019. c. Tablet [MEDICATION NAME] (an antidepressant) 5 mg daily orally for depression, with a start date of October 2019. d. Tablet Xarelto (an antidepressant) 2.5 mg daily orally [MEDICAL CONDITION]([MEDICAL CONDITION]- damage to the brain from interrupted blood supply) [MEDICATION NAME] (preventative) with a start date of October 2019. e. Tablet Aripiprazole (a [MEDICAL CONDITION] medication) 2.5 mg daily, orally for [MEDICAL CONDITION] (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) with a start date of December 2019. f. [MEDICATION NAME](a medication that lowers blood sugar) per sliding scale per blood sugar AC (before meals) and HS (at bedtime) A review of Resident 4's e-MAR for the month of February 2020, indicated Resident 4 neither received all doses of the scheduled medications as prescribed, nor was there documentation indicating the reason for omissions. The random omitted doses of medication from the e-MAR for the month of February 2020 are as follows: a. Tablet [MEDICATION NAME] 50 mg - Six of 40 scheduled doses. b. Tablet [MEDICATION NAME] 2.5 mg - Five of 20 scheduled doses. c. Tablet [MEDICATION NAME] 5 mg - Three of 20 scheduled doses. d. Tablet Xarelto 2.5 mg - Three of 20 scheduled doses. e. Tablet Aripiprazole 5 mg - Three of 20 scheduled doses. f. Tablet [MEDICATION NAME]and blood sugar monitoring - Four of 60 times. During an interview with LVN 2 on February 21, 2020, at 11:18 AM, she stated if there is any issue with e-MAR, the staff are required to document in the paper MAR. During an interview and concurrent record review on March 2, 2020, at 12:09 PM, with the MRD, she reviewed the paper MAR for Resident 4 for the month of February 2020. The MRD verified there was not documented evidence the above medications were given. During an interview and record review with the MRD and the MRA on March 2, 2020, at 1:56 PM, MRD stated when computer documentation is not accessible, the staff are required to document on the paper MAR. The MRD reviewed the paper MAR binder for the month of February and verified no medication administration was documented on the paper MAR. The MRD further stated If it (medication administration) is not documented it (medication) is not given. A review of the facility's medication destruction log dated February 16, 2020, indicated the facility disposed of five doses of [MEDICATION NAME] Tartate tablet 50 mg that were prescribed to Resident 4 and filled on January 23, 2020. A review of the facility's medication destruction log dated February 4, 2020, indicated the facility disposed of two doses of [MEDICATION NAME] tablet 50 mg that were prescribed to Resident 4 and filled on January 06, 2020. A review of the facility's medication destruction log dated February 16, 2020, indicated the facility disposed of 11 doses of [MEDICATION NAME] tablet 50 mg that were prescribed to Resident 4 and filled on January 23, 2020. A review of the facility's medication destruction log dated February 16, 2020, indicated the facility disposed of four doses of [MEDICATION NAME] tablet 5 mg that were prescribed to Resident 4 and filled on December 24, 2019. A review of the facility's medication destruction log dated February 16, 2020, indicated the facility disposed of 10 doses of [MEDICATION NAME] tablet 2.5 mg that were prescribed to Resident 4 and filled on December 24, 2019. 4. A record review of Resident 5's face sheet indicated he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 5's physician orders [REDACTED]. a. Tablet [MEDICATION NAME] (medication that lowers blood pressure) 20 mg capsule orally three times a day, hold SBP below 110, with a start date of February 1, 2019. b. Tablet Aspirin (a medication that treats pain) EC (coating to protect the stomach from irritation) 81 mg orally once a day with a start date of February 1, 2019. c. Tablet Losartan Potassium (a medication that lowers blood pressure) 100 mg two tablets daily for hypertension. Hold for SBP below 110 or Pulse below 60, with a start date of January 24, 2020. d. Atorvastatin (a medication that lowers cholesterol) 20 mg orally daily with a start date of December 14, 2019. e. Tablet [MEDICATION NAME] (a [MEDICAL CONDITION] medication) 2.5 mg orally every eight hours with a start date of January 20, 2020. A review of Resident 5's e-MAR for the month of February 2020, indicated Resident 5 neither receive all doses of the scheduled medications, nor was there documentation indicating the reason for omission. The omitted doses of medication from the e-MAR for the month of February 2020 are as follows: a. Tablet [MEDICATION NAME] 20 mg - 15 of 62 scheduled doses. b. Tablet Aspirin 81 mg - Four of 21 scheduled doses. c. Losartan Potassium 100mg - Four of 21 scheduled doses d. Atorvastatin 20 mg- eight of 21 scheduled doses e. Tablet [MEDICATION NAME] 2.5 mg- 12 of 62 scheduled doses. During an interview with LVN 2 on February 21, 2020, at 11:18 AM, she stated if there is any issue with e-MAR, the staff are required to document in the paper MAR. During an interview and concurrent record review on March 2, 2020, at 12:09 PM, with MRD, she reviewed the paper MAR for Resident 5 for the month of February 2020. The MRD verified there was not documented evidence the above medications were given. During an interview and record review with MRD and MRA on March 2, 2020 at 1:56 PM, MRD stated when computer documentation is not accessible, the staff were required to document in the paper MAR. The MRD reviewed the paper MAR binder for the month of February and verified no medication administration were documented in the paper MAR. The MRD further stated If it (medication administration) is not documented it (medication) is not given. 5. A review of Resident 6's face sheet indicated she was admitted to the facility on [DATE]. A review of Resident 6's History and Physical (H&P) dated February 2020, indicated Resident 6 was admitted to the facility with [DIAGNOSES REDACTED]. A review of Resident 6's physician orders [REDACTED]. a. [MEDICATION NAME] Sodium (a medication that affects the blood's ability to clot) 5000 units subcutaneously (Sub Q-under the skin) every eight hours for six days with a start date of February 13, 2020. b. Tablet Aspirin 81 mg twice a day with a start date of February 13, 2020. c. Injection [MEDICATION NAME] (a medication that treats certain infections) 1gram IV (intravenous-in the vein) piggyback (intermittent administration) every 8 hours for 6 weeks [MEDICAL CONDITION] (infection) of left hip wound infection, with a start date of February 13, 2020 and discontinued date of February 23, 2020. A review of Resident 6's e-MAR for the month of February 2020, indicated Resident 6 neither receive all doses of the scheduled medications, nor was there documentation indicating the reason for omission. The omitted doses of medication from the e-MAR for the month of February 2020 are as follows: a. [MEDICATION NAME] Sodium 5000 units sub Q - three of 12 scheduled doses. b. Tablet Aspirin 81 mg - four of 12 scheduled doses. c. Injection [MEDICATION NAME] 1 gram- 33 of 33 scheduled doses. During an interview with LVN 2 on February 21, 2020, at 11:18 AM, she stated if there is any issue with e-MAR, the staff are required to document in the paper MAR. During an interview with RNS 1, on February 21, 2020 at 1:20 PM, she stated the IV medications administrations were documented in a paper MAR. During an interview on February 21, 2020, at 1:56 PM, with the MRD, she stated the IV medications administrations were documented in a paper MAR. During an interview and concurrent record review on March 2, 2020, at 12:09 PM, with MRD, she reviewed the paper MAR for Resident 6, for the month of February 2020. The MRD verified there was not documented evidence the above medications were given. During an interview and record review with MRD and MRA on March 2, 2020 at 1:56 PM, MRD stated when computer documentation is not accessible, the staff were required to document in the paper MAR. The MRD reviewed the paper MAR binder for the month of February and verified no medication administration were documented in the paper MAR. The MRD further stated If it (medication administration) is not documented it (medication) is not given. 6. A review of Resident 7's face sheet indicated she was admitted initially to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 7's physician orders [REDACTED]. a. Salonpas (a pain medication) patch apply one patch [MEDICATION NAME] (through the skin) to affected areas once daily for pain management with a start date of August 2019. b. Tablet [MEDICATION NAME] (a medication that lowers cholesterol) 40 mg one daily at bedtime, with a start date of February 1, 2019. c. Tablet [MEDICATION NAME] (a [MEDICAL CONDITION] medication) 25 mg by orally daily at bedtime, with a start date of February 8, 2019. d. Tablet Divalporex (a medication that treats [MEDICAL CONDITION]) Sodium DR (delayed release) 125 mg orally every 12 hours with a start date of September, 20, 2019. e. Tablet [MEDICATION NAME] (a medication that lowers blood sugar) HCL 250 mg one tablet twice daily with meals, with a start date of July 22, 2019. f. Tablet [MEDICATION NAME] (a medication that treats anxiety) HCL 10 mg twice daily for anxiety, with a start date of January 15, 2020. g. Tablet Xarelto 20 mg orally daily with a start date of February 1, 2019. h. Tablet Aspirin 81 mg once daily, with a start date of February 1, 2019. i. Tablet Losartan Potassium 25 mg orally daily. Hold if SBP<110 or Pulse <60, with a start date of June 28, 2019. j. Tablet [MEDICATION NAME] (an antidepressant) 50 mg once daily, with a start date of July 3, 2019. k. Insulin [MEDICATION NAME] (a medication that lowers blood sugary) with sliding scale AC and HS, with a start date of January 1, 2019 and a stop date of February 17, 2020. A review of Resident 7's e-MAR for the month of February 2020, indicated Resident 7 neither receive all doses of the scheduled medications, nor was there documentation indicating the reason for omission. The omitted doses of medication from the e-MAR for the month of February 2020 are as follows: a. Insulin [MEDICATION NAME] with sliding scale QID and HS- 17 of 68 times. b. Tablet [MEDICATION NAME] HCL 10 mg -Two of 21 scheduled doses. c. Tablet [MEDICATION NAME] HCL 250 mg -24 of 43 scheduled doses. d. Tablet Xarelto 20 mg -Two of 21 scheduled doses. e. Tablet Aspirin 81 mg- Two of 21 scheduled doses. f. Tablet Losartan Potassium 25 mg- Two of 21 scheduled doses. g. Tablet [MEDICATION NAME] 50 mg- Two of 21 scheduled doses h. Salonpas patch - Four of 21 scheduled doses. i. Tablet [MEDICATION NAME] 40 mg -Eight of 20 scheduled doses. j. Tablet [MEDICATION NAME] 25 mg- Eight of 20 scheduled doses. k. Tablet Divalporex Sodium 125 mg-10 of 41 scheduled doses. During an interview with LVN 2 on February 21, 2020, at 11:18 AM, she stated if there is any issue with e-MAR, the staff are required to document in the paper MAR. During an interview and concurrent record review on March 2, 2020, at 12:09 PM, with MRD, she reviewed the paper MAR for Resident 7 for the month of February 2020. The MRD verified there was not documented evidence the above medications were given. During an interview and record review with MRD and MRA on March 2, 2020 at 1:56 PM, MRD stated when computer documentation is not accessible, the staff were required to document in the paper MAR. The MRD reviewed the paper MAR binder for the month of February and verified no medication administration were documented in the paper MAR. The MRD further stated If it (medication administration) is not documented it (medication) is not given. 7. A review of Resident 8's face sheet indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 8's physician orders [REDACTED]. a. Tablet [MEDICATION NAME] (a medication that affects the [MEDICAL CONDITION]) 100 mcg daily via PEG (a tube to the stomach) tube with start date of February 12, 2020. b. Tablet Trazadone (a medication that treats depression) 100 mg at bedtime via PEG tube, with a start date of February 12, 2020. c. Tablet [MEDICATION NAME] (a [MEDICAL CONDITION] medication) 20 mg daily at bedtime via PEG tube with a start date of February 12, 2020. d. Tablet [MEDICATION NAME] (a medication that treats [MEDICAL CONDITION]) DR 125 mg (give four tablets) twice a day with a start date of February 12, 2020. A review of Resident 8's e-MAR for the month of February 2020, indicated Resident 8 neither receive all doses of the scheduled medications, nor was there documentation indicating the reason for the omission. The omitted doses of medication from the e-MAR for the month of February 2020 are as follows: a. Tablet [MEDICATION NAME] DR 125 mg (give four tabs) -Six of 19 scheduled doses. b. Tablet [MEDICATION NAME] 100 mg -Seven of nine scheduled doses. c. Tablet Trazadone 100 mg- Three of eight scheduled doses. d. Tablet [MEDICATION NAME] 20 mg - Three of seven scheduled doses During an interview with LVN 2 on February 21, 2020, at 11:18 AM, she stated if there is any issue with e-MAR, the staff are required to document in the paper MAR. During an interview and concurrent record review on March 2, 2020, at 12:09 PM, with MRD, she reviewed the paper MAR for Resident 8 for the month of February 2020. The MRD verified there was not documented evidence the above medications were given. During an interview and record review with MRD and MRA on March 2, 2020 at 1:56 PM, MRD stated when computer documentation is not accessible, the staff were required to document in the paper MAR. The MRD reviewed the paper MAR binder for the month of February and verified no medication administration were documented in the paper MAR. The MRD further stated If it (medication administration) is not documented it (medication) is not given. 8. A review of Resident 9's face sheet indicated Resident 9 was admitted to the facility initially on September 2011 and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 9's physician orders [REDACTED]. a. Tablet [MEDICATION NAME] (a [MEDICAL CONDITION] medication) one mg at bedtime with a start date of February 3, 2020. b. Tablet Carvedilol (a medication that lowers blood pressure) 2.125 mg twice a day, orally [MEDICAL CONDITION](elevated blood pressure), hold if SBP<110, HR<60, with a start date of February 3, 2020. c. [MEDICATION NAME] 600 mg twice a day for nerve pain with a start date of February 3, 2020 d. Tablet Memantine (a medication that treats dementia (a condition that affects thinking)) HCL 10 mg twice a day for Alzheimer's with a start date of February 3, 2020. e. Tablet Rivastigmine (a medication that treats dementia) 3 mg twice a day for dementia with a start date of February 3, 2020 f. Tablet [MEDICATION NAME] 4mg twice a day for muscle spasms with a start date of February 3, 2020. g. Tablet Aspirin 81 mg daily with a start date of February 3, 2020. h. Tablet [MEDICATION NAME] (a medication that treats certain infections) 500 mg daily for five days for UTI, with a start date of February 3, 2020. i. Capsule [MEDICATION NAME] (an antidepressant) 30 mg, two capsule, daily for nerve pain with a start date of February 3, 2020. j. Tablet Nateglinide (a medication that lowers blood sugar) 120 mg orally three times a day before meals for diabetes (the body's inability to regulate blood sugar) with a start date of February 3, 2020 A review of Resident 9's e-MAR for the month of February 2020, indicated Resident 9 neither receive all doses of the scheduled medications, nor was there documentation indicating the reason for omission. The omitted doses of medication from the e-MAR for the month of February 2020 are as follows: a. Tablet [MEDICATION NAME] 1 mg- Six of 19 scheduled doses b. Tablet Carvedilol 3.125 mg -Six of 28 scheduled doses c. Tablet [MEDICATION NAME] 600 mg- Five of 28 scheduled doses. d. Tablet Memantine HCL10 mg- Five of 28 scheduled doses e. Tablet Rivastigmine 3 mg- Five of 28 scheduled doses f. Tablet [MEDICATION NAME] 4 mg- Five of 28 scheduled doses g. Tablet Aspirin 81 mg- Two of 19 scheduled doses h. Capsule [MEDICATION NAME] 30 mg, two capsules - Two of 19 scheduled doses i. Tablet [MEDICATION NAME] 500 mg -Two of five scheduled doses. j. Tablet Nateglinide 120 mg- Eight of 57 scheduled doses. During an interview with LVN 2 on February 21, 2020, at 11:18 AM, she stated if there is any issue with e-MAR, the staff are required to document in the paper MAR. During an interview and concurrent record review on March 2, 2020, at 12:09 PM, with MRD, she reviewed the paper MAR for Resident 9 for the month of February 2020. The MRD verified there was not documented evidence the above medications were given. During an interview and record review with MRD and MRA on March 2, 2020 at 1:56 PM, MRD stated when computer documentation is not accessible, the staff were required to document in the paper MAR. The MRD reviewed the paper MAR binder for the month of February and verified no medication administration were documented in the paper MAR. The MRD further stated If it (medication administration) is not documented it (medication) is not given. A review of the facility's medication destruction log dated February 16, 2020, indicated the facility disposed of 11 doses of Carvedilol tablet 3.125 mg that were prescribed to Resident 9 and filled on December 23, 2019. A review of the facility's medication destruction log dated February 16, 2020, indicated the facility disposed of nine doses of Rivastigmine capsule 3 mg that were prescribed to Resident 9 and filled on December 27, 2019. A review of the facility's medication destruction log dated February 16, 2020, indicated the facility disposed of nine doses of Nateglinide tablet 120 mg that were prescribed to Resident 9 and filled on December 27, 2019. A review of the facility's medication destruction log dated February 16, 2020, indicated the facility disposed of nine doses of Memantine tablet HCL 10 mg that were prescribed to Resident 9 and filled on December 23, 2019. A review of the facility's medication destruction log dated February 16, 2020, indicated the facility disposed of nine doses of [MEDICATION NAME] tablet 600 mg that were prescribed to Resident 9 and filled on December 23, 2019. 9. A review of Resident 10's face sheet indicated, Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 10's physician orders [REDACTED]. a. Tablet Bactrim DS (a medication to treat certain infections) one tablet orally every 6 hours for bacterial infection with a start date of January 31, 2020 and a stop date of February 21, 2020. b. Tablet [MEDICATION NAME] 5 mg daily for HTN, hold if SBP<110 or DBP <60, with a start date of January 30, 2020. c. Tablet Aspirin 81 mg daily, with a start date of January 30, 2020. d. Tablet Olmesartan Medoxomil (a medication that lowers blood pressure) 5 mg daily for HTN, hold if SBP<110 or DBP<60. e. Tablet [MEDICATION NAME] HCL 500 mg orally daily for diabetes with a start date of January 30, 2020. f. Tablet [MEDICATION NAME] (a medication to treat muscle spasms of the bladder) CL ER 15 mg po daily for over reactive bladder, with a start date of January 30, 2020. g. Tablet [MEDICATION NAME] (a medication to treat pain and depression) HCL ER 75 mg daily for nerve pain with a start date of January 30, 2020. h. Insulin [MEDICATION NAME] (a medication that lowers blood sugar), give sub Q before meals and HS per sliding scale, with a start date of January 30, 2020. i. Injection [MEDICATION NAME] (a medication that affects the blood's ability to clot) Sub Q daily, with a start date of January 30, 2020 and a stop date of February 21, 2020. A review of Resident 10's e-MAR for the month of February 2020, indicated Resident 10 neither received all doses of the scheduled medications, nor was there documentation indicating a reason for omission. The omitted doses of medication from the e-MAR for the month of February 2020 are as follows: a. Tablet Bactrim DS - Three of 21 scheduled doses. b. Tablet [MEDICATION NAME] 5 mg- Three of 21 scheduled doses. c. Tablet Aspirin 81 mg -Three of 21 scheduled doses. d. Tablet Olmesartan Medoxomil 5 mg -Three of 21 scheduled doses e. Tablet [MEDICATION NAME] HCL 500 mg- Three of 21 scheduled doses f. Tablet [MEDICATION NAME] 15 mg -Three of 21 scheduled doses g. Injection [MEDICATION NAME] - Three of 21 scheduled doses h. Tablet [MEDICATION NAME] HCL ER 75 mg- Three of 20 scheduled doses i. Insulin [MEDICATION NAME] - Five of 83 scheduled times During an interview with LVN 2 on February 21, 2020, at 11:18 AM, she stated if there is any issue with e-MAR, the staff are required to document in the paper MAR. During an interview and concurrent record review on March 2, 2020, at 12:09 PM, with MRD, she reviewed the paper MAR for Resident 10 for the month of February 2020. The MRD verified there was not documented evidence the above medications were given. During an interview and record review with MRD and MRA on March 2, 2020 at 1:56 PM, MRD stated when computer documentation is not accessible, the staff were required to document in the paper MAR. The MRD reviewed the paper MAR binder for the month of February and verified no medication administration were documented in the paper MAR. The MRD further stated If it (medication administration) is not documented it (medication) is not given. 10. A review of Resident 11's face sheet indicated, Resident 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 11's physician orders [REDACTED]. a. Tablet [MEDICATION NAME] 5 mg daily for high blood pressure with a start date of October 19, 2019. b. Tablet [MEDICATION NAME] HCL 1000 mg (give with meals) with a start date of December 23, 2019. c. [MEDICATION NAME] R 100 unit/ml sub Q per sliding scale per blood sugar AC and HS with a start date of October 25, 2019. A review of Resident 11's e-MAR for the month of February 2020, indicated Resident 11 neither received all the scheduled medications, nor was there documentation indicating the reason for omission. The omitted doses of medication from the e-MAR for the month of February 2020 are as follows: a. [MEDICATION NAME] 5 mg- Four of 21 scheduled doses b. [MEDICATION NAME] HCL 1000

Based on interview, and record review, the facility failed to ensure the residents were free from unnecessary medications, when: 1. Six of ten residents (Resident 2, 5, 6, 7, 8, and 9) who were receiving [MEDICAL CONDITION] medications (any drug that affects brain activities associated with mental processes and behavior) did not have any monitoring of [MEDICAL CONDITION] medication side effects. This failure had the potential for these residents to be exposed to unnecessary medications and their side effects. 2. Seven of ten residents (Resident 2, 4, 5, 6, 7, 8, and 9) did not have an informed consent obtained prior to administering [MEDICAL CONDITION] medication. This failure had the potential for residents or the resident's representatives to not be involved in the medication management process and result in the residents receiving unnecessary medications. Findings: An unannounced onsite visit was conducted on February 13, 2020, to investigate a facility reported incident of resident to resident altercation. 1.a. A record review of Resident 2's face sheet (a record that provides the demographic data) indicated he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A record review of Resident 2's physician orders for the month of February 2020, indicated, Resident 2, was receiving [MEDICATION NAME] (a [MEDICAL CONDITION] medication) 50 milligram (mg-a unit of measurement) twice a day since August 27, 2019. A record review of Resident 2's Medication Administration Record [REDACTED]. The potential side effects can include dizziness, restlessness, tremors, mood changes, thoughts of suicide, difficulty swallowing, interrupted breathing during sleep, [MEDICAL CONDITIONS], and high blood sugar. During an interview with Registered Nurse (RN)1, on February 21, 2020, at 4:16 PM, she stated the licensed staff are required to document the side effects of [MEDICAL CONDITION] medications in the MAR. b. A record review of Resident 5's face sheet indicated he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A record review of Resident 5's physician orders for the month of February 2020, indicated Resident 5 was receiving tablet [MEDICATION NAME] (a [MEDICAL CONDITION] medication) 2.5 mg every 8 hours since January 22, 2020. A record review of Resident 5's MAR indicated [REDACTED]. Potential side effects can include risk of death in older adults with dementia-related conditions, weight gain, high cholesterol, high blood sugar, dizziness. During an interview with the RN1, on February 21, 2020, at 4:16 PM, she stated the licensed staff are required to document the side effects of [MEDICAL CONDITION] medications in the MAR. c. A record review of Resident 6's face sheet indicated she was admitted to the facility on [DATE]. A record review of Resident 6's History and Physical (H&P) dated February 2020, indicated Resident 6 was admitted to the facility with [DIAGNOSES REDACTED]. A record review of Resident 6's physician orders for the month of February 2020, indicated Resident 6 was receiving the following [MEDICAL CONDITION] medications: [REDACTED] I. [MEDICATION NAME] XR (extended release) 150 mg daily at bedtime (start date February 13, 2020) II. [MEDICATION NAME] (a [MEDICAL CONDITION] medication) 0.5 mg three times a day whenever necessary (start date February 13, 2020) A record review of Resident 6's MAR indicated [REDACTED]. The potential side effects can include dizziness, restlessness, tremors, mood changes, thoughts of suicide, difficulty swallowing, interrupted breathing during sleep, [MEDICAL CONDITIONS] and high blood sugar. During an interview with RN 1, on February 21, 2020, at 4:16 PM, she stated the licensed staff are required to document the side effects of the [MEDICAL CONDITION] medications in the MAR. d. A record review of Resident 7's face sheet indicated she was admitted initially to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A record review of Resident 7's physician orders indicated Resident 7 was receiving tablet [MEDICATION NAME] 25 mg by mouth daily at bedtime with a start date of February 8, 2019 for depression/[MEDICAL CONDITION] disorder (a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks) manifested by mood swings. A record review of Resident 7's MAR indicated [REDACTED]. The potential side effects can include dizziness, restlessness, tremors, mood changes, thoughts of suicide, difficulty swallowing, interrupted breathing during sleep, [MEDICAL CONDITIONS] and high blood sugar. During an interview with RN 1, on February 21, 2020, at 4:16 PM, she stated the licensed staff are required to document the side effects of [MEDICAL CONDITION] medications in the MAR. e. A record review of Resident 8's face sheet indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A record review of Resident 8's physician orders for the month of February 2020, indicated Resident 8 was receiving [MEDICATION NAME] (a [MEDICAL CONDITION] medication) 100 mg at bedtime and [MEDICATION NAME] (a [MEDICAL CONDITION] medication) 20 mg at bedtime for [MEDICAL CONDITION]. A record review of Resident 8's MAR indicated [REDACTED]. The potential side effects for [MEDICATION NAME] can include dizziness, headache, nausea, vomiting, [MEDICAL CONDITIONS] (swelling), confusion, low blood pressure, sedation, and [MEDICAL CONDITION](fast heartbeat, which can increase the risk of stroke and [MEDICAL CONDITION]). The potential side effects for [MEDICATION NAME] can include asthenia (abnormal physical weakness), dizziness, drowsiness, extrapyramidal reaction (movement disorders, tremors, irregular- jerky movements), akinesia (loss or impairment of voluntary movement), drug induced [MEDICAL CONDITION] (a progressive nervous system disorder that affects movement), orthostatic [MEDICAL CONDITION] (a form of low blood pressure that happens when standing up from a sitting or lying down position), and personality disorder. The risk of death is increased in elderly patients with dementia related [MEDICAL CONDITION] treated with antipsychotic drugs . During an interview with RN 1, on February 21, 2020, at 4:16 PM, she stated the licensed staff are required to document the side effects of [MEDICAL CONDITION] medications in the MAR. f. A review of Resident 9's face sheet indicated Resident 9 was admitted to the facility initially in September 2011 and readmitted on [DATE], with a [DIAGNOSES REDACTED]. A record review of Resident 9's physician orders for the month of February 2020, indicated Resident 9 was receiving [MEDICATION NAME] (a [MEDICAL CONDITION] medication) 1 mg for [MEDICAL CONDITION] disorder, with a start date of February 3, 2020. A record review of Resident 9's MAR indicated [REDACTED]. The potential side effects for [MEDICATION NAME] can include drowsiness, [MEDICAL CONDITION], agitation, anxiety, headache, fatigue, drug induced [MEDICAL CONDITION], tremors, QT prolongation (electrical disturbance in the heart), fast or slow heart rate, extrapyramidal reaction, [MEDICAL CONDITION], diabetes mellitus (high blood sugar). During an interview with RN 1, on February 21, 2020, at 4:16 PM, she stated the licensed staff are required to document the side effects of [MEDICAL CONDITION] medications in the MAR. 2.a. A record review of Resident 2's face sheet (a record that provide the demographic data of the resident) indicated he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A record review of Resident 2's physician orders for the month of February 2020, indicated, Resident 2, was receiving [MEDICATION NAME] 50 (a [MEDICAL CONDITION] medication) milligram (mg-a unit of measure) twice a day since August 27, 2019. During an interview with the Administrator (ADM) on February 18, 2020, at 11:20 AM, she reviewed Resident 2's clinical record. The ADM stated Resident 2 had no documented evidence of a completed informed consent. She further stated, the informed consent form is incomplete without a physician's signature and the form did not indicate from whom the facility obtained consent. During an interview with RN 1 on February 21, 2020, at 4:16 PM, she indicated the facility's process is that the staff verifies the consent on admission and for any new [MEDICAL CONDITION] medication order. She further stated the consent form would be placed in the paper chart. During an interview with Resident 2's Responsible Party (RP) on February 21, 2020 at 10:26 AM, the RP stated, she was never informed of the resident's medication by any staff member of the facility or physician. b. A record review of Resident 4's face sheet indicated Resident 4 initially was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A record review of Resident 4's physician orders for the month of February 2020, indicated Resident 4 was receiving Aripiprazole (a [MEDICAL CONDITION] medication) 2.5 mg daily for [MEDICAL CONDITION] (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) with a start date of December 7, 2019. During an interview with RN 1 on February 21, 2020, at 4:16 PM, she indicated the facility's process is that the staff verifies the consent on admission and for any new [MEDICAL CONDITION] medication order. She further stated the consent form would be placed in the paper chart. A review of Resident 4's clinical record had no documented evidence of an informed consent obtained prior to the administration of Aripiprazole. c. A record review of Resident 5's face sheet indicated he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 5's physician orders for the month of February 2020, indicated Resident 5 was receiving [MEDICATION NAME] (a [MEDICAL CONDITION] medication) 2.5 mg every 8 hours since January 22, 2020. During an interview with RN 1 on February 21, 2020, at 4:16 PM, she indicated the facility's process is that the staff verifies the consent on admission and for any new [MEDICAL CONDITION] medication order. She further stated the consent form would be placed in the paper chart. A review of Resident 5's clinical record had no documented evidence of an informed consent obtained prior to the administration of [MEDICATION NAME]. d. A review of Resident 6's face sheet indicated she was admitted to the facility on [DATE]. A review of Resident 6's H&P dated February 2020, indicated Resident 6 was admitted to the facility with [DIAGNOSES REDACTED]. A review of Resident 6's physician orders for the month of February 2020, indicated Resident 6 was receiving following [MEDICAL CONDITION] medications: [REDACTED] I. [MEDICATION NAME] XR 150 mg daily at bedtime (start date February 13, 2020) II. [MEDICATION NAME] (used to treat certain mental/mood disorders) 0.5 mg three times a day whenever necessary (start date February 2020) During an interview with RN 1 on February 21, 2020, at 4:16 PM, she indicated the facility's process is that the staff verifies the consent on admission and for any new [MEDICAL CONDITION] medication order. She further stated the consent form would be placed in the paper chart. A review of Resident 6's clinical record had no documented evidence of an informed consent obtained prior to the administration of [MEDICATION NAME] and [MEDICATION NAME]. e. A review of Resident 7's face sheet indicated she was admitted initially to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 7's physician orders indicated Resident 7 was receiving [MEDICATION NAME] 25 mg by mouth daily at bedtime with a start date of February 8, 2019 for depression/[MEDICAL CONDITION] disorder manifested by mood swings. During an interview with RN 1 on February 21, 2020, at 4:16 PM, she indicated the facility's process is that the staff verifies the consent on admission and for any new [MEDICAL CONDITION] medication order. She further stated the consent form would be placed in the paper chart. A review of Resident 7's clinical record had no documented evidence of an informed consent obtained prior to the administration of [MEDICATION NAME]. f. A review of Resident 8's face sheet indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 8's physician orders for the month of February 2020, indicated Resident 8 was receiving [MEDICATION NAME] (an antidepressant) 100 mg at bedtime and [MEDICATION NAME] (a [MEDICAL CONDITION] medication) 20 mg at bedtime for [MEDICAL CONDITION]. During an interview with RN 1 on February 21, 2020, at 4:16 PM, she indicated the facility's process is that the staff verifies the consent on admission and for any new [MEDICAL CONDITION] medication order. She further stated the consent form would be placed in the paper chart. A review of Resident 8's clinical record had no documented evidence of an informed consent obtained prior to the administration of [MEDICATION NAME] and [MEDICATION NAME]. g. A review of Resident 9's face sheet indicated Resident 9 was admitted to the facility initially on September 2011 and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 9's Physician order for [REDACTED]. During an interview with RN 1 on February 21, 2020, at 4:16 PM, she indicated the facility's process is that the staff verifies the consent on admission and for any new [MEDICAL CONDITION] medication order. She further stated the consent form would be placed in the paper chart. A review of Resident 9's clinical record had no documented evidence of an informed consent obtained prior to the administration of [MEDICATION NAME]. A review of the facility policy and procedure titled Informed Consent-[MEDICAL CONDITION] Medications and Restraint Devices revised December 2017, indicated 1. Resident has the right to: a. Make decisions about his/her medical condition; b. Accept or refuse the proposed treatment . 2. The healthcare practitioner ordering psychotherapeutic medication (physician ordering [MEDICAL CONDITION] or any medication that is identified/ used as a chemical restraint) or prolonged use of devices is responsible for: a. Obtaining informed consent, providing risks/benefits and other related information from the resident and/or resident's representative for use of such medication/devices; b. Providing documentation that informed consent was obtained, including the diagnosis/clinical indications for the medication or physical restraint .Under guidelines; 1. The attending physician (healthcare practitioner) will be responsible for; a. Ordering psychotherapeutic (restraint) medication and obtaining informed consent. b. Obtaining informed consent from the resident/surrogate decision maker . 3. The facility will be responsible for: a. Documenting verification of informed consent . A review of the facility's flow chart attached with policy and procedure titled Informed Consent-[MEDICAL CONDITION] Medications and Restraint Devices revised December 2017, indicated, for administering antipsychotic medication to the resident, the physician determines capacity and documents obtained informed consent. The flow chart further indicated if the resident is not capable to consent, the physician contacts the designated family members for consent. The flow chart indicated the facility must verify informed consent was obtained and document it in the clinical record. An Immediate Jeopardy situation (a situation in which the facility's non-compliance has placed the health and safety of residents at risk for harm) was called on February 21, 2020, at 7:23 PM, in the presence of the Administrator due to the facility's failure to ensure six of ten residents were monitored for [MEDICAL CONDITION] drug side effects and seven of ten residents had an informed consent to administer [MEDICAL CONDITION] medications. The corrective action plan included the following: Immediate Corrective Action Plan: The facility will assure the informed consent has been obtained by the physician for the medications(psychoactive) for those identified during this abbreviated survey. The licensed nurses have begun re-education to the facility policy. The psychoactive medication side effects/ behavior monitoring will be updated for these residents according to the medication (Each medication will be addressed separately). The Licensed nurses have begun re-education to the facility policy and procedure . On February 24, 2020, at 5:40 PM, the IJ was removed in the presence of the Administrator (ADM), and the Vice President of Operations (VPO), after an onsite verification of implementation of the corrective action plan was confirmed.

Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status for one of 19 sampled residents (Resident 3). This failure occurred when Resident 3 sustained a 19.4 pound (lb.) or a 9.8 % (percent) weight loss in one month despite receiving all nourishment from a tube feeding (nutrition formula fed through a tube directly into the stomach) and Resident 3 was bedbound with minimal activity. This failure resulted in a severe weight loss in a medically fragile resident. Findings: A review of the medical record for Resident 3 indicated a [DIAGNOSES REDACTED]. According to the physician orders, Resident 3 had an order for [REDACTED]. During observations on the following dates and times Resident 3 was observed sleeping in bed: October 26, 2015 at 12:00 PM and 3:25 PM October 28, 2015 at 6:15 AM, 12:30 PM and 2:05 PM October 29, 2015 at 8:30 AM, 10:30 AM and 11:55 AM A review of Resident 3's care plan, dated August 2015 - November 2015, indicated a Problem as (Resident 3) at risk for weight loss, dehydration and malnutrition related to dependent on staff for GT (gastrostomy tube) . feeding . The Goal listed on the care plan was (Resident 3) will have no significant weight loss X (for) 90 days. There was no care plan for a planned weight change for Resident 3. Further review of the medical record for Resident 3 included a facility document titled, Monthly Record of Vital Signs and Weights, dated February 8, 2013 through October 6, 2015. This document noted Resident 3's weight as follows: January 6, 2015 - 197.0 lbs. February 5, 2015 - 198.6 lbs. March 5, 2015 - 195.4 lbs. April 6, 2015 - 196.4 lbs. May 5, 2015 - 197.2 lbs June 7, 2015 - 177.8 lbs. On June 7, 2015, Resident 3 sustained a severe weight loss of 19.4 pounds or a 9.8 % weight loss in 30 days. In a review of the Registered Dietitian (RD) note dated June 9, 2015, the 19.4 lb weight loss in one month was noted. The RD note further indicated a recommendation to increase Resident 3's tube feeding of Glucerna 1.2 from 50 ml per hour for 20 hours to 55 ml per hour for 20 hours due to the weight loss. If implemented, this recommendation would have increased the calorie, protein and other nutritional values Resident 3 would have received. A review of the physician orders [REDACTED]. On June 13, 2015, there was an order to discontinue this order and restart Glucerna 1.2 at 50 ml per hour for 20 hours. A review of the Doctor's Progress Notes, dated June 19, 2015, indicated, (Resident) Has weight loss. Also cut down G (gastrostomy) tube feeding. Will monitor weight. There was no indication in the physician's note that the weight loss was desirable or planned. A review of the RD note dated June 19, 2015, indicated, MD declined increase in TF (tube feeding) rate. A review of the physician's orders [REDACTED]. This order decreased the tube feeding from 50 ml per hour for 20 hours to 50 ml per hour for 18 hours. This was a decrease in the nutritional content of the feeding provided to Resident 3 approximately one month after she had lost 19 lbs. in one month. Further review of the Monthly Record of Vital Signs and Weights, indicated on August 6, 2015, Resident 3 weighed 173.6 lbs. This represented an additional 4.3 lb. weight loss. A RD note, dated August 11, 2015, showed the additional weight loss and recommended to increase the tube feeding from 50 ml per hour for 18 hours to 55 ml per hour for 18 hours. A review of the physician's orders [REDACTED]. The laboratory values for Resident 3, dated August 13, 2015, were reviewed. The resident's [MEDICATION NAME] (a protein in the blood that can be an indicator of nutritional status) was 2.4 with an indication that it was low. The normal value for [MEDICATION NAME] was listed as 3.4 - 5.0. Further review of the Monthly Record of Vital Signs and Weights, indicated on September 7, 2015, Resident 3 weighed 171.4 lbs. indicating further weight loss. The RD note, dated September 15, 2015, indicated the continued weight loss. The RD note further documented, MD continues to decline increase to resident's GTF (gastrostomy tube feeding). The Monthly Record of Vital Signs and Weights, indicated on October 6, 2015, Resident 3 weighed 170.8 lbs. During a telephone interview with the RD on October 28, 2015 at 1:50 PM, the RD stated she could not explain why Resident 3 had a 19 lb. weight loss in June 2015. She stated she had made recommendations to increase the resident's tube feeding, but the MD declined. She did not know if the Medical Director had been told of the resident's weight loss and the MD's refusal to increase the tube feeding to prevent further weight loss. She stated that she had not documented a weight goal for Resident 3. She verified that the resident's care plan indicated a goal of no significant weight loss. During an interview with the Director of Nursing (DON) and the Administrator on October 29, 2015 at 10:30 AM, the DON stated that the RD and the nursing staff agreed that the resident's tube feeding should have been increased in response to Resident 3's 19 lb. weight loss in June 2015. The DON and the Administrator were unable to state why Resident 3's weight loss and the MD's refusal to implement the RD and nursing staff's recommendations to increase the tube feeding were not specifically brought to the Medical Director's attention. During an interview with Resident 3's physician on October 29, 2015 at 11:20 AM, she stated, I didn't believe 19.4 lb. weight loss was accurate. She could not explain how resident's weight before the loss was stable around 195-198 lbs. and after the weight loss the resident continued to lose more weight. She stated that there had not been a documented plan for weight loss for Resident 3 prior to the weight loss. She further stated that she did not want Resident 3 to lose any more weight. She was unable to explain how Resident 3 would stop losing weight without increasing the tube feeding. Resident 3's weight on May 5, 2015 was 197.2 lbs. Her weight on October 6, 2015 was 170.8 lbs. This represented a 26.4 lb. or 13.4 % weight loss in 5 months. There was no documented weight loss plan in the medical record. The care plan goal was for Resident 3's weight to be without significant loss. The facility did not request a specific review by the Medical Director of Resident 3's weight loss and her physician's refusal to take the recommendations of the RD and the nursing staff.

Based on observation, interview and record review, the facility failed to ensure the right of 1 of 3 sampled residents (Resident A) to be free from sexual abuse as evidenced by Resident A's complaint that certified nursing assistant 1 (CNA 1, a direct patient caregiver), had touched her "private area" ( vagina the female body part that connects the womb and cervix {lower end of the womb} to the outside of the body) inappropriately while providing incontinence care (cleaning a resident's perineal area to remove urine and/or feces). This resulted in emotional and physical pain suffered by Resident A. Findings: On 8/15/12, at 12:50 PM, an unannounced visit was made to the facility to investigate an entity reported incident regarding an alleged abuse. A review of Resident A's medical record on 8/15/12, noted Resident A was [AGE] years of age, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The minimum data set (MDS) admission assessment dated [DATE], noted that Resident A did not have short or long term memory problems, no behavior or mood problems, and was able to communicate needs. Resident A was incontinent (unable to control the process of urination and/or bowel movements) of bowel and bladder and needed one person physical assistance with activities of daily living (ADL), such as dressing and hygiene. The resident's history and physical (H & P) examination on 7/25/12, noted that Resident A had the capacity to understand and make her own decisions. A review of the investigation reports provided by the facility administrator on 8/15/12, dated 7/23 - 7/26/12, noted that the alleged incident happened when Resident A complained that she felt uncomfortable when a male CNA, described as white, tall, skinny with wavy hair, on the night shift (11 PM - 7 AM), touched her "private area" inappropriately while cleaning her and changing her incontinent brief. The report identified the male CNA as CNA 1, who had worked on the 11-7 shift on 7/19/12, the date of the alleged incident, and was assigned to care for Resident A. During a record review, conducted on 8/15/12, of the interviews with Resident A, regarding the incident, the report documented Resident A was observed to be "a bit tearful" and had complained that while CNA 1 was changing her diaper, CNA 1, "Stuck his finger down there (Resident A's private area) and was being extremely rough," "... was painful," and "...uncomfortable." The report noted that Resident A told CNA 1 to, "Stop" and used her left leg to kick at him (CNA 1) to push him away." On 8/15/12, at 2:15 PM, an observation and interview of Resident A was conducted. Resident A was in bed awake, alert and able to communicate verbally. In the concurrent interview with Resident A regarding the alleged abuse incident on 7/19/12, Resident A stated, "I know what he (referring to CNA 1) did to me. There have been other male CNAs who took care of me in the past, but he was the only one who disrespected me." When asked further what had happened, Resident A, while demonstrating with her fingers stated, "He (referring to CNA 1) inserted his fingers into my 'vagina' when he was changing me that night." Resident A started crying, and stated, "Why don't they (facility administration) believe me and they believed him (CNA 1)?" Further review of the investigation report on 8/15/12, noted that the Assistant Director of Nursing (ADON) had conducted a phone interview with CNA 1 on 7/22/12, at 11:26 AM. During the interview between the ADON and CNA 1, CNA 1 denied caring for Resident A on the night shift of 7/19/12, the date of the alleged incident. CNA 1 offered to clean and change Resident A's diaper four times, at 12:30 AM, 1:30 AM, 2:45 AM and 4:30 AM, and Resident A had refused to be cleaned and to have her diaper changed. CNA 1 further claimed that at approximately 12:30 AM, he reported to Licensed Vocational Nurse (LVN 1) that Resident A had refused care. The facility investigation report concluded that there was no evidence that CNA 1 provided care to Resident A on the night in question and that there was no evidence of any wrong doing or that CNA 1's actions were inappropriate. Further review of Resident A's medical record on 8/15/12, showed however, the CNA Flow Sheets and the nurses notes, that Resident A did receive care from CNA 1 on the 11-7 shift on 7/19/12, 7/20/12 and 7/21/12. There was no documentation found in the resident's medical record that Resident A refused care or that CNA 1 reported Resident A's refusal of care to LVN 1 on the night of 7/19, 7/20 or 7/21/12. The CNA Flow Sheets contained documentation of care provided to the resident on the night shift of 7/19/12 (date of alleged incident), which included the initials of CNA 1. The CNA's initial verified the delivery of care and services including the number of incontinent care opportunities provided to the resident, 2 times (X2) on 7/19/12, 1 time (X1) on 7/20/12 and X1 on 7/21/12. The CNA 11-7 (Night Shift) work schedule for July 2012, further showed that CNA 1 worked on 7/19, 7/20 and 7/21/12. On 7/23/13, at 8:10 AM- 8:18 AM, in a telephone interview with LVN 1 and LVN 2, LVN 1 stated she did not work on the night of 7/19/12. This was a direct contradiction to what CNA 1 had claimed. LVN 2, who was the 11-7 shift charge nurse that night, confirmed she did not receive any notification from CNA 1 regarding Resident A's refusal of care. CNA 1 could not be interviewed due to the fact that he had already resigned from the facility at the time of this surveyor's investigation. On 8/15/13 at 2:35 PM, in an interview with the administrator, he acknowledged there were inconsistencies between the facility investigation, the resident's health record and the interviews conducted. A review of the facility's policy and procedure, 'Abuse Allegation Investigation', dated 12/2011, revealed that the resident's rights were to be protected, a method of investigation and reporting of alleged violations involving abuse should be implemented. The policy and procedure further noted that the facility should investigate thoroughly each alleged violation of suspected abuse that included review of the resident's medical record and other available information.