Every finding on record at Whittier Nursing and Wellness Center, Inc

Based on observation, interview and record review, the facility failed to follow safe and proper food storage practices in accordance with professional standards for food service safety and the facility's policy and procedure (P&P) by failing to label and date food items and discard expired food inside the facility's kitchen. This failure had the potential to cause food-borne illness (illness caused by the ingestion of contaminated food or beverages) and adversely affect the health of the residents. Findings: During a concurrent observation and interview on 12/1/2025 at 8:43 with the Dietary Supervisor (DS) in the kitchen, the following were found: An opened five pounds (a unit of weight) container of sour cream with use by 11/30/2025 label on the lid inside the refrigerator. An opened unlabeled and undated two bags of carrots inside the refrigerator. A tray of unlabeled and undated individually prepared ice cream cups with a marking 11/19 on the clear plastic wrap covering the tray inside the freezer. An opened unlabeled and undated one gallon (a unit of volume) of corn oil under a kitchen table. During the facility's initial observation of the kitchen on 12/1/2025 at 8:50 AM, an open five pounds container of sour cream was observed with a use by label date 11/30/2025 in the refrigerator. In a concurrent interview the DS stated she would discard sour cream today and it should not be used. During the same observation of the kitchen on 12/1/2025 at 8:51 AM, two opened bags of carrots were observed exposed in the refrigerator without an opened date or used by date written on the bags of carrots. The DS stated there was no need for open or use by date because carrots were produce. The DS stated she knows when the carrots go bad by visual check. During an observation of the kitchen freezer on 12/1/2025 at 8:54 AM, a tray of unlabeled and undated individually prepared ice cream cups with a marking 11/19 on the clear plastic wrap covering the tray with no used by date. The DS stated there was no need for use by date because ice cream was stored in the freezer and it was frozen. During the same observation of the kitchen on 12/1/2025 at 9 AM, an opened unlabeled and undated one gallon (a unit of volume) of corn oil under a kitchen table. The DS stated the corn oil should have open date so that staff know how long to use it for and when it will be discarded. During a review of the facility's policy and procedure (P&P) titled, Food receiving and storage, dated 10/2017, the P&P indicated, All foods stored in the refrigerator or freezer will be covered, labeled and dated.

Based on observations, interviews and record reviews, the facility failed to ensure that accurate and current nurse staffing data [total number and actual hours worked by licensed (Registered Nurses [RNs], License Vocational Nurses [LVNs]) and unlicensed nurses (Certified Nursing Assistant [CNAs])] were posted daily at the beginning of each shift (11 PM - 7 AM, 6:30 AM - 3 PM, and 3 PM - 11 PM) to care for 30 residents of 30 residents. These deficient practices of posting inaccurate and outdated nurse staffing data had the potential to mislead and prevent residents and families from verifying the facility's daily staffing levels. This could result in distrust and a perceived lack of accountability in maintaining accurate and adequate staffing necessary for timely resident care. Findings: During an observation on 12/02/2025 at 9:30 AM, an untitled facility document was observed posted in the facility's front lobby. The document posted in the front lobby indicated the Facility Census was 30. The facility document indicated the nursing staffing information according to licensed nurses and unlicensed nurses per category (RNs, LVNs, CNAs, ) directly responsible for resident care each shift (6:30 AM-3 PM, 3 PM-11 P, 11 PM-7 AM). The document did not indicate the actual time worked on 12/01/2025, for each category and type of nursing staff. During a subsequent observation on 12/2/2025 at 5PM, the same untitled facility document was observed posted in the facilities front lobby. The document had not had any revisions or updates from the original observation on 12/02/2025 at 9:30 AM. During a concurrent observation and interview on 12/3/2025 at 9:16 AM with Director of Staff Development (DSD), DSD stated the untitled document posted in the facility's front lobby was a staffing projection (based on future staffing need) prepared by the night shift nurse for the following day. The DSD stated the nurse preparing the document would fill out the projected hours based on the facility's schedule. The DSD stated the facility would not update the posted staffing hours during the day as they were only posting the projected staffing nursing hours. During an interview on 12/4/2025 at 12:25 PM with Director of Nursing (DON), DON stated the facility was only posting the projected staffing nursing hours daily in the facility's front lobby and in front of the nursing station. The DON stated if the actual nursing staffing hours were not posted accurately, it could result in the residents and the visitor/resident's representatives not to know the actual number of nursing staff working on that specific day that will provide care to the residents which was a misleading information. During a review of the facility's Policy and Procedure (P&P) Posting Direct Care Daily Staffing Number, with a revision date of July 2016, the P&P indicated the following information; within two hours of the beginning of each shift, the number of licensed nurses (RNs and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for the resident care is posted in a prominent location (accessible to residents and visitors) and in clear and readable format; and the information recorded on the form shall include among other details The actual time worked during that shift for each category and type of nursing staff.

Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) worked 8 consecutive hours seven days a week in the facility including the following weekends: 10/18/2025, 10/19/2025, 10/25/2025 10/26/2025, 11/16/2025/ 11/22/2025, and 11/29/2025 that care for 30 or 30 residents in the facility. This deficient practice had the potential for the residents' care not to be supervised and assessed clinically by the RN which could affect the quality of care and quality of life of the residents. Findings: During a review of the facility's Direct Care Service Hours Per Patient Day (DHPPD, a staffing metric ensuring enough caregiver time per resident, calculated as total direct care hours divided by patient census) from 9/2025 to 11/2025, indicated there was no RN on duty for 8 consecutive hours for the following dates: 10/18/2025, 10/19/2025, 10/26/2025, 11/16/2025/ 11/22/2025, and 11/29/2025 in the facility. During an interview with the Director of Nursing (DON) on 12/3/2025 at 1:42 PM, the DON stated the facility did not require an RN for 8 hours on the weekends because it was a small facility. The DON stated the facility has been exempted because the facility was small. The DON stated when she comes into work for direct care duties, she only signs in on the Nursing Staffing Assignment and Sign in Sheet. During a subsequent interview with the DON on 12/3/2025 at 2:36 PM, the DON stated she was at facility often and sometimes forgets to sign the Nursing Staffing Assignment and Sign in Sheet. The DON stated she goes to the facility on the weekends to fulfill weekend coverage. The DON confirmed she only signs on the assignment sheet and if she does not sign it means she was not at the facility. During a review of the facility's timecards for the facility's RNs and the Director of Nursing (DON) from 9/2025 to 11/2025, indicated there was no RN or DON for 8 consecutive hours for the following dates: 10/18/2025, 10/19/2025, 10/26/2025, 11/16/2025/ 11/22/2025, and 11/29/2025. During a review of the facility's Nursing Staffing Assignment and Sign in Sheet for the following dates: On 10/18/2025, indicated there was no Director of Nursing (DON) or RN signature 2.On 10/19/2025, indicated there was no DON or RN signature 2. On 10/26/2025, indicated there was no DON or RN signature 3. On 11/16/2025, indicated there was a DON signature, but did not indicate actual shift start/end time or actual meal break start/end time. 4. On 11/22/2025, indicated there was a DON signature, but did not indicate actual shift start/end time or actual meal break start/end time. 5. On 11/29/2025, indicated there was no DON or RN signature. During a concurrent record review of the DON's timecard and interview with the DON on 12/4/2025 at 12:44 PM, the DON stated she would always sign in on the Department Heads Daily Sign-in Sheet with the security guard upon entrance to the facility. During a concurrent interview and record review of the Department Heads Daily Sign-in Sheet with the security guard (SG) 1 on 12/4/2025 at 12:50 PM, SG 1 stated sign in for department heads from previous months are with the Business Office Manager indicated there was no RN in the facility on the following dates: On 10/18/2025, indicated there was no DON signature. 2. On 10/19/2025, indicated there was no DON signature. 3. On 10/26/2025, indicated there was no DON signature. 4. On 11/16/2025, indicated there was no DON signature. 5. On 11/22/2025, indicated there was no DON signature. 6. On 11/29/2025, indicated there was no DON signature. A review of the facility's policy and procedure (P&P) titled Departmental Supervision, dated 8/2006 indicated the DON is on duty during the day shift Monday through Friday at a minimum as due to their duties schedule will may vary. The P&P indicated during the absence of the DON, a Nurse Supervisor/ Charge Nurse is responsible for the supervision of all nursing department activities including the supervision of direct care staff. The P&P indicated in a skilled nursing facility with fewer than 60 beds, a DON can serve as the Charge Nurse. The P&P indicated the DON is responsible for ensuring that the facility provides quality care to the residents.

Based on interview and record review, the facility failed to ensure an assessment was completed and documented after dialysis (a treatment to clean one's blood by removing waste and extra fluid when the kidneys are unable to) for one of one sampled resident (Resident 7) reviewed for quality of care. This failure had the potential to put Resident 1 at risk for hypotension (low blood pressure [BP- the force of your blood pushing against your artery walls, like water in a hose]), bleeding, and access site (area on the body where the dialysis machine hooks up to the blood for dialysis) complications leading to hospitalization. Findings: During a review of Resident 7's admission Record (AR), the AR indicated the facility admitted Resident 7 on 9/21/2022 and was readmitted on [DATE] with diagnoses that included but not limited to end stage renal disease ( ESRD - an irreversible kidney failure), heart failure (when the heart can't pump enough blood to meet the body's needs, leading to symptoms like shortness of breath, fatigue, and swelling), and diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 7's Care Plan (CP), initiated 10/22/2025, the CP indicated Resident 7 is on dialysis due to the diagnosis of ESRD. The CP indicated Resident 7 would have no complications from dialysis treatment. The CP interventions indicated to document the date, time and condition of resident returning to the facility from dialysis and to monitor the resident's right groin access site for swelling, pain, bleeding, itching, signs and symptoms of infection. During a review of Resident 7's Physician order dated 11/1/2025, the Physician order indicated Resident 1 had scheduled dialysis every Tuesday, Thursday, and Saturday starting 10/28/2025. During a review of Resident 7's Minimum Data Set (MDS- a resident assessment tool) dated 11/12/2025, the MDS indicated Resident 7 had moderately impaired cognition (ability to think, reason, and function). The MDS indicated Resident 7 had ESRD and was on dialysis. During a concurrent interview and record review on 12/3/2025 at 1:25 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 7's dialysis resident communication record, dated 11/29/2025 was reviewed. The record did not indicate Resident 7's post dialysis vital signs (basic measurements including body temperature, pulse rate, respiration rate, and blood pressure), assessment of access site, dressing, and condition of resident were documented. LVN 1 stated the licensed nurse on duty should have assessed the resident and completed the dialysis resident communication record after the resident returned from dialysis. LVN 1 stated assessment of residents' post dialysis is important to ensure any changes in residents' conditions are monitored. LVN 1 stated access site assessment for swelling, redness, bleeding and dislodgement is important to ensure residents' safety and prevent potential complications. During an interview on 12/4/2025 at 12:39 p.m. with the Director of Nursing (DON), the DON stated that licensed nurses must perform post dialysis assessment upon the resident's return from dialysis and document the findings in the dialysis resident communication record form. The DON stated post dialysis assessment and documentation is important to be able to monitor resident's condition after dialysis and to prevent complications that may lead to hospitalization. During a review of the facility's policy and procedure (P&P) titled, Renal dialysis, care of resident, Hemodialysis access site, diet/fluid restrictions, care plan, dated 06/2009, the P&P indicated, Facility Licensed Nurse will complete the baseline information, pre and post dialysis section of the Nurses Dialysis Communication Record.

Based on interview, observation and record review, the facility failed to set the Alternating Pressure Mattress (APM, mattress that provides pressure redistribution by filling and un-filling air cells within the mattress so that contact points with the body are reduced) according to the resident's weight as indicated in the manufacturer's recommendation and physicians orders for one of one sampled residents (Resident 14) reviewed for pressure ulcer (skin injury due to prolonged unrelieved pressure or skin friction). Resident 14's mattress was observed set for 350 pounds (lbs.) while the resident weights 99lbs. This deficient practice had the potential for Resident 14 to develop worsened or new pressure ulcer or injury and/or delay the resident's wound to heal. Findings: During a review of Resident 14's admission Record (AR), the AR indicated the facility originally admitted Resident 14 on 5/10/2023 and most recently readmitted on [DATE] with diagnoses that included type 2 diabetes mellitus (DM2 - a condition that results in too much sugar circulating in the blood), muscle weakness (when your muscles can't work with the expected amount of force). During a review of Resident 14's History and Physical (H&P), dated 4/27/2025, the H&P indicated Resident 14 has fluctuating capacity to understand and make decisions. During a review of Resident 14's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/31/2025, the MDS indicated Resident 14's cognition (ability to think, remember, and reason) was moderately impaired. The MDS indicated Resident 14 needed supervision assistance in eating. The MDS indicated resident 14 is at risk for developing pressure ulcers. During a review of Resident 14's Order Summary Report (OSR), the OSR indicated the physician ordered on 4/25/2025, without an end date, indicated an order for Low Air Loss mattress (LALM-a type of the APM) keep setting between 80-150 pounds every shift for wound management. During a review of Resident 14's care plan for Resident 14's at risk for skin breakdown initiated 12/1/2025 indicated Resident 14 is at risk for re-occurring pressure injury Resident 14 needs continues use of LAL bed mattress due to history of resolved pressure injury. The care plan intervention included LAL bed mattress setting to be at 80lbs - 150 lbs. for preventative measures. During an observation on 12/01/2025 at 9:20 AM in Resident 14's room, Resident 14 was observed lying in bed with the head of the bed slightly elevated the LAL mattress was observed set at Firm for 350lbs. During a concurrent observation and interview on 12/1/2025 at 11:15 AM with Licensed Vocational Nurse (LVN 1) in Resident 14's room, Resident 14 was lying in bed with the head of bed slightly elevated and the LAL mattress setting was set at Firm 350 lbs. LVN 1 confirmed Resident 14's mattress setting was for a 350 lbs. resident. LVN 1 stated, she did not know what the correct setting for Resident 14's LAL mattress the Treatment Nurse (TN) was in charge of adjusting the LAL mattress settings for the residents. During a concurrent interview and observation on 12/01/2025 at 11:21 AM with TN 1 in Resident 14's room, TN 1 stated Resident 14s LAL mattress should always be in the correct setting according to the Resident 14's Physician order based on resident's 14's weight range. TN 1 stated, Resident 14's LALM setting should be between 80-150 pounds maximum to help Resident 14 prevent further occurrence of a pressure injury as Resident 14 was not mobile and had a previous Sacro coccyx pressure injury in the past. TN 1 stated, he did not know why the LALM was set at 350 lbs., which was not the correct setting for the Resident 14. During a review of manufacture's guidelines for Drive-Med Aire Melody control unit, indicated the following: - The Med Aire Melody Alternating Pressure and Low Air Loss Mattress as indicated for the prevention and treatment of any and all stage pressure ulcers when used in conjunction with a comprehensive pressure ulcer management program. During a review of the facility's Policy and Procedure (P&P) Low Pressure Mattress, Utilization and Management dated 12/12/2024, the P&P indicated the following information: Low -pressure mattresses will be made available to patients at risk for pressure injuries based on clinical assessment. The policy further indicated the staff must ensure proper use, cleaning, and maintenance of these mattresses according to manufactures guidelines to ensure functionality and safety.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) reviewed for resident's rights did not have Advance Directive (a legal document for stating medical wishes if one was unable to communicate) in resident's medical chart. This deficient practice had the potential to result in misinformation of medical care and treatment and not honoring resident's wishes in cases where the resident and/or responsible party was unable to participate in making healthcare decisions. Findings: During a review of Resident 3's admission Record indicated the resident was admitted on [DATE] with diagnoses that included disorder of brain, cellulitis (a bacterial infection of the skin and the tissues beneath the skin) of right lower limb, and type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood) with diabetic neuropathy (nerve damage in people with diabetes). During a review of Resident 3's History and Physical (H&P), dated 8/7/2025, indicated the resident was able to make decisions for activities of daily living. During a review of Resident 3's Physician Orders for Life-Sustaining Treatment (POLST, a written medical order from a physician, nurse practitioner, or a physician assistant which specifies what a patient's lifesaving treatment wishes are) dated 3/21/2025 indicated resident had an Advance Directive. The POLST did not indicate the date of the Advance Directive. During a review of Resident 3's Advance Directive Acknowledgement form dated 8/6/2025 indicated the form was incomplete. The form did not indicate if a copy of Resident 3's Advance Directive was provided to the facility. During a concurrent interview and record review of Resident 3's Advance Directive Acknowledgment form and POLST on 12/2/2025 at 2:26 PM, Social Services Director (SSD) verified resident's form and POLST was not completed and a copy of Resident 3's Advance Directive was not in resident's medical chart. SSD stated the advance directive should be in the chart and Resident 3 had an advance directive. SSD stated Resident 3's Advance Directive was probably in overflow medical records. SSD stated it was important to have the advance directive in resident's chart because in the case of an emergency, if the staff find resident unresponsive the staff would know what resident's wishes were. During an interview on 12/4/2025 at 12:39 PM, the Director of Nursing (DON) stated it was important for resident's Advance Directive to be in the medical chart, to ensure everyone was aware what the resident's code status (refers to a patient's pre-determined wishes for medical intervention if their heart or breathing stops, typically decided upon hospital admission) was and what the resident's requests would be in case of an emergency. A review of the facility's policy and procedure (P&P) titled Advance Directive, dated 12/2016 indicated advance directives will be respected in accordance with state law and facility policy. The P&P indicated the nurse supervisor will be required to inform emergency medical personnel of resident's advance directive regarding treatment options and provide such personnel with a copy of such directive when transfer from the facility via ambulance or other means is made.

Based on observation, interview and record review, the facility failed to provide a minimum of 80 square feet (sq. ft., unit of measurement) per resident area for fourteen (14) out of eighteen (18) resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 12, 13, 14, 15, and 16). The 14 resident rooms consisted of 14 -two (2) bed capacity rooms. This deficient practice had the potential to impact the ability of the staff to provide safe nursing care and privacy to the residents. Findings: During an interview with the Administrator (ADM) on 12/1/2025 at 10:44 AM, the ADM stated the facility would like to request a room waiver (a document recording the waiving of a right or claim) this year. A review of the facility's letter to request for additional room waiver dated 12/1/2025 indicated the size of the rooms caused no negative outcome with regards to the health, safety, and welfare of all the residents in the facility. The request indicated the following resident bedrooms were: room [ROOM NUMBER] (2 beds) 2 residents 134.42 sq. ft. 67.21 sq. ft. room [ROOM NUMBER] (2 beds) 1 resident 134.42 sq. ft. 67.21 sq. ft. room [ROOM NUMBER] (2 beds) 2 residents 131.99 sq. ft. 66 sq. ft. room [ROOM NUMBER] (2 beds) 2 residents 131.99 sq. ft. 66 sq. ft. room [ROOM NUMBER] (2 beds) 2 residents 135.63 sq. ft. 67.82 sq. ft. room [ROOM NUMBER] (2 beds) 1 resident 139.27 sq. ft. 69.64 sq. ft. room [ROOM NUMBER] (2 beds) 2 residents 147.74 sq. ft. 73.87 sq. ft. room [ROOM NUMBER] (2 beds) 2 residents 147.74 sq. ft. 73.87 sq. ft. room [ROOM NUMBER] (2 beds) 2 residents 135.63 sq. ft. 67.82 sq. ft. room [ROOM NUMBER] (2 beds) 2 residents 135.63 sq. ft. 67.82 sq. ft. room [ROOM NUMBER] (2 beds) 2 residents 135.63 sq. ft. 67.82 sq. ft. room [ROOM NUMBER] (2 beds) 2 residents 147.74 sq. ft. 73.87 sq. ft. room [ROOM NUMBER] (2 beds) 1 resident 135.63 sq. ft. 67.82 sq. ft room [ROOM NUMBER] (2 beds) 0 residents 138.05 sq. ft. 69.03 sq. ft. During an interview with the ADM on 12/3/2025 at 3:20 PM, the ADM stated there have been no complaints regarding care and services from residents, resident families, and staff about the room size. During an observation from 12/1/2025 to 12/4/2023, Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 12, 13, 14, 15, and 16 had adequate space, nursing care, comfort, and privacy to the residents. The residents residing in the affected rooms were observed to have enough space for the residents to move freely inside the rooms. Each resident inside the affected rooms had beds and bedside tables with drawers. There was an adequate room for the operation and use of the wheelchairs (a chair fitted with wheels for use as a means of transport by a person who is unable to walk as a result of illness, injury, or disability), walkers (is a device that gives additional support to maintain balance or stability while walking,), or canes. The room size did not affect the care and services provided to the residents when nursing staff were observed providing care to the residents. During an interview on 12/3/2025 at 3:08 PM, Resident 3 stated he had enough space in room [ROOM NUMBER] to move in and out with a wheelchair. A review of the facility's policy and procedure titled Accommodation of Needs, dated 4/2019 indicated resident has the right to reside and receive services in the facility with reasonable accommodation of individual needs and preferences. The P&P indicated reasonable accommodations of individual needs and preferences meant the facility's efforts to individualize the resident's physical environment including resident's bedroom and bathroom. The P&P indicated the facility will evaluate the resident's unique needs and make environmental accommodations to the extent reasonable.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 1), who was unable to carry out activities of daily living (ADLs), received services to maintain good oral hygiene as indicated in the care plan by the certified nurse assistant (CNA) 1 after Resident 1 had been assisted and finished with his meal. This deficient practice had the potential to place Resident 1 at risk for diseases of the mouth, gums, and teeth, and aspiration (something other than air gets into your airways) of the food pieces in the mouth could further lead to pneumonia (an infection/inflammation in the lungs). Findings: During a review of Resident 1's admission Record (AR) the AR indicated that the facility originally admitted Resident 1 on 10/3/2024 and readmitted on [DATE], with diagnoses including metabolic encephalopathy (a series of neurological disorders result from systemic illness), dysphagia (difficulty swallowing), and depression (mental health condition that causes a persistent feeling of sadness and changes in how you think, sleep, eat and act.).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 7/5/2025, the MDS indicated that Resident 1 was severely cognitively impaired (rarely/ never made decisions). The MDS also indicated that Resident 1 was dependent (helper does all the effort) on eating, oral hygiene, and personal hygiene. During a review of Resident 1's Physician Orders dated 6/29/2025, the Orders indicated to provide fortified (extra nutrients added) puree diet with nectar-thick (liquid consistency that helps prevent choking and stop fluid from entering the lungs) liquid. During a review of Resident 1's Care Plan dated 6/29/2025, the Care Plan indicated that Resident 1 had self-care deficits, impaired functional abilities related to metabolic encephalopathy. The Care Plan indicated interventions to anticipate and provide resident's daily needs and dental/ oral care BID (twice daily) and PRN (as needed). During a review of Resident 1's Flowchart for Activities of Daily Living (ADLs Flowchart) dated from 7/1/2025 to 7/10/2025, the ADLs Flowchart indicated that Resident 1 was dependent on oral hygiene. During a concurrent observation and interview on 7/10/2025 at 9:10 AM, Resident 1 was observed sleeping in bed in a semi-Fowler_position (a position in which the individual lies on their back on a bed with the head of the bed elevated at 30-45 degrees), having call light and a television remote control in each hand, mouth open with visible traces of food/ milk on Resident 1's gums. CNA 1 stated Resident 1 was not provided with oral care on that day, 7/10/2025. CNA1 stated she was supposed to provide oral care to Resident 1 after the resident had his breakfast and it was one of her responsibilities to maintain residents in good hygiene. During an interview on 7/10/2025 at 9:40 AM with the licensed vocational nurse (LVN) 1, LVN 1 stated Resident 1 was dependent on nearly all ADLs including oral hygiene. LVN 1 stated Resident 1's dental health will be at risk if not done. During an interview on 7/10/2025 at 11:05 AM with the Director of Staff Development (DSD), DSD stated she was responsible for supervising CNA's and ensuring the CNA's provide proper care and assistance to residents. DSD stated oral hygiene was important and the assigned CNA for Resident 1 should have provided oral care once Resident 1 was done with his meal. DSD also stated by not having oral hygiene maintained, the resident could be at risk for bad mouth odor or even aspirate on anything remaining from the gum and that can lead to pneumonia.During a review of the facility's Policy and Procedures (P&P) titled Activities of Daily Living (ADLs), revised 3/2018, the P&P indicated that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The P&P also indicated that appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, grooming, and oral care)

Based on observation, interview, and record review, the facility failed to provide a comfortable and homelike environment to one of thirteen sampled residents (Resident 2) by failing to provide the resident an extra blanket when the resident was cold at night. This deficient practice had the potential to expose the resident to an increased risk of hypothermia, discomfort, chills, worsening of existing medical conditions, and potential for skin breakdown from cold exposure. Findings: A review of Resident 2 ' s Admission Record indicated that the facility admitted the resident on 3/16/2023 and readmitted the resident on 1/29/2024 with diagnoses that include generalized muscle weakness and depression (a serious mental health condition that can impact how a person feels, thinks, and acts). A review of Resident 45 ' s Minimum Data Set (MDS - a resident assessment tool), dated 11/18/2024, indicated that the resident ' s cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and senses) was moderately impaired. During an interview with Resident 2 on 12/13/2024 at 12:22 PM, he stated that since the cold nights have started, the staff did not provide him an additional blanket when he requested for another one on several occasions. He stated that he felt irritated and neglected when the staff told him that they did not have a blanket available. During an interview with the Maintenance Supervisor (MS) on 12/13/2024 at 12:30 PM, who has been working in this facility for nine years, he stated that the laundry department is under his supervision. The MS stated that if there are no available blankets in the linen cart, the staff should check the laundry room and tell him if they still could not find a blanket so he could get a new blanket in the storage room. During an interview with Licensed Vocational Nurse (LVN) 1 on 12/13/2024 at 12:45 PM, LVN 1 stated that the Certified Nurse Assistants (CNAs) go to the charge nurse when they could not find a blanket in the linen cart or the laundry room. LVN 1 stated that the charge nurse would then go to the MS to request for a new blanket; however, LVN 1 stated that the MS is not available during the night shift, which leaves the charge nurse and the CNA helpless. During an interview with CNA 3 on 12/16/2024 at 5:55 AM, CNA 3 stated that Resident 2 asked for a blanket last November, but a blanket was not available in the linen cart. CNA 3 stated she asked LVN 2 where she could get a blanket for a resident, but LVN 2 told her We do not have any. A review of the facility ' s undated policy titled, Quality of Life - Homelike Environment revised in 5/2017 indicated that the facility staff and management should maximize to the extent possible the characteristics of the facility that reflect a personalized homelike setting which includes the provision of extra blankets upon the request of a resident.

Based on observation, interview, and record review, the facility failed to post an accurate facility staffing data in a prominent place where 32 of 32 residents and their representaives and visitors could easily view. This deficient practice had the potential to compromise the quality of care the residents receive due to potential insufficient staffing in the facility. Findings: During an observation on 11/04/24 at 04:28 PM, a staffing data dated 11/04/24 was posted to a wall behind the counter of the facility's nurse's station. The staffing data was not easily visible to read from the countertop in the nursing station that was approximately 10 feet away and was not accessible to the residents or visitors. During a concurrent review of the staffing data, the form indicated that the census was 41 for 11/04/24. A review of the facility's census dated 11/4/24 indicated that the resident census was 32. During an interview with the Director of Staff Development (DSD) on 11/06/24 at 01:07 PM, she stated that the staffing data that she posted on the wall at the Nurses Station in the beginning of the day shift on 11/04/24, indicated that the resident census was 32. She stated she does not know who scribbled over the resident census and wrote 41. A review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, Version 1.1, revised in 7/2016, indicated that within two hours of the beginning of each shift, the number of licensed nurses (Registered Nurses and Licensed Vocational Nurses) and the number of unlicensed nursing personnel (Certified Nurse Assistants) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format.

Based on interview and record review, the facility failed to accurately and complete the medical information for 3 of 3 sampled residents (Residents 2, 25, and 27) by failing to: 1. For Residents 2 and 25, the facility did not ensure that the responsible party who signed the Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) indicated his relationship to the resident and facility representative who signed the form indicated her title. 2. For Resident 27, the facility did not follow its own policy and procedure in documenting the resident's change of condition and nursing notes. These deficient practices can lead to misdiagnoses, inappropriate treatment, and gaps in patient care that could ultimately result to adverse health outcomes. Findings: 1. A review of Resident 2's Admission Record indicated that the facility admitted the resident on 12/01/2010 and readmitted the resident on 03/23/2024 with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought). A review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 08/30/2024, indicated that the resident's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and senses) was intact. A review of Resident 2's Advance Directive indicated that he was not capable of making medical decisions. The resident's representative signed the Advance Directive on but did not indicate his relationship to the resident. The facility representative signed the same Advance Directive on 3/23/24 but did not indicate her title. During an interview on 11/4/24 at 1:11 PM, Registered Nurse (RN) 1 stated that Resident 2 was not capable of making medical decisions for himself. During a concurrent review of his chart with RN 1, she stated that the representative of the resident signed the resident's Advance Directive on 3/23/24 but did not indicate his relationship to the resident. RN 1 stated that not knowing the relationship of the person who signed the form could result in a delay in treatment in case of an emergency. A review of Resident 25's Admission Record indicated that the facility admitted the resident on 10/22/2024 with diagnoses that included schizophrenia. A review of Resident 25's MDS, dated [DATE], indicated that the resident's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and senses) was impaired. A review of Resident 25's records indicated that her representative signed her Advance Directive on 10/22/24 but did not indicate his relationship to the resident. The facility representative signed the same Advance Directive on 10/22/24 but did not indicate her title. During an interview on 11/5/24 at 9:10 AM, the Social Services Director (SSD) stated that the purpose of the Advance Directive is for the facility to know the resident's choice during an emergency. She stated that not knowing the relationship of the representative to the resident could result to a delay in treatment in case of an emergency. During a concurrent review of the Advance Directive of Resident 2 and Resident 25 with the SSD, she stated that the representatives for Residents 2 and 25 signed the form but did not indicate their relationship to the resident. She stated that she also signed the Advance Directive forms for Residents 2 and 25 but she forgot to put her title. A review of the facility's policy titled, Charting and Documentation, Version 1.2, revised in 7/2017, indicated that documentation in the medical record should be complete and accurate. 50012 2. During a review of Resident 27 ' s Admission Record (Face Sheet), dated 10/23/2021, the face sheet indicated the facility admitted Resident 27 on 10/14/2024 with diagnoses including diabetes mellitus (elevated sugar in the blood), hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated), and history of falling. During a review of Resident 27 ' s History and Physical (H&P), dated 10/16/2024 indicated, Resident 27 had the mental capacity to make medical decisions. During a review of Resident 27's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 10/20/2024, indicated the cognitive (the ability to think and process information) skills for daily decisions making was severely impaired, and needed supervision to extensive assistance from the staff for the activities of daily living. During a concurrent interview and record review on 11/7/2024 at 11:15 AM, the Director of Nursing (DON) reviewed Resident 27 ' s Progress Notes and Change of Condition (COC), both dated 10/30/2024. The DON stated that she documented the progress notes on behalf of the charge nurse, who was busy, but the charting did not include the name or title of the person who provided the care. The DON also stated she documented the COC based on information provided by the charge nurse, but the entry was written as if she herself had performed the procedures, when it was the charge nurse who implemented the interventions. The DON stated that she should have included the charge nurse ' s name and title in both instances to accurately reflect who provided the care. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, revised 2017, indicated: Documentation of procedures and treatments will include care-specific details, including: The date and time the procedure/treatment was provided; The name and title of the individual(s) who provided the care; The assessment data and/or any unusual findings obtained during the procedure/treatment; How the resident tolerated the procedure/treatment; Whether the resident refused the procedure/treatment; Notification of family, physician or other staff, if indicated; and The signature and title of the individual documenting.

Based on observation, interview, and record review, the facility failed to ensure six of 6 sampled residents (Resident 28, 20, 21, 2, 5, and 81), received personal mails when delivered on Saturdays at the facility. This failure resulted in violating Resident 28, Resident 20, Resident 21, Resident 2, Resident 5, and Resident 81 rights to received mail on Saturdays which could result of missing important and timely correspondence. Findings: During an interview on 11/5/2024 at 10:00 AM, during Resident Council Meeting, Resident 28, Resident 20, Resident 21, Resident 2, Resident 5, and Resident 81 stated they received mail unopened on Monday through Friday but did not receive mails on Saturdays. During an interview on 11/5/2024 at 10:45 AM with the Business Office Manager (BOM), the BOM stated she was responsible for releasing the mail from Monday through Friday to Social Service Director (SSD-also was the Activity Director in the facility) or Activity Assistant. The BOM stated the SSD or Activity Assistant were responsible to deliver the mails to the residents. The BOM stated the facility did not deliver mails to resident on Saturdays. During a concurrent observation and interview on 11/6/2024 at 10:51 AM, at the nurse station, a locked mailbox was noted hanging on the wall. The SSD stated the activity staff delivered the mails to residents on Monday through Friday after they (SSD or AA) received the mail from the business office. The SSD stated mails delivered on Saturdays would be placed in the locked mailbox at the nurse station. The SSD stated the business office staff would check the mailbox on Monday and give the residents' mail to activity staff on Monday to deliver to the residents. During an interview on 11/6/2024 at 11:47 AM with the Director of Nursing (DON), the DON stated it was the resident's right to receive the mail timely, and the facility should ensure the residents received the mail on Saturdays. During a review of Resident 28's Admission Record (Face Sheet), the Face Sheet indicated Resident 28 was admitted on [DATE] with diagnoses including metabolic encephalopathy (a change in how the brain works due to an underlying condition), polyneuropathy (damage to multiple nerves outside of the brain and central nervous system), congestive heart failure (a heart disorder which causes the heart to not pump the blood efficiently), dysphagia (difficulty swallowing), muscle weakness, benign prostatic hyperplasia ( a condition in which the prostate gland grows larger than normal), schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (a mental illness that causes extreme mood swings, along with changes in energy, sleep, thinking, and behavior). During a review of Resident 28's Minimum Data Set (MDS - a resident assessment tool) dated 10/9/2024, the MDS indicated Resident 28 had moderate impairment in cognitive (ability to remember things, solve problems, or make decisions) skills for daily decision making. The MDS indicated Resident 28 needed substantial/maximal assistance (another person does more than half the effort) to complete the activity. During a review of Resident 20's Admission Record (Face Sheet), the Face Sheet indicated the facility originally admitted Resident 20 on 8/19/2024 and readmitted on [DATE] with diagnoses including type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), dysphagia, primary hypertension (HTN-high blood pressure), depression, bipolar disorder, anxiety disorder (a mental illness that causes people to experience excessive and uncontrollable feelings of fear or anxiety), schizophrenia, acute kidney failure (a sudden and often reversible reduction in kidney function). During a review of Resident 20's MDS dated [DATE], the MDS indicated Resident 20 had moderate impairment in cognitive skills for daily decision making. The MDS indicated Resident 20 needed partial/moderate assistance (another person does less than half the effort) to complete the activity. During a review of Resident 21's Face Sheet, the Face Sheet indicated the facility admitted Resident 21 on 7/21/2022 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), dysphagia, muscle weakness, chronic kidney disease (progressive damage and loss of function in the kidneys), moderate dementia (a progressive state of decline in mental abilities), anemia (a condition where the body does not have enough healthy red blood cells), schizophrenia, and anxiety disorder. During a review of Resident 21's History and Physical (H&P), dated 6/29/2024, the H&P indicated Resident 21 had fluctuating capacity to understand and make decisions. During a review of Resident 21's MDS dated [DATE], the MDS indicated Resident 21 had moderate impairment in cognitive skills for daily decision making. The MDS indicated Resident 21 needed setup or clean-up assistance (another person sets up or cleans up and resident completes the activity). During a review of Resident 2's Face Sheet, the Face Sheet indicated the facility admitted Resident 2 on 3/23/2024 with diagnoses including type 2 diabetes mellitus, dysphagia, malignant neoplasm of cerebral ventricle (a cancerous brain tumor that develops in the brain's cavities), epilepsy (happens as a result of abnormal electrical brain activity, also known as a seizure), hemiplegia and hemiparesis (complete or partial weakness on one side of the body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain), primary hypertension, schizophrenia. During a review of Resident 2's History and Physical (H&P), dated 3/25/2024, the H&P indicated Resident 2 could make needs known but could not make medical decisions. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had no impairment in cognitive skills for daily decision making. The MDS indicated Resident 2 needed supervision or touching assistance (another person provided verbal cues and/or touching/steadying assistance) to walk 50 feet with two turns. During a review of Resident 5's Face Sheet, the Face Sheet indicated Resident 5 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (a chronic lung disease causing difficulty breathing), epilepsy (happens as a result of abnormal electrical brain activity, also known as a seizure), primary hypertension, schizophrenia, dysphagia, psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality). During a review of Resident 5's History and Physical (H&P), dated 4/15/2024, the H&P indicated Resident 5 could make decisions for activities of daily living. During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 had no impairment in cognitive skills for daily decision making. The MDS indicated Resident 5 needed supervision or touching assistance to walk 50 feet with two turns. During a review of Resident 81's Face Sheet, the Face Sheet indicated Resident 81 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), muscle weakness, heart failure, schizophrenia, bipolar disorder, moderate dementia (a progressive state of decline in mental abilities). During a review of Resident 81's History and Physical (H&P), dated 4/15/2024, the H&P indicated Resident 81 did not have the capacity to understand and make decisions. During a review of Resident 81's MDS dated [DATE], the MDS indicated Resident 81 had moderate impairment in cognitive skills for daily decision making. The MDS indicated Resident 81 needed supervision or touching assistance to walk 50 feet with two turns. During a review of the facility's policy and procedure (P&P) titled, Resident [NAME] of Right, undated, the P&P indicated the facility should ensure resident have the right to associate and communicate privately with person of the resident's choice, and to send and receive his or her personal mail unopened. The residents should have ready access to letter writing materials, including stamps, and to mail and received unopened correspondence. The resident has the right to privacy in written communications, including

Based on observation, interview, and record review, the facility failed to follow the facility ' s infection control policy and procedure for three of 3 sampled residents (Resident 11, 16, and 19) by failing to: Ensure that Enhanced Barrier Precautions (EBP-a set of infection control measures that use personal protective equipment (PPE) to reduce the spread of multidrug-resistant organisms (MDROs) were implemented by Certified Nursing Assistant (CNA 1, and 2 ) for three of 3 sampled Residents (Resident 11, 16, and 19) who all have indwelling catheter (a medical device that remains inside the body and provides a direct path for pathogens [any organism that causes disease] to enter the body and cause infection) and were at risk for Multi-Drug Resistant Organisms (MDRO, disease causing organism that have become resistant to certain antibiotics). These deficient practices had the potential to result in the spread of diseases and infections among the residents, visitors and staffs. Findings: During an observation on 11/4/2024 at 2 PM, a Stop sign on the door indicated all who enter the Enhanced Barrier Precautions room should clean their hands and wear Personal Protective Equipment (PPE), (gown and gloves), and wash hands with soap and water. The sign also indicated to Do not wear the same gown and gloves for the care of more than one person. During an observation on 11/4/2024 at 2 PM, Certified Nursing Assistant (CNA) 1 and CNA 2 were observed donning (putting) on gloves and into Resident 16 ' s room to reposition Resident 16. During an observation on 11/4/2024 at 2:05 PM, CNA 1 and CNA 2 were observed sanitizing hands and donned new gloves. CNA 1 and CNA 2 did not change isolation gown and proceed to repositioning Resident 11 with the same gown. During an interview on 11/4/2024 at 2:15 PM with the CNA 2, CNA 2 stated he should not wear the same gown and should have change the isolation gown because it was important for preventing infection from spreading. During an interview on 11/4/2024 at 2:16 PM with the CNA 1, CNA 1 stated l should have changed my isolation gown in between residents to prevent possible spread of infection. During an observation on 11/5/2024 at 8:45 AM, License Vocational Nurse (LVN) 1, LVN 1 was observed administering medications for Resident 19 via Gastrostomy-Tube (G-tube, a tube that is inserted through the abdominal wall and into the stomach to provide nutrition and medication) without donning an isolation gown. During an interview on 11/5/2024 at 8:45 AM License Vocational Nurse 1 (LVN), LVN 1 stated she should have put on an isolation gown to administer medications, because it is important to prevent the spread of infection. During an interview on 11/7/2024 at 1:45 PM, the Infection Preventionist (IP) Nurse stated the IP ' s expectation was for all staff to wear proper PPE, such as a gown, during medication administration via G-tube due to the high potential risk of bodily fluid exposure. The IP Nurse stated EBP ensures staff reduce the risk of MDRO transmission. The IP Nurse stated the facility should have ensured that all staff members have a clear knowledge of EBP practices and are in accordance with the Center for Disease Control and Prevention (CDC) EBP guidelines. The IP nurse stated the facility tries to keep up with CDC guidelines and always seek guidance from the Los Angeles County Department of Public Health regarding changes in Infection Prevention and Control practices and guidelines.

Based on observation, interview, and record review, the facility failed to implement the professional standard of practice and the facility ' s policy and procedure titled Emergency Management Codes and Procedures for medical emergency (Code Blue- is a hospital code to alert the facility staffs of a medical emergency) by failing to ensure: 1. Call Code Blue was announced on the facility ' s paging system when Resident 27 was found unresponsive to verbal stimuli and responsive to painful stimuli with decreased heart rate, respiratory rate, and blood pressure (the measurement of the pressure in the blood vessels when the heart relaxes or contracts the force of blood pushing against artery walls as the heart pumps blood throughout the body). 2. Cardiopulmonary Resuscitation (CPR-a lifesaving emergency procedure for a victim who has signs of cardiac arrest [a situation when a victim becomes unresponsive, no normal breathing, and no pulse]) was initiated immediately and not wait until full code (the patient required resuscitation and all life saving measures during a medical emergency) status of Resident 27 was determined. 3. Rescue breaths (a part of CPR, or cardiopulmonary resuscitation, that involves blowing air into a victim's mouth to deliver oxygen to their lungs) were provided after 30 chest compression (the application of pressure to the chest to prevent it from expanding, used in cardiopulmonary resuscitation) during CPR was performed. These deficient practices resulted in the delayed in providing CPR and/or provisions of emergency care to Resident 27 who was found unresponsive, and the resident could not be revived by the paramedics (emergency medical personnel). Resident 27 was pronounced expired by the paramedics on [DATE] at 10:45 PM in the facility. Findings: During a review of Resident 27 ' s Admission Record (Face Sheet), dated [DATE], the face sheet indicated the facility admitted Resident 27 on [DATE] with diagnoses including diabetes mellitus (elevated sugar in the blood), hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated), and history of falling. During a review of Resident 27 ' s Physician Orders for Life Sustaining Treatment (POLST- a medical order that allows residents or their representative indicate their preferences for end-of-life care) signed by Resident 27 ' s Family Member 1 (FM 1) on [DATE] and signed and dated by the Resident 27 ' s Physician on 10 /,d+[DATE], indicated to attempt CPR to Resident 27 to restore breathing and heart circulation and heartbeat. During a review of Resident 27 ' s History and Physical (H&P), dated [DATE] indicated, Resident 27 had the capacity to make medical decisions. During a review of Resident 27's Minimum Data Set (MDS - a resident assessment tool), dated [DATE], indicated the cognitive (the ability to think and process information) skills for daily decisions making was severely impaired, and required supervision and extensive assistance from the staff for the activities of daily living. During a review of Resident 27 ' s Change of Condition (COC) record, dated [DATE] indicated at 10:25 PM, during a facility round Certified Nursing Assistance 3 (CNA 3) observed that Resident 27 Did not look good. CNA 3 then called charge nurse to check Resident 27 right away. License Vocational Nurse (LVN) 2, LVN 2 observed Resident 27 unresponsive to verbal stimuli but responsive to painful stimuli. The COC indicated vital signs (measurements of the body ' s basic functions such as the heart rate, respiratory rate, blood pressure) check respiratory rate 8 pulse 30/min blood pressure (BP) ,d+[DATE] Oxygen (O2) absent, O2 inhalation initiated 5 Liters/minute, then bp and carotid pulse diminish, CPR initiated right away. The COC indicated 911 was called and paramedics (person trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) was notified immediately, the paramedics arrived within 5 minutes and took over resident. The COC indicated on [DATE] at 10:50 PM the paramedics could not revive the resident and pronounced Resident 27 diseased by the paramedics. The COC indicated Resident 27s family and doctor was notified that Resident 27 expired. During a review of the paramedics run sheet (a report from the paramedics) dated [DATE] timed at 10:20 PM, indicated paramedics arrived at facility at 10:25PM and assessed Resident 27. The report indicated the paramedics found Resident 27 unresponsive and placed the resident on [NAME] device (a device used compress the resident ' s chest to resume blood circulation) and established intraosseous insertion (method of administering medications through the bone) per CPR protocol (a system of rules that explain the correct conduct and procedures to be followed in correct situations). Resident 27 ' s electrocardiogram (EKG- a reading of the electrical activity of the heart) showed asystole (an EKG reading that indicates the heart to stopped pumping) at 10:26 PM. The report indicated TOR (Termination of Resuscitation) and pronounced Resident 27 expired at 10:46 PM During a telephone interview on [DATE] at 4:58 PM with LVN 2, LVN 2 stated he was notified by the Certified Nurse Assistant (CNA) 3 that Resident 27 was found unresponsive. LVN 2 stated he assessed Resident 27 ' s vital signs but was not able to check resident ' s oxygen blood level. LVN 2 stated he instructed CNA 3 to go to Nursing Station (located in front of the Resident 27 ' s room) to get Resident 27 ' s chart and look for the POLST. LVN 2 stated he did not start CPR until CNA 3 informed him that Resident 27 ' s POLST indicated the resident was a full code (full support which includes CPR if the resident has no heartbeat and is not breathing). During an interview on [DATE] at 5:30 PM with CNA 3, stated when she entered Resident 27 ' s room, CNA 3 observed Resident 27 lying in bed and not breathing. CNA 3 stated she went outside Resident 27 ' s room to call the charge nurse for help and returned to Resident 27 ' s bedside. She stated LVN 2 instructed her to check Resident 27 ' s chart for code status. Then CNA 3 stated I went to grab the backboard (a flat piece of platform that is placed under a person ' s body for the purpose of providing effective CPR). CNA 3 stated, CNA 4 helped her place the backboard under Resident 27 ' s back. LVN 2 instructed CNA 3 and CNA 4 to take over CPR, as LVN 2 went to the Nursing Station to call 911. During an interview on [DATE] at 5:40 PM with CNA 4, CNA 4 stated on [DATE] she was working inside another resident ' s room when CNA 3 ask her for help. CNA 4 stated LVN 2 was performing CPR to Resident 27. CNA 4 She stated that on [DATE] she did not hear a Code Blue announced in the facility ' s paging system. CNA 4 stated that she and CNA 3 was performing CPR while LVN 2 was on the phone in the Nursing Station, calling 911. CNA 4 stated that after they took over the CPR, LVN 2 placed Resident 27 on oxygen delivered via face mask. CNA 4 stated he CNA 3 only performed chest compressions and did not provide rescue breaths to Resident 27. CNA 4 stated she and CNA 3 continued to perform CPR until paramedics arrived. During a follow up telephone interview on [DATE] at 6:11 PM with LVN 2, LVN 2 stated that he cannot remember if he called out a code blue when Resident 27 was found unresponsive to verbal stimuli and vital signs were checked, LVN 2 stated he stepped out from the room to get the mouthpiece from the crash cart to use to give the two breaths Resident 27, then he started the chest compressions. LVN 2 stated that after completing about one set of CPR (consisting of 2 rescue breaths and 30 chest compressions), LVN 2 stated that he went to grab a mask and deliver oxygen to Resident 27. LVN 2 stated I stepped outside the room to call 911 and the Director of Nurses (DON) and ask for help. I don ' t remember if I called the doctor. LVN 2 stated he only checked the vital signs once when he started the CPR. During an interview on [DATE] at 8:45 AM with the Director of Staff Development (DSD), DSD stated to call for medical emergency in the facility, the staff should overpage Code blue in the facility ' s paging system three times to alert other staff members so they can come to assist. The charge nurse is in charge of assigning roles during the code. During an interview on [DATE] at 11:15 AM with the DON, DON stated in a medical emergency the staff need to page Code Blue and state the room number so everyone could help. The DON stated, CPR should be initiated by facility any staff that comes first to the room and there should be a designated team leader, which is usually the charge nurse. The DON stated any available staff can call 911 in an emergency. DON stated that procedures should be delegated, and the resident should not be left alone. During a review of the facility's policy and procedure (P&P) titled, Emergency Procedure-Cardiopulmonary Resuscitation, revised 2018, indicated if an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: the P&P indicated the facility will: 1. Instruct a staff member to activate the emergency response system (code) and call 911. 2. During CPR rescue breaths will be provided after providing 30 chest compression provide via ambu bag or manually (Manual resuscitator) with CPR shield. 3. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death (e.g., rigor mortis). 4. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR. 5. If the first responder is not CPR-certified, that person will call 911 and follow the 911 operator's instructions until a CPR-certified staff member arrives. During a review of the facility's policy and procedure (P&P) titled, Emergency Management Codes and Procedures, revised 2014, indicated Medical Emergency (Code Blue).

Based on interview and record review, the facility failed to provide pharmaceutical services as indicated in the facility's policy and procedure title Administering Medications for one of 3 sampled residents (Resident 27), who was administered Amlodipine (medication used to treat high blood pressure) when the resident ' s blood pressure was below the parameters (a fixed limit) set by the physician's order. These deficient practices had the potential to result in unintended complications such as dizziness, drowsiness, syncope (loss of consciousness) due hypotension (abnormally low blood pressure) that could lead to falls and injury. Findings: During a review of Resident 27 ' s Admission Record, dated 10/23/2021, the face sheet indicated the facility admitted Resident 27 on 10/14/2024 with diagnoses including diabetes mellitus (elevated sugar in the blood), hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated), and history of falling. During a review of Resident 27 ' s History and Physical (H&P), dated 10/16/2024 indicated, Resident 27 had the mental capacity to make medical decisions. During a review of Resident 27's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 10/20/2024, indicated the cognitive (the ability to think and process information) skills for daily decisions making was severely impaired, and needed supervision to extensive assistance from the staff for the activities of daily living. During a review of Resident 27 ' s physician's order, dated 10/16/2024, indicated to administer Amlodipine Besylate Oral Tablet 2.5 milligrams (mg-a unit of measurement) one tablet by mouth one time a day for hypertension, and to hold if systolic blood pressure (SBP - the amount of pressure in the arteries during contraction of the heart muscle) is less than 110 mm Hg (millimeter mercury) or if heart rate is less than 60. During a record review of Resident 27 ' s Medication Administration Record (MAR), for the month of October 2024, the MAR indicated, to administer Amlodipine 2.5 mg one tablet was administered to the resident on 10/29/2024, at 9AM, and 10/30/2024, at 9AM when the systolic blood pressure was below 110 mm Hg and had a BP systolic readings ranged 102 mm Hg to 108 mm Hg. During a concurrent interview and record review on 11/06/2024 at 12:36 PM with the Director of Nursing (DON), stated Amlodipine 2.5 mg should have not been administered to Resident 27 when systolic blood pressure was less than 110 mmHg according to the physician ' s order. A review of the facility's policy of Administering Medications revised in April 2019 indicated the medications must be administered in accordance with the physician ' s orders.

Based on observation, interview, and record review, the facility failed to ensure the call light was in good functioning condition for one of sixteen sampled residents (Resident 23). This failure had the potential for Resident 23 not being able to call for assistance especially during emergency that could result in fall and injury. Findings: During a concurrent observation and interview on 11/4/2024 at 10:25 AM, in Resident 23's room, Resident 23 stated the call light system was not working then pressed the call light button to show the call light was not working. The call light did not make an audible sound and the call light above Resident 23's door did not turn on. During a concurrent observation and interview on 11/4/2024 at 10:45 AM with Certified Nursing Assistant (CNA) 1, in Resident 23's room, CNA 1 pressed the call light, but the call light did not make an audible sound and the light above Resident 23's door did not turn on. CNA 1 stated the call light was not working due to a loose plug on the wall, and she would report to the charge nurse and the maintenance. CNA 1 stated if the call light was not working the resident would not be able to call for assistance and accident like fall could happen. During a concurrent interview and record review on 11/4/2024 at 10:58 AM with Licensed Vocational Nurse (LVN) 1, the Maintenance Repair Log Sheet for October and November 2024 were reviewed. The Maintenance Repair Log Sheet indicated Resident 23's call light had no sound on 10/14/2024 at 10 AM and was repaired. LVN 1 stated the facility should make sure the call light was functioning. LVN 1 stated the charge nurse should inform maintenance if they found the call light was not working, and the maintenance should fix it right away. LVN 1 stated the facility should ensure the residents were able to call for help at all times to help prevent accidents like falls. During an interview on 11/6/2024 at 10:41 AM with Maintenance Supervisor (MS), the MS stated Resident 23's call light was not functioning because the call light plug on the wall was loose, and he fixed it on 11/4/2024 after the nurse reported the call light was not working. The MS stated every morning he checked the Maintenance Repair Log Sheet and made rounds to ensure the call lights were functioning to ensure to residents' needs were met. During an interview on 11/6/2024 at 11:47 AM with the Director of Nursing (DON), the DON stated it was important to ensure the call light was working and ensure resident get assistance on time to meet resident's needs. During a review of Resident 23's Admission Record (Face Sheet), the Face Sheet indicated that Resident 23 was admitted on [DATE] with diagnoses including left ankle, right ankle, left knee, and right knee contracture (a stiffening or shortening at any joint, that reduces the joint's range of motion), muscle weakness, dysphagia (difficulty swallowing), benign prostatic hyperplasia (a condition in which the prostate gland grows larger than normal), primary hypertension (high blood pressure), depression, bipolar disorder (a mental illness that causes extreme mood swings, along with changes in energy, sleep, thinking, and behavior), anxiety disorder (a mental illness that causes people to experience excessive and uncontrollable feelings of fear or anxiety), schizophrenia (a mental illness that is characterized by disturbances in thought), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 23's History and Physical (H&P), dated 1/29/2024, the H&P indicated Resident 23 could make needs known but could not make medical decisions. During a review of Resident 23's Minimum Data Set (MDS - a resident assessment tool) dated 8/20/2024, the MDS indicated Resident 23 had moderate impairment in cognitive (ability to remember things, solve problems, or make decisions) skills for daily decision making. The MDS indicated Resident 23 needed partial/moderate assistance (another person provided less than half of the effort) to complete the activities including oral hygiene, roll left and right, sit to lying, and lying to sitting on side bed. The MDS indicated Resident 23 was dependent and needed two or more helpers do all the effort for the resident to complete the toileting hygiene, personal hygiene, shower/bathe, lower body dressing, and bed to chair transfer activity. During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, dated revised December 2009, the P&P indicated the Maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personnel include but are not limited to maintaining the paging system in good working order. During a review of the facility's P&P titled, Answering the Call Light, dated 2001, revised October 2010, the P&P indicated the facility should ensure to respond to the resident's request and needs. The facility should ensure that the call light be plugged in at all times and report all defective call lights to the nurse supervisor promptly.

Based on observation, interview and record review, the facility failed to provide a minimum of 80 square feet (sq. ft., unit of measurement) per resident for fourteen (14) out of sixteen (16) resident rooms (room [ROOM NUMBER],2,3,4,5,6,7,8,10,12,13,15 and 16). This deficient practice had the potential to negatively impact the quality-of-care and the ability of the nursing care to safely provide care and privacy to the residents. Findings: During the entrance conference interview with the Administrator (ADM) on 11/6/2024 at 9:06 AM, the ADM stated there were fourteen rooms (room [ROOM NUMBER],2,3,4,5,6,7,8,10,12,13,15 and 16) in the facility that did not meet the federal regulation [a regulation that the Long-Term Facilities was required to follow to meet federal requirement of by Centers for Medicare & Medicaid Services (CMS)] to ensure at least 80 square feet of space per resident in each room. The ADM stated the facility would like to request a room waiver (a document recording the waiving of a right or claim) this year. During a concurrent observation and interview on 11/5/2024 at 11:10 AM in room [ROOM NUMBER], room [ROOM NUMBER] had 2 beds, each bed had their own drawers. Resident 23 stated, he had no concern with the room size, and stated, the facility staffs and him were able to move around freely. During an observation on 11/6/2024 at 9 AM, Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 12, 13, 14, 15, and 16 had adequate space, provide privacy, comfort, and nursing care to the residents. The residents residing in the affected rooms were observed to have enough space for the residents to move freely inside the rooms. Each resident inside the affected rooms had beds an During a concurrent observation and interview on 11/6/2024 at 9:40 AM in room [ROOM NUMBER], Certified Nurse Assistant 2 (CNA 2) stated he had no concern with the room size, and stated, he can perform task such as transferring residents with a Hoyer lift (is a mobility tool designed to help individuals with mobility challenges) from the bed to the wheelchair without any issues. and is able to move around freely. During a review of the facility ' s request letter for room waiver, dated 11/6/2024, indicated the following resident bedrooms were: room [ROOM NUMBER] (2 beds) 146.52 sq ft 73 sq. ft. room [ROOM NUMBER] (2 beds) 146.52 sq ft 73 sq. ft. room [ROOM NUMBER] (2 beds) 143.88 sq ft 71.5 sq. ft. room [ROOM NUMBER] (2 beds) 143.88 sq ft 71.5 sq. ft. room [ROOM NUMBER] (2 beds) 149.16 sq ft 74.5 sq. ft. room [ROOM NUMBER] (2 beds) 141.21 sq ft 70.5 sq. ft. room [ROOM NUMBER] (2 beds) 119.92 sq ft 59.96 sq. ft. room [ROOM NUMBER] (2 beds) 119.92 sq ft 59.96 sq. ft. room [ROOM NUMBER] (2 beds) 147.84 sq ft 73.5 sq. ft. room [ROOM NUMBER] (2 beds) 147.84 sq ft 73.5 sq. ft. room [ROOM NUMBER] (2 beds) 147.84 sq ft 73.5 sq. ft. room [ROOM NUMBER] (2 beds) 119.92. sq ft 59.96 sq. ft. room [ROOM NUMBER] (2 beds) 119.92 sq ft 59.96 sq. ft. room [ROOM NUMBER] (2 beds) 147.84 sq ft 73.5 sq. ft. The room waiver indicated; the facility will ensure: That the approval of the waiver will not adversely affect the health, safety, and welfare of each resident that we care for as the waiver is in accordance with meeting the special needs of each resident.

Based on interview and record review, the facility failed to provide necessary services (drug counseling and surveillance [monitoring of behavior; activities]) and develop person centered care plans for the behavioral healthcare needs for substance abuse for one of three sampled residents (Resident 1), who had a history of drug abuse (the excessive or addictive use of drugs for nonmedical purposes) and prevent Resident 1 from experiencing a drug overdose (an excessive and dangerous dose of a drug) of opiate (a controlled drug used to treat pain or cause sleep) and fentanyl (a powerful, controlled drug that is used to treat severe pain) while residing in the facility by failing to: 1. Develop and implement behavior health care plans for drug abuse to meet the behavioral needs of Resident 1 ' s when Resident 1 was readmitted to the facility from the General Acute Care Hospital 2 (GACH) on [DATE] in accordance with the facility policies and procedures [P&P] titled Behavioral assessment, intervention and monitoring and Care plans, comprehensive person-centered. 2. Develop individualized interventions, which included drug abuse counseling and surveillance of a drug abuser, upon Resident 1 ' s readmission to the facility on [DATE], when Resident 1 was diagnosed with opiate and fentanyl overdose in GACH 3 on [DATE], in accordance with the facility P&P titled Behavioral assessment, intervention and monitoring and Care plans, comprehensive person-centered. 3. Assess and identify Resident 1 ' s behavioral needs for drug counseling and surveillance, upon readmission back to the facility from GACH 3 on [DATE], by identifying risk factors, causes and how Resident 1 was exposed to illicit (illegal) drug use, due to a recent opiate/fentanyl overdose incident in the facility, as indicated in the facility ' s policy and procedure [P&P] titled Management of Illicit Drug Use and Referrals, Social Services. 4. Attempt to perform voluntary inspections of Resident 1 ' s belongings, when facility staff had reasonable suspicion of possession of illicit drugs to prevent recurrence of illicit drug use and overdose. The facility did not conduct voluntary inspection of Resident 1 ' s belongings to ensure illicit drugs were no longer present in the resident ' s possession, upon readmission back to the facility, on [DATE], after being transferred to GACH 3 for opiate/fentanyl overdose, in accordance with the facility ' s P&P titled Behavioral assessment, intervention and monitoring and Management of Illicit Drug Use. On [DATE] at 6:56 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider ' s noncompliance [not following rules] with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the failure to obtain necessary services, develop person centered care plans for the behavioral healthcare needs of a resident who had history of substance abuse and opiate/fentanyl overdose. The survey team notified the Director of Nursing (DON) and the Administrator (ADM) of the IJ situation on [DATE] at 6:56 PM, due to the facility ' s failure to obtain necessary services, develop person centered care plans for the behavioral healthcare needs of Resident 1. On [DATE] at 1:30 PM, the ADM provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings). On [DATE] at 2:27 PM, while onsite and after the surveyor verified/confirmed the facility ' s full implementation of the IJ Removal Plan, through observation, interview, and record reviews, and determined the IJ situation was no longer present, the IJ was removed onsite, in the presence of the ADM and the DON. The IJ Removal Plan dated [DATE], included the following: -On [DATE], the facility reviewed and developed a behavior care plan for drug abuse for Resident 1 ' s past history of drug abuse. The facility conducted an Interdisciplinary Team [IDT - a group of professionals from different disciplines who work together to provide personalized care)] meeting on [DATE], with Resident 1 regarding any drug use, which Resident 1 denied at the time. -The ADM conducted an investigation on [DATE], to determine the possibilities on how the incident on [DATE], could have happened. Based on ADM investigation (concluded on [DATE]) closer supervision could be needed by the gate. -On [DATE], the facility Security guards was immediately given in-service to be in close proximity (near) to the gate. The Security Guard was placed at the facility gate at 8 PM on [DATE]. Security Guards ' shifts are 7 AM to 3 PM and 3 PM to 11 PM, seven days a week. Security Guards will screen everyone they encounter, with an emphasis on looking for suspicious behavior and drug contraband [illicit goods] from all persons, including staff, residents and visitors. Security Guards will document all person interactions with time, date, and name. Security Guards will report abnormal findings to nursing supervisor. Staff will also have the responsibility for facility wide supervision and was in-serviced specifically for Fentanyl, regarding how to spot signs of active, potential usage and its physical form by the Director of Staff Development (DSD) on [DATE]. 48 staff out of 54 staff informed with an expected completion date [DATE]. ADM called the police to report the incident on [DATE], the call was placed at 1:55 PM, on [DATE]. In the ADM or DON ' s absence, the nursing supervisor can inform the police of any illicit activity. -On [DATE], the IDT reviewed all residents' charts to determine if there are other residents that have history of drug abuse, two residents found. The facility updated their behavior care plans to ensure their needs are met and completed. History of drug abuse created and placed at the Nursing Station with contents identifying all current residents that have a history of drug abuse, for staff reference. Staff informed regarding newly identified residents on [DATE]. -Developed an individualized intervention for Resident 1, which included scheduling of counseling from the facility Psychologist [a person who specializes in the study of mind and behavior] on [DATE], with a focus on opiate and fentanyl overdose and drug abuse. The Psychologist will visit Resident 1, two times a month. -Upon readmission, Resident 1 will be interviewed by Social Services, questions will include an emphasis on history of illicit drug abuse. -All nursing staff will review residents' records to establish if there is a history of drug abuse/use, care plans will be implemented for residents that are found to have a history of drug abuse. -Resident belongings will also be thoroughly checked (with the resident ' s permission) to ensure no contraband is present and brought into the facility. -Residents suspected of illicit drug usage (Fentanyl) will be drug tested in according to the facility ' s Illicit drug policy. Residents have the right to refuse drug testing as it is voluntary. -For ongoing suspicion of illicit drug use of residents, the IDT team will conduct and IDT meeting informing the resident of the facility policy, including that all drug testing is voluntary. -On [DATE], the facility staff conducted a search in Resident 1 ' s room with the resident ' s consent. This search was repeated on [DATE], no contraband found. The facility also conducted a whole facility search and no contraband was found on [DATE]. The facility will conduct weekly contraband searches every 4 weeks and them monthly for the next 6 months. -Resident 1 was prescribed Norco (a drug used to treat moderate to severe pain) every eight hours as needed for pain management. This is to prevent Resident 1 from seeking pain relief through illicit means. Findings: During a review of Resident 1 ' s GACH 2 records titled History and Physical [H&P] Report dated [DATE], indicated the resident came to the emergency room for worsening left shoulder pain. The H&P indicated under Assessment and Plan to rule out stroke [a medical emergency that occurs when blood flow to the brain is disrupted, damaging or killing brain tissue], adjust psychiatric [relating to mental illness] medications and for pain management. The GACH 2 record indicated Resident 1 was discharged with Acetaminophen [over the counter pain medication] 325 mg oral tablet: two tablets orally every 4 hours, as needed, for mild pain (,d+[DATE]) pain scale. The GACH 2 record indicated the resident was discharged to the facility on [DATE]. The H&P under Social History indicated, Resident 1 has a remote history of smoking. Resident 1 has a history of drug abuse. During a review of Resident 1 ' s facility records titled Admission Record indicated a facility readmission on [DATE], with diagnoses that included flaccid hemiplegia (a neurological condition characterized by weakness or paralysis and reduced muscle tone) affecting left non dominant side, chronic obstructive pulmonary disease (COPD -a group of lung diseases that block airflow and make it difficult to breathe). During a review of Resident 1 ' s facility records titled Order summary Report indicated the following active medication orders for Resident 1 dated [DATE]: Amlodipine Besylate (medication for blood pressure) 10 milligram [mg - unit of measurement] one time a day. Aspirin 81 mg (medication for CVA) 81 milligram one time a day. Ativan (medication for anxiety) 0.5 mg two times a day. Folic Acid (medication for anemia) 1 mg one time a day. Gabapentin (medication for numbness and pain from nerve damage) 300 mg three times a day. Ibuprofen (medication for pain) 600 mg as needed every 12 hours. Lactulose (medication to prevent complication of liver disease) 10 grams in 15 mg, one time a day. Lidocaine patch (medication for pain) 5% apply for 12 hours. Lisinopril (medication for blood pressure) 5 mg one time a day Milk of Magnesia (medication for constipation) 30 ml as needed one time a day Olanzapine (medication for mental illness) 5 mg 1 time a day Tylenol (medication for mild pain) 325 mg give 1 as needed every 6 hours Tylenol (medication for pain level ,d+[DATE]) 325 mg give 2 as needed every 6 hours Vitamin B1(supplement) 100 mg one time a day Vitamin C (supplement) 500 mg one time a day Zolpidem Tartrate (medication for inability to sleep) 5 mg give one tablet During a review of Resident 1 ' s facility records titled History and Physical (H&P) dated [DATE], indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 1 ' s facility records titled Social Service History & Initial assessment dated [DATE], authored by the Social Services Director [SSD] indicated under Social Factors and History of drug/alcohol abuse, was left unmarked. During a review of Resident 1 ' s facility records titled Situation, Background Assessment, Recommendations [SBAR] dated [DATE] timed at 9:45 AM, indicated at 9:30 AM, Resident 1 was up in the wheelchair and conversing [talking] with the staff. The SBAR indicated Resident 1 started drooling (when saliva flows out of your mouth unintentionally) on the right side of his mouth. Resident 1 was non-verbal, non-responsive to pain and skin color was purple/clammy skin (skin that is wet from sweating). The SBAR further indicated Resident 1 ' s blood pressure was ,d+[DATE], pulse rate was 94, respirations was 12. Resident 1 ' s oxygen saturation (the amount of oxygen carried by red blood cells) was absent and a non-breather mask (a special medical device that helps provide you with oxygen in emergencies) oxygen inhalation at 10 Liters (metric unit of capacity) was placed on Resident 1. The SBAR indicated Resident 1 still remained unresponsive . The resident ' s pupil of eye constricted (to reduce the light entering the eye) and fixed (a pupil that does not respond to light). The resident ' s physician (Physician 1) was notified and made aware. The SBAR indicated 911 emergency services was notified and the resident was transferred to GACH 3. During a review of Resident 1 ' s GACH 3 records titled History and Physical dated [DATE], indicated [Resident 1] was found slumped [sitting with the body leaning forward, for example, because a person was asleep or unconscious] over in the wheelchair, then became unresponsive. No seizure [a sudden, uncontrolled movement] activity noted. Resident 1 was started on CPR (cardiopulmonary resuscitation, [an emergency treatment that's done when someone's breathing or heartbeat has stopped]) when paramedics arrived. Resident 1 was noted with agonal breathing (when someone who is not getting enough oxygen is gasping for air) and pinpoint pupils [a condition where the pupils of the eyes appear unusually small] with Glasgow coma scale (used to objectively describe the extent of impaired consciousness) of 3 (is the lowest possible score and is associated with an extremely high mortality rate). Resident 1 was given Narcan (is a medicine that treat someone from fentanyl or prescription opioid medicine overdose) with improvement. During a review of Resident 1 ' s GACH 3 Urine Drug Screen [UDS- used to detect illegal and some prescription drugs in the urine] dated [DATE] timed at 12:15 PM, the UDS indicated Resident 1 ' s urine indicated Presumptive Positive [shows a response, which is usually because a drug is present] for Fentanyl Urine and Opiates [a drug that contains opioids (a class of controlled drug used for moderate to severe pain)], Urine. During a review of Resident 1 ' s GACH 3 Physician Progress Notes dated [DATE], the Progress Notes indicated Resident 1 ' s Chest X-ray [a way for providers to get pictures of the inside of your body] and CT [Computed Tomography - an imaging test that helps healthcare providers detect diseases and injuries] of the head did not indicate any acute abnormal process. The GACH 3 Physician Progress Notes indicated under Problem List, indicated Resident 1 had syncope (a loss of consciousness for a short period of time), unresponsiveness, opiate overdose, possible respiratory arrest [a condition that exists at any point a patient stops breathing] due to accidental fentanyl overdose, and fentanyl/opioid positive on UDS. The Progress Notes further indicated to continue monitoring Resident 1 ' s vital signs [clinical measurements, specifically pulse rate, temperature, respiration [breathing] rate, and blood pressure] and administer Narcan as needed. During a review of Resident 1 ' s facility records titled Admission Record indicated another readmission back to the facility on [DATE], with diagnoses that included syncope and collapse [fall down], personal history of other specified condition, flaccid hemiplegia affecting left non dominant side and COPD. During a review of Resident 1 ' s facility records titled Nursing Admission Screening/History dated [DATE] indicated Resident 1 was readmitted back to the facility from GACH 3 with the following reasons . Possible respiratory arrest . Unresponsive and Syncope. During a review of Resident 1 ' s facility records titled IDT /Comprehensive Care Plan Summary dated [DATE], indicated the IDT met with Resident 1 and reviewed Resident 1 ' s plan of care. The IDT record indicated Resident 1 was readmitted from GACH 3 on [DATE] , under the care of Physician 1 with left flaccid paralysis/hemiplegia [loss of strength in the arm, leg, and sometimes face on one side of the body], cerebrovascular accident [CVA -caused by blood clots and broke vessels in the brain), hepatic encephalopathy (brain disfunction caused by liver disfunction), anxiety (condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), hypertension (a condition in which the force of the blood against the artery walls is too high) .and bipolar disorder (a disorder associated with episodes of mood swings). The IDT record further indicated that the IDT had met with Resident 1 today [[DATE]] regarding GACH 3 reports of Fentanyl overdose. The IDT record indicated Resident 1 denied taking any medications other than what was prescribed for him. The IDT record indicated, Resident 1 denied taking opioids and/ or any other illegal substance. The IDT record indicated . Will continue to monitor Resident 1 ' s condition. Will provide frequent visual check for safety. Will continue current plan of care. During a review of Resident 1 ' s facility records titled Telephone Order (TO) dated [DATE], the TO indicated Physician 1 ' s telephone orders to continue previous medications and treatments as ordered. During an interview and observation on [DATE] at 1:43 PM, with Resident 1, Resident 1 was observed sitting in the wheelchair at the facility ' s Dining Room. Resident 1 stated, The day ([DATE]) I went to the hospital [GACH 3] I took a pill my friend gave me; it was supposed to make me feel better. I don ' t remember what happened that day, I woke up in the hospital (GACH 3). Resident 1 stated his friend dropped off the pill in front of the facility through the gate. Resident 1 stated the facility ' s security guard was present outside, when his friend gave him the pill. Resident 1 stated the security guard was not paying attention when he was handed the pill through the facility gate. Resident 1 stated he did not want to say who the friend was who gave him the pill. Resident 1 further stated, I learned my lesson and I would not do that again. During an interview on [DATE] at 3:45 PM with the ADM and concurrent record review of the facility ' s investigation regarding the incident that happened with Resident 1 on [DATE], the ADM provided typewritten staff interview statements that indicated the following information: -Facility record titled Facility Interview dated [DATE] and signed by the facility ADM, indicated a typewritten statement from Registered Nurse [RN] 1. The interview statement indicated, Registered Nurse (RN 1) stated that on she saw Resident 1 ' s change of condition. Immediately went to help and call 911. Did not notice anything unusual during the shift. -Facility record titled Facility Interview dated [DATE] and signed by the facility ADM, indicated a typewritten statement from Certified Nursing Assistant (CNA) 1. The interview statement indicated CNA 1 had [Resident 1] for an assignment. CNA 1 responded to the change of condition. Did not notice anything unusual during the shift. No visitors for Resident 1. No out on pass, aware of. -Facility record titled Facility Interview dated [DATE], and signed by the facility ADM, indicated [CNA 2] responded to the change of condition. Did not notice anything unusual during the shift. -Facility record titled Facility Interview dated [DATE], and signed by the facility ADM, indicated [CNA 3] night shift, did not notice anything unusual. No issues. -Facility record titled Facility Interview dated [DATE], and signed by the facility ADM, indicated [Resident 1] does not recall taking anything unusual. Felt fine until the incident, feels safe, no issues with facility. During an interview on [DATE] at 2:10 PM, CNA 1 stated she came in to work at 6:30 AM in the morning of [DATE] and remembered seeing Resident 1. CNA 1 stated before 8 AM, she helped Resident 1 get out of bed and up to the shower chair. CNA 1 stated that after the shower, CNA 1 took Resident 1 to the bathroom dressed him and helped him brush his teeth and get dressed. CNA 1 stated she recalled seeing Resident 1 wheeling himself out in his wheelchair into the hallway between 8:30 AM to 9:00 AM. CNA 1 stated a few minutes after that she heard RN 1 calling for help for Resident 1. CNA 1 stated she rushed over and saw Resident 1 looked pale and blue. CNA 1 stated, the paramedics arrived and took Resident 1 between 9:20 AM to 9:30 AM on [DATE]. During an interview on [DATE] at 2:15 PM, RN 1 stated she remembered in the morning of [DATE], Resident 1 came up to RN 1 to get his medications after breakfast around 8:50 AM to 9:00AM. RN 1 stated she gave Resident 1 an Ibuprofen (over the counter pain medication), for pain. RN 1 stated seeing Resident 1 wheeled himself away and was hanging out with the other residents in the hallway. RN 1 stated around 9:30 AM, she saw Resident 1 in the facility hallway in his wheelchair, drooling, with the head tilted to the side. RN 1 stated she called a Code Blue (a code that indicated that someone is experiencing a life-threatening medical emergency) and asked a CNA [unknown CNA] to assist her to put Resident 1 down to the floor. RN 1 stated Resident 1 ' s oxygen saturation level on [DATE] was around 91% to 92% [normal oxygen saturation levels are 95 % to 100%]. RN 1 stated she increased Resident 1 ' s oxygen level to 10 Liters (a unit of measurement) and instructed someone to call 911 emergency services. RN 1 stated Resident 1 would slightly open his eyes after he got oxygen but could not talk. During an interview with on [DATE] at 2:24 PM, with the DON, the DON stated Resident 1 was transferred to GACH 3 on [DATE], after being found unresponsive and drooling. The DON stated on [DATE], before Resident 1 arrived back at the facility, the DON spoke to a GACH 3 licensed nurse, who notified the facility that Resident 1 ' s urine drug test, tested positive for Fentanyl and other opiates. The DON stated the GACH 3 licensed nurse stated Resident 1 was admitted to GACH 3 for medication overdose. The DON stated there was no way he [Resident 1] can overdose . that did not happen. I think it was a stroke because of Resident 1 ' s history of CVA [cerebrovascular accident]. During the same interview on [DATE] at 2:24 PM and concurrent review of Resident 1 ' s Medication Administration Records (MAR) for [DATE] to [DATE], the DON stated that Resident 1 was not on Fentanyl or any types of opioid medications prior to the change in condition [syncope and unresponsiveness] on [DATE]. During another interview and concurrent record review on [DATE] at 2:45 PM, Resident 1 ' s active care plans was reviewed with the DON. During the interview, the DON stated there was no documented evidence that a care plan was developed for Resident 1 ' s history of drug abuse in the past as indicated in GACH 2 record dated [DATE] and GACH 3 records dated [DATE], or the recent fentanyl/opiate overdose on [DATE]. The DON stated, We [facility] did not do care plan because it [overdose] did not happen . that he [Resident 1] had an overdose (fentanyl or opioids). The DON further stated that the facility did not have any residents receiving fentanyl. During the same interview and concurrent record review on [DATE] at 2:45 PM, Resident 1 ' s IDT/Comprehensive care pan summary dated [DATE] was reviewed with the DON. When asked what the licensed nurses were monitoring for Resident 1, as indicated in the IDT care plan summary, the DON stated Resident 1 was being monitored for vitals sign abnormalities once a shift. During an interview on [DATE] at 3:24 PM, with the facility ' s security guard (SG 1), SG 1 stated that when someone comes to the facility gate, he would open the gate and inform the nurses. SG 1 stated he was never instructed to intervene or question if an unknown individual was seen outside the gate talking to a resident in the facility. During the same interview, on [DATE] at 3:24 PM, the SSD stated when a new resident is admitted or readmitted to the facility, the facility SSD and the licensed nurses would go over all of the resident ' s GACH records. The SSD stated that the SSD would complete a full social services assessment upon admission/readmission. The SSD stated the facility did not order or arrange any behavioral referrals for Resident 1 to see a psychologist or psychiatrist [a doctor specializing in the diagnosis and treatment of mental illness] for substance abuse counseling upon his readmission on [DATE], from GACH 3. During a concurrent interview and record review of Resident 1 ' s care plans developed from [DATE] to [DATE], with the facility ' s SSD on [DATE] at 2:22 PM, the SSD stated there was no care plan developed for Resident 1 ' s history of substance abuse from [DATE] and [DATE] facility readmissions. The SSD stated she did not know Resident 1 had a history of drug abuse as indicated in the GACH 2 Social History record, dated [DATE]. The SSD further stated Resident 1 did not have care plans developed for fentanyl overdose or drug abuse or any type of surveillance monitoring for substance abuse, because the facility did not believe Resident 1 ' s fentanyl and opiate overdose was real. The SSD stated the facility did not have any residents taking fentanyl medications. The SSD stated she did not search Resident 1 ' s entire room and belongings to search for illicit drugs, with Resident 1 ' s consent on [DATE] upon Resident 1 ' s readmission back to the facility from GACH 3 on [DATE]. During an interview on [DATE] at 4:29 PM with the DON, the DON stated there was no care plan developed to perform voluntary inspections of Resident 1 ' s room and belongings for possession of illicit drugs, upon Resident 1 ' s readmission from GACH 3 on [DATE]. The DON stated she searched Resident 1 ' s room on [DATE] with another facility staff but could not recall who the staff was and did not document the inspection. During a review of the facility ' s P&P titled, Management of Illicit Drug Use [not dated], the P&P indicated the purpose of the policy was To establish a consistent, complaint, and legal response to the identification, prevention, and management of illicit drug use among residents to ensure safety . The aim is to ensure the safety of all residents, staff, and the facility. The P&P further indicated 1. Prevention and Education- All new resident ' s history and physical will be reviewed upon admission for substance abuse history. This information will guide care planning and the prevention of potential issues. During a review of the facility ' s P&P titled, Referrals, Social Services revised on [DATE], the P&P indicated Social Services personnel shall coordinate most resident referrals with outside agencies . The P&P further indicated 3. Referrals for residents with psychological, history of alcohol or substance abuse related needs must be based on physician evaluation of resident need, after which Social Services will collaborate with the nursing department to arrange for recommended services. 4. Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician. 5. Social services will document the referral in the resident ' s medical record. 6. Social services and administration will maintain a listing of referral agencies that may provide assistance or therapy to residents with special problems and/or needs . During a review of the facility ' s P&P titled, Behavioral assessment, intervention and monitoring revised [DATE], the P&P indicated 1. The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident ' s change in condition The care plan will incorporate findings from the comprehensive assessment and be consistent with current standards of practice. During a review of the facility ' s P&P titled Care plans, comprehensive person-centered, revised on [DATE], the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical and functional needs is developed and implemented for each resident.

Based on observation, interview, and record review the facility failed to manage a resident ' s pain timely and effectively for one of two sampled residents (Resident 1), in accordance with the facility ' s policy and procedure titled Pain Assessment and Management, by failing to: 1. Follow the General Acute Care Hospital (GACH) 1 recommendations on pain management and the physician ' s order for Norco as needed for severe pain dated [DATE]. 2. Follow up with the pharmacy to ensure the ordered pain medication [Norco] was received and delivered timely. 3. Notify the physician when Resident 1 ' s pain management regimen was ineffective, and the resident received pain medication for mild pain [Ibuprofen], almost daily. 4. Update Resident 1 ' s Pain Care Plan to reflect specific resident-centered interventions needed to relieve the resident ' s pain. 5. Implement the facility ' s policy & procedure (P&P) titled Pain Assessment and Management that included monitoring for the effectiveness of interventions and modifying approaches as necessary. Assessing pain consists of identifying characteristics of pain and the pattern of pain. Report the following information to the physician or practitioner: prolonged, unrelieved pain despite care plan interventions. These deficient practices resulted in Resident 1 taking an unknown medication to relieve moderate to severe pain and was sent to GACH for an overdose of Fentanyl (a potent synthetic opioid drug used as pain relief and anesthetic) with the potential of having a negative effect on the resident ' s physical comfort and psychosocial well-being. Findings: A review of Resident 1 ' s GACH 1 record dated [DATE], indicated the resident was evaluated for left arm pain and prescribed Norco ,d+[DATE] (Hydrocodone bitartrate 5 mg [unit of measurement] and Acetaminophen 325 mg) mg per tablet, take one tablet by mouth every six hours as needed for severe pain (,d+[DATE]) for up to five days. During a review of Resident 1 ' s GACH 2 records titled History and Physical [H&P] Report dated [DATE], indicated the resident came to the emergency room for worsening left shoulder pain. The H&P indicated under Assessment and Plan to rule out stroke [a medical emergency that occurs when blood flow to the brain is disrupted, damaging or killing brain tissue], adjust psychiatric [relating to mental illness] medications and for pain management. The GACH 2 record indicated Resident 1 was discharged with Acetaminophen [over the counter pain medication] 325 mg oral tablet: two tablets orally every 4 hours, as needed, for mild pain (,d+[DATE]) pain scale. The GACH 2 record indicated the resident was discharged to the facility on [DATE]. The H&P under Social History indicated, Resident 1 has a remote history of smoking. Resident 1 has a history of drug abuse. During a review of Resident 1 ' s facility records titled Admission Record indicated a facility readmission on [DATE], with diagnoses that included flaccid hemiplegia (a neurological condition characterized by weakness or paralysis and reduced muscle tone) affecting left non dominant side, chronic obstructive pulmonary disease (COPD -a group of lung diseases that block airflow and make it difficult to breathe). A review of the facility records indicated Resident 1 ' s Change in Condition (COC) dated [DATE] timed at 8:40 AM, indicated the resident had intractable pain to the left shoulder with a pain level of 8 on the pain scale (a way to measure how much pain someone was experiencing - a score of 0 meant no pain, and 10 meant the worse pain you have ever known) with increased left shoulder weakness, and left shoulder limitation. The COC indicated the current pain reliever - Ibuprofen was ineffective. The COC indicated the physician was notified and the facility received orders to transfer the resident to GACH 1 for further evaluation. A review of the facility records indicated Resident 1 ' s PRN Pain Assessment Flowsheet dated from [DATE] to [DATE], the PRN Pain Assessment indicated the resident had generalized body pain with a pain level of 8 out of 10 on the pain scale. The PRN Pain Assessment Flowsheet indicated non-pharmacological interventions included repositioning, dim light/quiet environment, snack/drinks, 1:1 attention, re-direction, music, massage, or toileting. The PRN Pain Assessment Flowsheet indicated the non-pharmacological interventions were not effective and the resident ' s pain level was the same before the interventions were implemented, resulting in the resident receiving pain medication every time Resident 1 complained of pain. A review of the facility records indicated Resident 1 ' s Medication Administration Record (MAR) dated from [DATE] to [DATE], indicated the resident received Ibuprofen every day for the month of [DATE], except for four days. The MAR indicated for two of the four days Resident 1 did not receive Ibuprofen, the resident received Norco. A review of the facility records indicated Resident 1 ' s Minimum Data Set (MDS, a standardized resident assessment and care-planning tool) dated [DATE], indicated the resident had moderate cognitive impairment (could not navigate to new places, and they have significant difficulty completing complex tasks such as managing finances). The MDS indicated the resident had impairment on both upper and lower extremity sides and utilized a walker and a wheelchair for mobility devices. The MDS indicated the resident received scheduled and as needed (PRN) pain medication. The MDS indicated the resident had the presence of pain occasionally, the pain did not affect the resident ' s sleep, and Resident 1 ' s pain rarely interfered with the resident ' s day-to-day activities. The MDS indicated the residents pain scale was a three from a zero to 10 pain scale. A review of the facility records indicated Resident 1 ' s History and Physical (H&P) dated [DATE], indicated the resident had fluctuating capacity to understand and make decisions. A review of the facility records indicated Resident 1 ' s Drug Regimen Review on [DATE] timed at 7:59 PM, indicated the resident ' s primary admission diagnosis was chronic pain syndrome. The Drug Regimen Review indicated new medications ordered on admission included Tylenol oral tablet 325 mg (Acetaminophen) two tablets on 4-,d+[DATE] pain scale every six hours, Tylenol oral tablet 325 mg (Acetaminophen) one tablet on 1-,d+[DATE] pain scale every six hours, and Ibuprofen 600 mg PRN every 12 hours for pain scale 7-,d+[DATE]. The Drug Regimen Review indicated there were no potential medication issues noted, and the medications were reviewed by the pharmacist and the physician. A review of the facility records indicated Resident 1 ' s Pain Care Plan dated [DATE], indicated the resident had neuropathic pain related to diagnoses. The Care Plan goal indicated the resident would verbalize and/or show decrease physical signs in pain with pain relieving strategies. The Care Plan interventions included assessing level of pain using the pain rating scale, implement non-pharmacological interventions of repositioning and dim lighting, and provide relaxation techniques. The Care Plan interventions continued with aromatherapy, reassuring words/gestures, administer pain medication as ordered, monitor response using pain scale related to medications, treatments, and procedures, and evaluate the need to provide medications prior to treatment or therapy. During a review of Resident 1 ' s facility records titled Order summary Report indicated the following active medication orders for Resident 1 dated [DATE]: Amlodipine Besylate (medication for blood pressure) 10 milligram [mg - unit of measurement] one time a day. Aspirin 81 mg (medication for CVA) 81 milligram one time a day. Ativan (medication for anxiety) 0.5 mg two times a day. Folic Acid (medication for anemia) 1 mg one time a day. Gabapentin (medication for numbness and pain from nerve damage) 300 mg three times a day. Ibuprofen (medication for pain) 600 mg as needed every 12 hours. Lactulose (medication to prevent complication of liver disease) 10 grams in 15 mg, one time a day. Lidocaine patch (medication for pain) 5% apply for 12 hours. Lisinopril (medication for blood pressure) 5 mg one time a day Milk of Magnesia (medication for constipation) 30 ml as needed one time a day Olanzapine (medication for mental illness) 5 mg 1 time a day Tylenol (medication for mild pain) 325 mg give 1 as needed every 6 hours Tylenol (medication for pain level ,d+[DATE]) 325 mg give 2 as needed every 6 hours Vitamin B1(supplement) 100 mg one time a day Vitamin C (supplement) 500 mg one time a day Zolpidem Tartrate (medication for inability to sleep) 5 mg give one tablet A review of the facility records indicated Resident 1 ' s Progress Note dated [DATE] timed at 12:52 PM, indicated the resident was complaining of pain to the left arm/shoulder with a ,d+[DATE] on the pain scale. The Progress Note indicated the resident received PRN pain medication as ordered. A review of the facility records indicated Resident 1 ' s Physician ' s Order dated [DATE] timed at 2:39 PM, indicated Ibuprofen oral tablet 600 mg, give one tablet by mouth every 12 hours as needed for pain scale 4-,d+[DATE] and give with food/snack. A review of the facility records indicated Resident 1 ' s Physician ' s Order dated [DATE] timed at 2:50 PM, indicated Norco oral tablet ,d+[DATE] mg give 1 tablet my mouth every 8 hours as needed for pain 7-,d+[DATE], hold if respiration rate (the number of breaths a person takes in a minute) was less than 12 breaths/min and notify MD (Doctor of Medicine). Do not exceed 3G (grams, unit of measurement) APAP (acetaminophen, a common pain reliever and fever reducer)/24 hours. A review of the facility records indicated Resident 1 ' s PRN Pain Assessment Flowsheet dated from [DATE] to [DATE], indicated the resident had left shoulder pain with a pain level ranging from six to eight on the pain scale. The PRN Pain Assessment Flowsheet indicated the non-pharmacological interventions were not effective and the residents pain level was the same before the interventions were implemented, resulting in the resident receiving pain medication every time Resident 1 complained of pain. A review of the facility records indicated Resident 1 ' s MAR dated from [DATE] to [DATE], indicated the resident received Ibuprofen on [DATE], [DATE] to [DATE], and [DATE] to [DATE]. The MAR indicated the resident received Norco on [DATE] to [DATE]. During a review of Resident 1 ' s facility records titled Situation, Background Assessment, Recommendations [SBAR] dated [DATE] timed at 9:45 AM, indicated at 9:30 AM, Resident 1 was up in the wheelchair and conversing [talking] with the staff. The SBAR indicated Resident 1 started drooling (when saliva flows out of your mouth unintentionally) on the right side of his mouth. Resident 1 was non-verbal, non-responsive to pain and skin color was purple/clammy skin (skin that is wet from sweating). The SBAR further indicated Resident 1 ' s blood pressure was ,d+[DATE], pulse rate was 94, respirations were 12. Resident 1 ' s oxygen saturation (the amount of oxygen carried by red blood cells) was absent and a non-breather mask (a special medical device that helps provide you with oxygen in emergencies) oxygen inhalation at 10 Liters (metric unit of capacity) was placed on Resident 1. The SBAR indicated Resident 1 still remained unresponsive . The resident ' s pupil of eye constricted (to reduce the light entering the eye) and fixed (a pupil that does not respond to light). The resident ' s physician (Physician 1) was notified and made aware. The SBAR indicated 911 emergency services was notified and the resident was transferred to GACH 3. During a review of Resident 1 ' s GACH 3 records titled History and Physical dated [DATE], indicated [Resident 1] was found slumped [sitting with the body leaning forward, for example, because a person was asleep or unconscious] over in the wheelchair, then became unresponsive. No seizure [a sudden, uncontrolled movement] activity noted. Resident 1 was started on CPR (cardiopulmonary resuscitation, [an emergency treatment that's done when someone's breathing or heartbeat has stopped]) when paramedics arrived. Resident 1 was noted with agonal breathing (when someone who is not getting enough oxygen is gasping for air) and pinpoint pupils [a condition where the pupils of the eyes appear unusually small] with Glasgow coma scale (used to objectively describe the extent of impaired consciousness) of 3 (is the lowest possible score and is associated with an extremely high mortality rate). Resident 1 was given Narcan (is a medicine that treat someone from fentanyl or prescription opioid medicine overdose) with improvement. During a review of Resident 1 ' s GACH 3 Urine Drug Screen [UDS- used to detect illegal and some prescription drugs in the urine] dated [DATE] timed at 12:15 PM, the UDS indicated Resident 1 ' s urine indicated Presumptive Positive [shows a response, which is usually because a drug is present] for Fentanyl Urine and Opiates [a drug that contains opioids (a class of controlled drug used for moderate to severe pain)], Urine. During an interview and observation on [DATE] at 1:43 PM, with Resident 1, Resident 1 was observed sitting in the wheelchair at the facility ' s Dining Room. Resident 1 stated, The day ([DATE]) I went to the hospital [GACH 3] I took a pill my friend gave me; it was supposed to make me feel better. I don ' t remember what happened that day, I woke up in the hospital (GACH 3). Resident 1 stated his friend dropped off the pill in front of the facility through the gate. Resident 1 stated the facility ' s security guard was present outside, when his friend gave him the pill. Resident 1 stated the security guard was not paying attention when he was handed the pill through the facility gate. Resident 1 stated he did not want to say who the friend was who gave him the pill. Resident 1 further stated, I learned my lesson and I would not do that again. During an interview on [DATE] at 3:34 PM, Licensed Vocational Nurse (LVN) 1 stated Resident 1 ' s pain was not being managed well in the facility, because the resident received pain medication daily. LVN 1 stated Resident 1 was in pain every day and needed pain medication every day. LVN 1 stated she was unsure when to refer a resident for a pain evaluation and had not spoken with the physician regarding Resident 1 ' s pain. LVN 1 stated if the interventions were not working, the resident could be angry, and the pain could affect Resident 1 ' s mood and sleep. LVN 1 stated the facility should have been re-assessing and implementing new pain interventions when the previous pain interventions were not effective. During another interview on [DATE] at 4:18 PM, Resident 1 stated the pain on his left arm/shoulder started three to four weeks ago and the resident was unable to lift up a fork or spoon. Resident 1 stated getting the order for Norco took two days after coming back to the facility from GACH 2 and when the resident asked the licensed nurses why getting the Norco was taking so long, the nurses did not know. Resident 1 stated because he was in so much pain, Resident 1 stated he took something because of the pain. Resident 1 stated he was unsure what medication he took, but thought the medication were pain killers. Resident 1 stated he did not want to go into details about the incident but probably would not have taken something if he had received appropriate pain medication from the facility because the Ibuprofen was not working. During an interview on [DATE] at 6:03 PM, the Medical Director (MD) stated when a resident was in pain, the physician would assess the pain, check vital signs (measurements of the body ' s basic functions, such as breathing rate, temperature, blood pressure, and pulse rate), check the resident ' s medication list, and try to find out the cause of the pain. The MD stated if the pain was chronic, then a medication would be prescribed but if a new pain was present then the resident would be sent to the GACH emergency room (ER) to further evaluate the pain. The MD stated pain consults were sometimes ordered but the availability of pain doctors was very few and there would be a delay, so ordering a pain consult would be an alternative if the resident refused to go to the GACH ER. The MD stated if a resident was in continued pain, the physician should have re-assessed the resident, but trying to be appropriate with the pain medication was not easy because of dependency on residents. During an interview on [DATE] at 11:48 AM, the Registered Nurse Supervisor (RNS) stated once an order was obtained from the physician, the RNS would fax the order to the pharmacy and confirm the pharmacy had received the medication order. The RNS stated on [DATE] an order for Norco was obtained for Resident 1. RNS stated she faxed the Norco order to the Pharmacy, and the RNS received a confirmation that the fax went through but did not get a verbal confirmation from the pharmacy. The RNS stated she endorsed the medication to the oncoming LVN for the next shift, but did not remember who the RNS endorsed the information to and also did not document the endorsement. The RNS stated there should have been documentation regarding the order and endorsement so there would not be any confusion if the medication was received or not because the resident should have been getting the Norco for pain. The RNS stated she also endorsed the Norco order to the DON, but there was no documentation regarding that endorsement. During an interview on [DATE] at 12:13 PM, the Pharmacy Technician (PT) stated the pharmacy received the Norco order via fax on [DATE]. The PT stated on [DATE] the pharmacy followed up with the ordering physician because the Norco order required an authorization to dispense the medication to the facility and the pharmacy had not received the authorization yet. The PT stated on [DATE] the pharmacy was informed Resident 1 had been admitted to the acute hospital, therefore the Norco order was placed on hold. The PT stated when a resident was admitted to the acute hospital, the facility must inform the pharmacy of the admitted and the return to facility date to ensure the resident receives the ordered medication. The PT stated the pharmacy was unaware Resident 1 was readmitted back to the facility on [DATE]. The PT stated the physician did not release the hold on the Norco order to the pharmacy which was what the physician was supposed to do. The PT stated on [DATE] the physician re-sent the Norco order that was on hold from [DATE], to be dispensed. The PT stated on [DATE] [2 days from readmission] the facility received the Norco medication. During an interview on [DATE] at 2:45 PM, the OT stated the resident receives occupational therapy five times a week. The OT stated the resident was never in pain during therapy, so the OT never addressed Resident 1 ' s pain and only focused on feeding and grooming. The OT stated he was aware of the resident ' s left shoulder pain and knew the resident went to the hospital recently due to the pain. The OT stated he had not provided any exercises to alleviate the resident ' s pain. The OT stated if the resident was in a good position, then that could help with the pain and would screen Resident 1 for any movements that would make him hurt. During a concurrent observation and interview in the Activities Room on [DATE] at 3:20 PM, Resident 1 was observed bringing his face down to his hand to wipe his mouth. Resident 1 stated the worst pain level experienced was an eight or nine on the pain scale and the pain had affected him a lot. Resident 1 stated he tried to be more positive but was very frustrated because he was unable to use his arm to eat and raise his arm up. Resident 1 stated he was also frustrated because he was stuck in a wheelchair and could not walk to alleviate some of the pain. During a concurrent interview and record review of the facility ' s policy and procedure (P&P) revised ,d+[DATE], titled Pain Assessment and Management on [DATE] at 5:03 PM, the P&P stated Pain management was a multidisciplinary care process that included the following: monitoring for the effectiveness of interventions and modifying approaches as necessary. Assessing pain consists of identifying characteristics of pain and the pattern of pain. Report the following information to the physician or practitioner: prolonged, unrelieved pain despite care plan interventions. During the interview, the DON stated if the interventions were not working, the interventions should have been updated. The DON stated the resident should have been referred to a pain specialist so the resident could be treated properly because he was consistently in pain. The DON stated the facility did not document the characteristics of pain or the pattern of pain when assessing the resident for pain. The DON stated documenting the characteristics and pattern of pain were important to validate the effectiveness of the medication to provide different interventions as needed.

Based on interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the facility ' s policy and procedure [P&P] titled Admission Assessment and Follow Up: Role of the Nurse, for one of two sampled residents (Resident 1) when it failed to ensure all appropriate discharge orders from General Acute Care Hospital (GACH) 3 were verified with the attending physician (Physician 1) upon Resident 1 ' s readmission to the facility on [DATE]. This deficient practice could result in Resident 1 not receiving emergency medications such as Narcan (is a medicine that treat someone from fentanyl or prescription opioid medicine overdose) needed to treat opioid overdose. Findings: During a review of Resident 1 ' s GACH 3 records titled History and Physical dated [DATE], indicated [Resident 1] was found slumped [sitting with the body leaning forward, for example, because a person was asleep or unconscious] over in the wheelchair, then became unresponsive. No seizure [a sudden, uncontrolled movement] activity noted. Resident 1 was started on CPR (cardiopulmonary resuscitation, [an emergency treatment that's done when someone's breathing or heartbeat has stopped]) when paramedics arrived. Resident 1 was noted with agonal breathing (when someone who is not getting enough oxygen is gasping for air) and pinpoint pupils [a condition where the pupils of the eyes appear unusually small] with Glasgow coma scale (used to objectively describe the extent of impaired consciousness) of 3 (is the lowest possible score and is associated with an extremely high mortality rate). Resident 1 was given Narcan (is a medicine that treat someone from fentanyl or prescription opioid medicine overdose) with improvement. During a review of Resident 1 ' s GACH 3 Urine Drug Screen [UDS] dated [DATE] timed at 12:15 PM, the urine drug screen indicated Resident 1 ' s urine indicated Presumptive Positive for Fentanyl Urine and Opiates, Urine. During a review of Resident 1 ' s GACH 3 Physician Progress Notes dated [DATE], the Progress Notes indicated Resident 1 ' s Chest X-ray [a way for providers to get pictures of the inside of your body] and CT [Computed Tomography - an imaging test that helps healthcare providers detect diseases and injuries] of the head did not indicate any acute abnormal process. The GACH 3 Physician Progress Notes indicated under Problem List, indicated Resident 1 syncope, unresponsiveness, opiate overdose, possible respiratory arrest due to accidental fentanyl overdose, and fentanyl/opioid positive on UDS. The Progress Notes further indicated, to continue to monitor Resident 1 ' s vital signs and administer Narcan as needed. A review of GACH 3 ' s Patient ' s Home Medications added during Discharge Reconciliation dated [DATE], indicated a list of Resident 1 ' s medications ordered from GACH 3. Narcan 4 milligrams/ 0.1 milliliters nasal spray, 1 spray intranasally every 8 hours as needed for opioid overdose. During a review of Resident 1 ' s facility records titled Admission Record indicated a facility readmission on [DATE], with diagnoses that included flaccid hemiplegia (a neurological condition characterized by weakness or paralysis and reduced muscle tone) affecting left non dominant side, chronic obstructive pulmonary disease (COPD -a group of lung diseases that block airflow and make it difficult to breathe). During a review of Resident 1 ' s facility records titled Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) dated [DATE], the MDS indicated the Resident 1 had moderately impaired cognition (thought process). During a review of Resident 1 ' s facility records titled History and Physical (H&P) dated [DATE], indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 1 ' s facility records titled Nursing Admission Screening/History dated [DATE] indicated Resident 1 was readmitted back to the facility from GACH 3 with the following reasons . Possible respiratory arrest . Unresponsive and Syncope. During a review of Resident 1 ' s facility records titled Telephone Order (TO) dated [DATE], the TO indicated Physician 1 ' s telephone orders to continue previous medications and treatments as ordered. During an interview on [DATE] at 4:29 PM with the Director of Nursing (DON), and concurrent record review of Resident ' s 1 current Order Summary Report, the DON stated there was no documented evidence that Resident 1 ' s Narcan medication was ordered upon Resident ' s 1 readmission back to the facility on [DATE] by Resident 1 ' s primary physician, as indicated in the GACH 3 discharge orders. During an interview on [DATE] at 4:30 PM, the DON stated it is a standard of practice and expected that the admitting licensed nurse should review all GACH records and care plans when completing a resident admission or readmission to ensure all admission orders are addressed with the resident ' s Physician. The DON stated she was Resident 1 ' s admission nurse and did not see the Narcan order. The DON stated, if I would have seen I would have notified Resident 1 ' s physician and completed a drug regimen review for Resident 1. The DON stated she spoke to Resident 1 ' s physician and informed him there were no changes to Resident 1 ' s previous medications, she did not read each discharge medication orders one by one to Resident 1 ' s Physician over the phone. A review of facility policy and procedure titled Admission Assessment and Follow Up: Role of the Nurse with a revision date of [DATE] indicated, 11. Reconcile the list of medications from the medication history, admitting orders, the previous medication administration review (if available), and the discharge summary from the previous institution, according to established procedures. 12. Contact attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings.

Based on observation, interview, and record review, the facility failed to follow its policy and one of three sampled resident's (Resident 1) plan of care, who was confused, and had a high risk for falls and elopement (unauthorized absence of an admitted resident from the facility without staff knowledge, which presents a threat to the health and safety of the resident or others). Resident 1 left the facility unsupervised for two consecutive days and on the second day, the resident fell on a busy traffic street and sustained a [MEDICAL CONDITION] (a deep cut or tear in the skin). These deficient practices resulted in Resident 1 eloping multiple times outside of the facility onto a busy street, and had an unwitnessed fall. Resident 1 sustained a [MEDICAL CONDITION], requiring one day of general acute care hospital (GACH) admission. These deficient practices also had the potential for other residents to sustain serious physical harm and death. Findings: A review of Resident 1's Resident Information Sheet (Face Sheet), indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Client [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 12/12/17, indicated the resident was not able to report the current year, month, and day of the week. The MDS indicated the resident was not able to recall three of three words repeated to him and had behaviors of inattention. According to the MDS, Resident 1 required an extensive physical assistance from one person, for bed mobility, toilet use, and personal hygiene and was totally dependent on staff for locomotion off the unit. The MDS indicated the resident was not steady, and was only able to stabilize with staff assistance moving from a seated to standing position, and surface-to-surface transfer. The MDS indicated the resident had impairment on both sides of the lower extremity and used a walker and wheelchair as assistive mobility devices. A review of Resident 1's Elopement Risk Evaluation, dated 9/11/17, upon admission, indicated the resident was at moderate risk for elopement. Resident 1's Fall Risk Assessment, dated 9/11/17, indicated the resident was at high risk for falls. A review of Resident 1's Care Plan, titled, Elopement Risk, dated 9/11/17, indicated staff interventions to monitor the resident's location with visual checks every two hours, and assess, record, and report to the physician factors for potential elopement, such as wandering, and attempts to leave the facility. A review of Resident 1's Care Plan, titled, At Risk for Falls, dated 9/11/17, indicated the resident had poor safety awareness, and was receiving anti-psychotic medications (used to treat various mental disorders). The Care Plan indicated the staff intervention would keep the environment free of safety hazards and provide frequent visual checks. A review of Resident 1's Weekly Summary, dated 11/9/17, and timed at 10:30 a.m., indicated the resident had periods of confusion, forgetfulness, and disorganized thought processes. The Summary indicated the resident was at risk for falls and injury, and the staff would provide a safe and secure environment. A review of Resident 1's Paramedic Run Sheet (Paramedic Narrative Sheet), dated 11/18/17, indicated the resident had an unwitnessed fall outside of the facility, was bleeding from a laceration on the head. According to the Run Sheet, a bandage was placed on the resident's head to stop the bleeding. The record indicated Resident 1 was also in a wheelchair trying to leave the facility on 11/17/17. A review of Resident 1's Physician and Telephone Orders, dated 11/18/17, and timed at 12 p.m., indicated to transfer the resident to the GACH. A review of Resident 1's Change of Condition (C[NAME]) Assessment, dated 11/18/17, and timed at 11:35 a.m., indicated the resident eloped from the facility. The C[NAME] Assessment indicated Resident 1 had fall risk factors, which included poor safety judgment, required assistance for toileting, and was receiving [MEDICAL CONDITION], diuretic medication (to increase the amount of water and salt expelled from the body as urine), and cardiac (heart) medications. The C[NAME] Assessment indicated that staff observed the resident going outside of the facility's gate and into the facility's driveway. The C[NAME] Assessment indicated the paramedics arrived at the facility and transported the Resident 1 to the GACH. A review of Resident 1's GACH records indicated the resident was admitted on [DATE] at 11:56 a.m., with a scalp abrasion (superficial wound to the skin) to the right side of his head, from a fall. The GACH record indicated the resident frequently elopes from his healthcare facility and got out with his wheelchair, and was found on the ground next to the wheelchair. A review of a Police Department (PD) Report and Original Narrative, dated 11/24/17, indicated on 11/18/17 at 11:20 a.m., a neighboring homeowner next to the facility, witnessed Resident 1 out of his wheelchair, outside the facility, after rolling down the facility's steep driveway into the street, and was bleeding from the head. The report indicated the homeowner observed the resident crawling from one lane on the main street, to his wheelchair at the bottom of the driveway. The report indicated Resident 1 was also observed in his wheelchair, outside the facility, in the middle of the street, the day prior (11/17/17). According to the PD report, the Police Officer (PO), observed Resident 1 to be conscious but appeared to be confused and had trouble forming sentences. The PD report indicated, five minutes past and no one from the facility had come outside, or even realized that the resident was missing from the facility. The PD report indicated Licensed Vocational Nurse 1 (LVN 1), whom the PO interviewed, informed the PO that an employee entered the facility's gate and the resident was able to escape before the gate closed. The PD report indicated that the PO informed LVN 1 that Resident 1 eloped from the facility two days in a row, to the main busy street with numerous vehicles driving at high rates of speed. A review of Resident 1's Weekly Summary, dated 11/23/17, and timed at 8 p.m., indicated the resident was able to propel himself when in the wheelchair, but was oblivious to his surroundings, and has impaired safety awareness. A review of the facility's undated Policy and Procedure titled, Fall Prevention and Reduction, indicated that the resident's plan of care should include interventions to alter the resident's immediate physical environment to compliment the resident's weaknesses, provision of monitoring, and supervision to the resident. On 12/18/17, and timed at 4:15 p.m., during a concurrent observation and interview, Resident 1 was in the wheelchair in the outdoor smoking patio, for a smoke break. Resident 1 was observed with a Band-Aid on his right forehead. The Activity Staff (SA) stated Resident 1's right forehead wound used to be larger, and the resident would keep scratching the wound. On 2/1/18 at 7:36 a.m., during an observation, the facility had an inclined driveway, which led to the facility's outdoor gate. A push button was required for staff to automatically open the gate in order to pass through the facility's outdoor parking lot and into the main entrance. Resident 2 was observed in the wheelchair near the gate in the outside parking lot unsupervised by staff. On 2/1/18 at 10:50 a.m., during a telephone interview, the family member of Resident 1 (FM 1) stated that the resident had behaviors of wandering and getting lost when he was residing at home. FM 1 stated that the facility's staff should not have allowed Resident 1 to go beyond the facility's gate, and or leave the facility unsupervised because the resident could get lost and would be in an unsafe environment. On 2/1/18 at 1:20 p.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated Resident 1 enjoyed going around the facility and outdoor parking lot area in the wheelchair. CNA 1 stated Resident 1 was not always alert and required more supervision. CNA 1 stated there are usually no CNAs outside supervising when it was not time for the resident's smoke breaks. On 2/1/18 at 1:37 p.m., during an interview, CNA 2 stated Resident 1 liked to roam around the outdoor parking lot in his wheelchair. CNA 2 stated Resident 1 liked sitting in the wheelchair near the facility's gate. CNA 2 stated Resident 1 went outside of the facility's gate after the gate opened and she saw the resident on the sidewalk. CNA 2 stated the nurse in charge controls the button that opens the gate and that the nurse in charge monitors the video camera prior to opening the gate. CNA 2 stated after Resident 1's elopement incident, in addition to viewing the video camera, staff are required to physically look outside for residents left in the parking lot area unsupervised. CNA 2 stated that staff should wait until the gate closed if there were residents in the outdoor smoking patio and parking lot. On 2/1/18, and timed at 3:06 p.m., during a concurrent interview and record review, LVN 1 stated all staff are responsible to visually monitor if the facility's gate was safe to open, and ensure that no residents were wandering the premise unsupervised. LVN 1 stated there was no specific documentation or area on the nursing assignment record to indicate which staff were assigned to supervise and inspect the outdoor parking lot and gate periodically. LVN 1 stated a staff member was not always sitting by the nursing station, viewing the video camera. LVN 1 was unable to answer how often residents at risk for elopement were visually checked. LVN 1 stated she opened the gate for a staff member entering, and after saw Resident 1 on the video camera on the other side of the gate (outside the facility). LVN 1 stated she left through the facility's emergency exit door (on the other side of the gate), to meet the resident, and found him to the left side of the facility on a neighbor's driveway. LVN 1 stated the video camera could not capture the full view or the corners of the driveway. LVN 1 stated the quality of the facility's outdoor lighting near the gate, and camera needed improvement. LVN 1 stated she was unsure if there were staff outside the parking lot area when the gate opened and prior to Resident 1 eloping. LVN 1 stated the slope on the facility's driveway is scary and the gate takes too long to close. At 3:40 p.m., on 2/1/18, during an interview, LVN 1 stated Resident 1 would look as though he had plans to escape when a truck or ambulance would enter the facility. LVN 1 stated Resident 1's elopement should not have happened.