Every finding on record at Windsor Gardens Convalescent Hospital

Based on observation, interview and record review, the facility failed to ensure the resident had the capacity to sign a consent for anti-psychotropic medications (a medication that changes brain function and results in alterations in perception, mood, consciousness or behavior) for two of five sampled residents (Resident 62 and Resident 3).This failure violated the residents' right to make an informed decision regarding the use of anti-psychotropic medications and had the potential for Resident 62 and Resident 3 to have unnecessary continuation of psychotropic medication. Findings: 1.Resident 62's admission Record, the admission record indicated that Resident 62 was initially admitted to the facility on [DATE], with diagnoses including hepatic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition a disease in which the functioning of the brain is affected by severe liver disease), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and transient ischemic attack (TIA-a temporary blockage of blood flow to the brain). During a review of Resident 62's Minimum Data Set (MDS - a resident assessment tool) dated 01/14/2026, MDS indicated that Resident 62's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 62 required partial to substantial assistance from staffs for activities of daily living (ADLs – toileting hygiene, shower/bathing). During a review of Resident 62's History and Physical (H&P), dated 1/23/2026, H&P indicated that Resident was admitted from General Acute Care Hospital (GACH) from Assisted Living Facility for confusion and agitation. During a review of Resident 62's records titled Order Summary Report dated 04/16/2026, indicated a physician order for; Escitalopram Oxalate (medication to treat depression and general anxiety disorder) oral tablet 10 milligram (mg-unit of measurement) give one tablet by mouth one time a day for depression manifested by verbalization of sadness. Informed consent obtained. Risks and benefits explained. Initiated on 01/09/2026. Seroquel Oral Tablet 50 mg (Quetiapine Fumarate) (medication to treat schizophrenia, bipolar disorder [mania and depression] and major depressive disorder [mood disorder characterized by persistent sadness and low energy]) give one tablet by mouth one time a day for schizoaffective disorder manifester by verbal aggression, paranoia others are after him, auditory hallucinations as evidenced by talking to persons not there. Informed consent obtained by physician. Risks and benefits explained. Initiated on 02/20/2026. During a concurrent observation and interview on 4/13/2026 at 10:40 a.m. with Resident 62, Resident 62 was lying in bed, awake, alert and oriented to name but not to place and time. Resident 62 stated, I'm just laying here, and I want to get out. During a review of Resident 62's Psychotropic medication administration informed consent for Seroquel and Escitalopram dated 01/09/2026 indicated that a verbal consent was obtained from Resident 62. The informed consent form, however, did not include the name of the licensed staff that verified the informed consent prior to initiation of the medication. During a concurrent interview and record review on 4/14/2026 at 12:00 p.m. with Assistant Director of Nursing (ADON), Resident 62's Psychotropic medication informed consent and MDS were reviewed. ADON stated residents prescribed with anti-psychotropic medication requires informed consent outlining the risks and benefits. ADON stated that Resident 62's Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score dated 01/14/2026 were two which indicated lack of capacity to make decisions. ADON further stated that it was inappropriate to obtain informed consent for Resident 62's lack of capacity. ADON added that there should be a complete licensed staff name and not only signature for verification of consent. ADON stated that anti psychotropic medication may act as restraints and could compromise the residents' safety. During an interview on 4/16/2026 at 8:43 a.m. with Director of Nursing (DON), DON stated the process in obtaining an informed consent was for the physician to speak with the resident or their representative to provide informed consent. When a resident can sign, the licensed nurse verifies informed consent to ensures residents are aware of risks and benefits and have the right to accept or refuse the treatment. DON added that nurses with licenses must confirm informed consent when residents are prescribed anti psychotropics, since these medications can cause side effects that may be viewed as chemical restraints. DON stated that it is important to respect residents' right to know and decline medications, even those recommended by a doctor. DON added that if residents cannot understand, the resident is not able to give informed consent. During a review of facility's Policy and Procedure (P&P) titled, Informed Consent for Psychotropic Drugs, reviewed on 03/05/2026, the P&P indicated, the procedures for obtaining, verifying, and documenting informed consent to ensure resident rights, safety, and proper medication use for those with behavioral or psychotic symptoms, including dementia. 2.During a review of Resident 3's admission Record (face sheet), dated 4/15/2026, the face sheet indicated Resident 3 was initially admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including but not limited to Parkinsonism (a general term for brain disorders that cause slowed movements, stiffness, and tremors), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities), bipolar disorder (a chronic mental health condition characterized by intense extreme mood swings that interfere with daily life), and anxiety (feelings of worry or nervousness). No family or resident representative on record. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 is rarely/never understood and is dependent on staff for all functional abilities. Resident 3 can never/rarely make decisions. Resident 3 does not have any mood or behavior symptoms. During a review of Resident 3's physician's order, dated 1/6/2026, the order indicated to give Resident 3 buspirone (a medication used to treat anxiety) 15 milligrams tablet twice a day. During a review of Resident 3's physician's order, dated 1/24/2025, the order indicated to give Resident 3 valproic acid (a medication used to treat bipolar disorder manifested by mood swings) 750 milligrams three times a day. During a review of Resident 3's care plan titled The Resident uses Anti-Anxiety Medication: Buspirone, dated 8/29/2024, the care plan indicated the resident/family/caregivers must be educated about the risks and benefits of the medication. The facility must monitor side-effects such as drowsiness, memory loss, and impaired thinking. During a review of Resident 3's care plan titled Black Box Warning for Use of Valproic Acid, dated 8/27/2024, the care plan indicated side effects of valproic acid include dizziness, weakness, and sleepiness. During a review of Resident 3's Interdisciplinary Care Conference (ICC) note, dated 1/26/2025, the ICC note indicated one Licensed Vocational Nurse (LVN) was in attendance to decide Resident 3's psychotropic medication management upon readmission to the facility. The ICC note did not indicate a physician or resident representative was in attendance. Decision was made to continue with psychotropic medication. During an observation on 4/13/2026 at 9:36 AM in Resident 3's room, Resident 3 was lying in bed, awake with eyes open. Resident 3 did not verbally respond to attempts of conversation. During an interview on 4/15/2026 at 9:12 AM with the Social Services Director (SSD), the SSD stated Resident 3 does not have consent for psychotropics because she is not able to consent for herself and she has no designated representative. A representative from the Long-Term Care Representative Program (LTCRP - a state program to represent residents who lack the capacity to make medical decisions and have no other representatives) has not come to participate in the ICC to discuss the necessity of psychotropic medications for Resident 3 throughout stay in facility. It is the facility's responsibility to contact LTCRP when a resident without the capacity to consent needs an informed consent signed for the initiation of psychotropic medication. During an interview on 4/15/2026 at 2:17 PM with the Assistant Director of Nursing (ADON), ADON stated Resident 3 was initially ordered buspirone and valproic acid during a short-term hospitalization. Upon re-admission to the facility on 1/24/2025, the facility's physician ordered for Resident 3 to receive these medications in the facility. The facility did not obtain consent for buspirone and valproic acid because they were medications initiated in the hospital. It is important for the facility to obtain informed consent for psychotropic medications upon initiation in the facility because residents have a right to be informed of the side effects of the medications and have a right to refuse. During an interview on 4/16/2026 at 8:43 AM with the Director of Nursing (DON), DON stated the facility must assess the resident to determine if the resident can consent to psychotropic medications. If a resident cannot consent, their responsible party should be contacted for consent. If the resident does not have a responsible party, the resident must be referred to the LTCRP to obtain informed consent. It is important to obtain informed consent before administering psychotropic medications because residents have the right to refuse medication. Psychotropic medications can be considered a chemical restraint if used inappropriately because of their side effects. During a concurrent interview and record review on 4/16/2026 at 11:10 AM with ADON, Resident 3's Psychotropic Medication Administration Informed Consent, dated 1/6/2026 was reviewed. The consent indicated Resident 3 gave verbal consent to receive buspirone and was verified by ADON. ADON stated she did not complete the form correctly because Resident 3 does not have the capacity to consent. Consent was not obtained for buspirone or valproic acid. During a review of the facility's policy and procedure (P&P ) titled, Informed Consent for Psychotropic Drugs, last reviewed 3/5/2026, the P&P indicated the prescribing practitioner must obtain informed consent for all psychotropic medications prior to initiation or dose increase. The facility is prohibited from using psychotropics as chemical restraints. The facility must have procedures to identify substitutes for residents lacking capacity to give consent. The interdisciplinary team (consisting of the physician, registered nurses, and the resident/representative) must be involved in reviewing the use of psychotropics.

Based on observation, interview and record review, the facility failed to ensure person centered care plan was implemented for three of six (6) sampled residents:1. When Resident's 16 non-pharmacological (evidence-based, non-chemical, and non-invasive methods used to treat, manage, or prevent health conditions without medication) intervention for pain was not offered prior to pain medication administration.2. Resident's 3 who was receiving nutrition through a gastrostomy tube (G tube, a flexible tube surgically inserted through the abdomen into the stomach for the administration of nutrition, fluids, and medications) head of the bed (HOB)was not elevated to at least 30 degrees during feedings. 3. Resident's 50 indwelling catheter (a tube inserted into the bladder to drain urine) care was done.The deficient practice of not offering non-pharmacological interventions had a potential to cause inadequate pain management and unnecessary medication administration for Resident 16.The deficient practice of not elevating HOB while feeding is on has a potential for risk of aspiration (accidentally inhaling food, liquids, stomach acid, or saliva into lungs) during enteral feedings (a method of delivering liquid nutrition directly into the stomach) for Resident 3. The deficient practice of not providing indwelling catheter care has the potential to increase the risk of urinary tract infection (UTI- an infection in the bladder/urinary tract) for Resident 50.Findings: 1.During a record review of Resident 16 admission record, the admission record indicated Resident 16 was admitted to the facility on [DATE] with diagnoses of end stage renal disease (ESRD, late stage of kidney failure to filter blood and produce urine), difficulty in walking, pathological fracture of left hand (fracture of bones in hand due to weak bone mass), wedge compression fracture of t11-t12 vertebra (fracture of spinal bones), osteoporosis (weak bones, low density of bones), encounter for fitting and adjustment of extracorporeal dialysis catheter (dialysis access, tubing inserted into the blood vessel) dependence on hemodialysis (artificial filtration of blood to remove body wastes, replacing kidney function). During a record review of Resident 16's Minimum Data Set (MDS, resident assessment tool) dated 2/10/2026 the MDS indicated Resident's 16 Brief Interview for Mental Status (BIMS tool to assess cognition, memory, comprehension) score was 6, indicates severe impairment in cognitive function (diminished capacity to answer questions appropriately, to remember and comprehend concepts). The MDS indicated the functional abilities (abilities to perform daily tasks like dressing, walking, toileting) of Resident 16 required partial/moderate assistance - helper does less than half the effort with activities of daily living (dressing, standing, sitting, and walking, transfers from bed to chair, toileting and showering). During an observation on 4/13/2026 at 9:15 a.m. during morning care of Resident 16 by Certified Nurse Assistant 1 (CNA) 1, Resident 16 yelled, I am hurting all over my head, arm, and asking for help. Resident 16 stated to CNA 1 about having pain in his head, repeating help my boo-boo. During an interview on 4/14/2026 at 11:10 a.m. with CNA 2, CNA 2 stated that one of her duties was to observe signs and symptoms of being uncomfortable such as moaning during care, residents (in general) may be moving a lot, trying to get up, or verbalizing pain. CNA 2 stated that she would stop providing care and would notify the LVN about the pain. During interview on 4/14/2026 at 11:31 a.m. with LVN 1, LVN 1 stated part of non-pharmacological interventions were to provide coffee, let resident watch TV, talk to him, call his wife, reposition, take him outside, or activities' room, or to a patio. LVN 1 stated that on 4/13/2026 she administered pain medication to Resident 16 without doing non-pharmacological interventions prior to administering pain medicine. During the 04/15/2026 interview at 8:14 a.m., the Registered Nurse Supervisor (RNS) stated that pain is assessed and managed according to the physician's order and the care plan, with documentation in the MAR under pain monitoring. The RNS explained that non pharmacological interventions should be tried first and their effectiveness documented by the LVN in Progress Notes. The RNS was unable to find documentation showing that non pharmacological measures were attempted before medication was given on 4/13/2026. The RNS added that the care plan must be followed and least invasive measures attempted first due to the dependency risks associated with narcotics. During a record review of the care plan for Resident 16 with focus area: Potential for Alteration in Comfort/Pain dated 02/28/2024 indicated Non-pharmacological intervention: (Positioning for comfort, Hot Pack, Cold Pack, massage, distraction). During a record review of policies and procedures (P & P) for Pain Management dated 3/5/2026, the P & P indicated Residents receiving interventions for pain will be monitored for the effectiveness non-pharmacological interventions and effectiveness. 2.During a review of Resident 3's admission Record (face sheet), dated 4/15/2026, the face sheet indicated Resident 3 was initially admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including but not limited to Parkinsonism (a general term for brain disorders that cause slowed movements, stiffness, and tremors), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities), dysphagia (medical term for difficulty swallowing), and gastrostomy status (medical condition of having an artificial, surgically created opening in the stomach wall that allows a feeding tube to be inserted directly into the stomach for nutrition, hydration, and medication). During a review of Resident 3's MDS dated [DATE], the MDS indicated the resident is rarely/never understood. The MDS also indicated the resident receives nutrition through a feeding tube and has impairment in range of motion to both sides of the upper and lower extremities. During a review of Resident 3's Nursing Documentation Evaluation, dated 8/23/2024, the evaluation indicated Resident 3 receives nutritional supplements through enteral feeding via G-tube. During a review of Resident 3's physician's order, dated 1/24/2025, the order indicated Resident 3's head of bed should be elevated to at least a 30-degree angle during feeds and for one hour after feeding. During a concurrent observation and interview on 4/13/2026 at 12:59 PM with the Assistant Director of Nursing (ADON) in Resident 3's room, Resident 3 was lying nearly flat in bed with the tube feeding machine on. ADON stated Resident 3 is lying flat and the head of bed is at less than a 30-degree angle. ADON stated the facility does not have a measuring device to measure the angle of the resident's head of bed. ADON stated that Resident 3's head should be raised higher, to at least a 30-degree angle, while the resident is receiving tube feedings to prevent the risk of aspiration. During an interview on 4/15/2026 at 9:49 AM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated residents could be neglected in their care if the resident's care plan is not followed. It could harm the resident physically, emotionally, and financially. During a concurrent interview and record review on 4/15/2026 at 2:15 PM with the Assistant Director of Nursing (ADON), Resident 3's care plan titled, Resident is at risk for aspiration related to G-tube, created on 1/3/2026, was reviewed. The care plan indicated Resident 3's head of bed should be elevated to at least 30 degrees during feeding and for one hour after feeding. ADON stated that this care plan was not implemented based on the previous observation of Resident 3. During an interview on 4/16/2026 at 9:07 AM with the Director of Nursing (DON), DON stated care plans are created to describe what and how interventions are implemented. Care plans are how nurses know what interventions to perform. It is important for care plans to be followed, and if they are not, we must investigate why. During an interview on 4/16/2026 at 9:19 AM with DON, DON stated that aspiration is a complication of enteral tube feeding. The resident's head of bed should be raised to a 30–45-degree angle during feeds to prevent the risk of aspiration to the resident. During a review of the facility's P&P titled, Care Plan Comprehensive, last reviewed 3/5/2026, the P&P indicated the interdisciplinary team must implement a comprehensive person-centered care plan for each resident. 3.During a review of Resident 50's admission Record, the record indicated that Resident 50 was originally admitted on [DATE] and readmitted on [DATE] for polyneuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), sepsis (a life-threatening blood infection), and a urinary tract infection. During a review of Resident 50's MDS dated [DATE], the MDS indicated that Resident 50's cognitive patterns (thought processes) were fully intact. The MDS indicated that Resident 50 needed supervision for eating, oral hygiene, and upper body dressing; and moderate assistance with toileting, showering, and lower body dressing. The MDS also indicated that Resident 50 is always incontinent and has an indwelling catheter. During a review of the physician's orders for the indwelling catheter on 4/16/2026, the following active orders indicated the following: Indwelling Catheter: Monitor for S/S of possible urinary infection and notify MD. Document 0=none / FP = Flank Pain or SP= Suprapubic pain or T = Tenderness/ CU = change in character of urine (New bloody urine; foul smell of urine or change in urinary sediment)/ MC = mental change or FC = functional change worsening of status) Every shift document 0 for no characteristics or letter of signs/symptoms. Start date 2/11/2026. Indwelling Catheter: Monitor for change in urine character: Document 0 = none/ C = Cloudiness/ S = Sediment FS = Foul Smell/ B = Blood in urine/ DC = deepening or concentrating urine output. Notify MD for potential UTI. Every shift document letter or urine characteristic or 0 for no urine characteristics. Start Date 2/11/2026. Indwelling Foley catheter care: Cleanse the urethral meatus (where the catheter enters) with NS, gently wiping away any debris every day shift for infection prevention. Start Date: 2/12/2026. During an interview on 4/15/2026 at 9:49 a.m. with Licensed Vocational Nurse (LVN2), LVN 2 stated indwelling catheter needs to have a physician's order and care plan. LVN 2 stated the nurses must implement the care plan to prevent complications like UTI and the Treatment Nurse performs indwelling catheter care during the day shift. The Registered Nurse (RN) is the one who initiates and develops care plan for residents. LVN 2 stated that if the care plan is not implemented there is potential for physical and emotional harm to the residents and possible neglect. During a concurrent interview, and record review of the Physician's Order and Treatment Administration Record (TAR) with LVN 5 on 4/15/2026 at 1:45 p.m., LVN 5 stated that proper indwelling catheter care is important to prevent bacteria from entering and causing infection or UTI. LVN 5 stated that catheter care should be documented in the electronic medical record (EMR). While reviewing the orders, care plan, and TAR for Resident 50, LVN 5 stated that the TAR showed blank spaces instead of an X or check mark to indicate the task was completed. LVN 5 stated that documenting each completed task is important, so staff know who performed it, when it was done, and whether it was completed. LVN 5 emphasized that documentation ensures proper monitoring and keeps the residents safe. During concurrent interview and record review of the TAR with the Registered Nurse Supervisor (RN1) on 4/15/2026 at 2:10 p.m., RN1 stated that the TAR was blank on 2/15/2026 evening shift for indwelling catheter care monitoring. RN1 stated she is unsure why it is blank and would need to ask someone what it means. During concurrent interview, and record review of Resident 50's TAR with Director of Nursing (DON) on 4/16/2026 at 9:00am, DON stated the treatment nurse comes during the day shift to complete the indwelling catheter care. The DON stated for evening and night shifts, the charge nurse completes the indwelling catheter care. The DON stated that care plans determine how staff care for the patient; if a care plan is not being followed, we [staff] investigate. The DON stated the importance of following the care plan for indwelling catheter is to prevent infection. The DON stated that the TAR dated 2/15/2026 was blank for indwelling catheter care and monitoring. The DON stated if there is a blank spot on the TAR, that means it was not documented or not completed. The DON stated the charge nurse did not follow the care plan for that shift, and there is no excuse for why it was not completed. During a review of the facility's P & P titled Care Plan Comprehensive dated 8/25/2021, the policy stated, The facility's interdisciplinary Team.must develop and implement a comprehensive person-centered care plan for each resident.

Based on observation, interview, and record review, the facility failed to ensure proper sanitation and food handling practices were upheld in the kitchen when: 1. Cups of milk and pineapple stored in the refrigerator were not labeled with preparation or use-by date. 2. A kitchen food scoop was stored in the container of food thickener.3. Apples and onions beyond their use-by date were not disposed of.4. Kitchen Dishwasher (KD) 1 and 2 handled washed dishes with dirty gloves.5. Kitchen aide (KA) handled bread with dirty gloves. These failures had the potential to spread pathogens (a germ that causes disease) to the residents, increasing their risk of developing foodborne illnesses that could lead to medical complications and hospitalization. Findings: During an observation on 4/13/2026 at 7:26 AM in the kitchen's walk-in refrigerator, there were three trays of pre-poured milk cups on a shelf. On a separate shelf there was a tray of individually packed pineapple chunks. The cups of milk and pineapple, and the trays they were placed on, did not have labels indicating when they were prepared or the use-by date. During a concurrent observation and interview on 4/13/2026 at 7:36 AM with the Dining Services Manager (DSM) in the kitchen, a food scoop was stored inside a container of white powder. DSM stated this is a container of food thickener that is added to food depending on the recipe. She stated the scoop should not be kept in the container because it is dirty and can increase the risk of contamination of the resident's food. During a concurrent observation and interview on 4/13/2026 at 7:40 AM with the DSM in the kitchen walk-in refrigerator, three trays of milk cups and one tray of pineapple chunks did not have a preparation and use-by date label on them. DSM stated the trays of milk and pineapple chunks must be labeled so staff know when they were prepared and when they expire, because if expired, they can harm the residents. During a concurrent observation and interview on 4/13/2026 at 7:47 AM with the DSM in the kitchen, there was a bucket of onions and a separate bucket of apples. The label on the onion bucket indicated a preparation date of 3/23/2026 and a use-by date of 4/10/2026. The label on the apple bucket indicated a preparation date of 4/1/2026 and a use-by date of 4/10/2026. DSM stated the onions and apples should have been thrown out because they are not good anymore and are expired. She stated it is important to make sure foods are discarded by the label's use-by date because they could be spoiled or have fungi, which could harm the residents when eaten. During a concurrent observation and interview on 4/13/2026 at 7:53 AM with the DSM in the kitchen, KD 1 was rinsing dirty water pitchers in the sink wearing gloves. With the same gloves, he pulled out a tray of freshly sanitized dishes from the dishwasher. He then proceeded to load the dirty water pitchers into the dishwasher still wearing the same gloves. DSM stated KD 1 needs to wash the dishes again because now the dishes are contaminated from his dirty gloves. His gloves could have bacteria that could spread and harm the residents. During a concurrent observation and interview on 4/14/2026 at 8:31 AM with the DSM in the kitchen, KD 2 was rinsing dirty plates in the sink wearing gloves. With the same gloves, he pulled out a tray of freshly sanitized plate covers from the dishwasher. DSM stated KD 2 should not have done this because of his dirty gloves. During an observation on 4/14/2026 at 12:08 PM in the kitchen, KA was wearing gloves serving lunch for the residents. KA used food scoops to scoop vegetables and rice onto the lunch plate. KA then used the same gloves to grab a dinner roll and put it on the plate to serve to the resident. During an interview on 4/14/2026 at 12:18 PM with KA, KA stated she forgot that she should use tongs to handle the bread and should not have used her dirty gloves. She said this is important to keep the food clean. During an interview on 4/14/2026 at 2:27 PM with DSM, DSM stated KA should not have used the same gloves to serve the dinner rolls that she used to touch the various plates and scoops because it could contaminate the food. During an interview on 4/15/2026 at 11:13 AM with the Infection Preventionist (IPN), IPN stated that after kitchen staff are done cleaning dirty plates, they should immediately wash their hands and switch gloves before moving onto another task. It is important to take off dirty gloves before moving onto another task to prevent the spread of bacteria and cause contamination of food, which would harm the residents. This hand hygiene practice is for infection control. IPN further stated that expired foods are an infection risk. Foods have a use-by date, which is their expiration date. Once that date is past, the food is not good anymore because it can cause someone to get sick. During an interview on 4/16/2026 at 10:15 AM with KD 2, KD 2 stated that there should be two people doing the dishwashing job. One person handles the dirty dishes and loads them into the dishwasher. The second person takes out the cleaned dishes from the dishwasher. It is important because if there is only one dishwasher and they use their gloves to touch the dirty and clean dishes, it can cause contamination and infection. During a review of the facility's policy and procedure (P&P) titled, Labeling and Dating, undated, the P&P indicated all foods should be dated before being stored with a label that includes the food item name, the date of preparation, and the use-by date. During a review of the facility's P&P titled, Food: Preparation, last reviewed 3/5/2026, the P&P indicated all staff will practice proper hand-washing techniques and glove use. It also indicated all foods should be prepared in accordance with the Food and Drug Administration (FDA) Food Code. During a review of the FDA Food Code, last full revision 2022, the FDA Food Code indicated food shall be protected from cross contamination by the separate storage of spoiled foods

Based on interview and record review, the facility failed to ensure staff followed facility's Infection Prevention Control Policy to prevent the spread of infection, when facility failed to ensure:The facility's Water Management Program ([WMP] - a written, step-by-step plan for buildings to ensure their water system was safe, clean, and efficient) was implemented as written.Licensed Vocational Nurse (LVN 2) did not don (put on) a gown prior to applying a lidocaine patch (a medication Patch) to Resident 93, who was on enhanced based precautions ( an infection control intervention designed to reduce transmission of multidrug-resistant organisms {MDROs} in nursing homes).These deficient practices had potential to spread infections and illnesses among residents, staff and visitors.Findings: A. During a concurrent interview and record review on 4/16/2026 at 10:33 a.m. with Maintenance Supervisor (MS) of WMP and maintenance logs on 4/16/2026 at 10:33 a.m., MS stated that he handled water monitoring, while the Infection Preventionist (IPN) ensured implementation of the WMP. MS stated that water temperatures are checked weekly every Friday. MS stated that chlorine residuals and pH (measure of acidity or alkalinity of an aqueous solution) levels were not tested in the facility as it was not required. MS further stated the need for regular water quality testing and documentation to prevent the growth and spread of waterborne pathogens (bacteria, viruses, or parasites found in contaminated water), which could put residents, staff, and visitors at risk for waterborne infections (illnesses caused by bacteria, viruses, or parasites from human or animal waste that contaminate drinking or recreational water) and related complications. During an interview on 4/16/2026 at 11:43 a.m. with IPN, IPN stated that MS is responsible for monitoring the water quality. IPN stated she was unsure whether chlorine residuals and pH were monitored. IPN further stated that following the WMP is crucial for maintaining water quality and preventing bacterial growth that could threaten the safety of residents, staff, and visitors. During a review of the facility's WMP, undated, the WMP indicated that control measures are actions implemented within building water systems to reduce the growth and dissemination of Legionella. These measures include processes such as heating, disinfectant application, and cleaning. Operational monitoring covered the TELS preventative maintenance program and internal facility logs to track control measures. The WMP further stated that the effectiveness of the control plan will be assessed through infection control surveillance. During a review of facility's Policy and Procedures (P&P) titled, Infection Prevention and Control, dated 12/2023, the P&P indicated, that the infection prevention and control policies aim to monitor, prevent, detect, investigate, and manage infections in the facility; ensure a safe, sanitary, and comfortable environment for all staff, residents, visitors, and the public; and offer evidence-based guidelines reflecting current best practices. 2.During a review of the Resident's admission record, the admission record indicated Resident 93 was admitted on [DATE] with a diagnosis of diffuse large B-cell lymphoma (a cancer that affects the lymphatic system), diabetes mellitus (DM- a condition in which blood sugar levels are not adequately controlled), and unspecified fracture of the lower, left leg (injury in the leg with an unknown cause). During a review of Resident's 93 Minimum Data Set (MDS- a resident assessment tool) dated 3/10/26, the MDS indicated Resident 93's cognitive abilities (thought process) were intact. Resident 93 is independent for eating, moderate assistance for personal hygiene and upper body dressing; requires supervision for oral hygiene; and is dependent (needs complete assistance from a helper or helpers) for management of footwear, toileting, lower body dressing and showering. During a concurrent observation and interview on 04/14/2026 at 8:12 a.m. with LVN 2 while doing medication pass, LVN 2 entered Resident 93's who is on EBP. LVN 2 applied lidocaine patch on Resident 93's left arm without donning a gown before administering the medication. LVN 2 stated that since Resident 93 is on EBP, staff should perform hand hygiene, put on gloves, and a gown. LVN 2 stated he didn't put on a gown before entering Resident 93's room. During a concurrent interview and record review on 04/15/2026 at 7:30 a.m. with Registered Nurse (RN 1), Resident 93's physician's order was reviewed. RN1 stated that Resident 93 had orders for EBP for a wound. RN 1 stated, the nurse (in general) would need to use gown and gloves when applying the lidocaine patch before entering the EBP room. RN 1 stated that applying a lidocaine patch on the skin is considered a close contact activity. During a concurrent interview, record review, with Director of Nursing (DON) on 4/15/2026 7:45 a.m., DON stated that for EBP rooms, nurses (in general), nurses (in general), would need to use gown and gloves for close contact with the residents. The DON stated that it is considered close contact with the resident when a nurse (in general) performs activities that require them to touch the patient, including application of a lidocaine patch. DON stated the nurse (in general) would need to don a gown and gloves for the lidocaine application. During a subsequent interview and record review on 4/15/2026 at 7:45 a.m. with the DON, the DON stated that the policy section indicated .targeted gown and gloves use during high contact resident care activities. The DON stated that LVN should have used gowns while applying the patch. During a review of the facility's policy and procedure titled Enhanced Standard/Barrier Precautions dated 3/5/2026 indicated that .Enhanced Barrier Precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound .

Based on interview and record review, the facility failed to ensure informed consent was obtained in a timely manner from the resident before administering COVID-19 (highly contagious respiratory illness caused by the SARS-CoV-2 virus) vaccine (a preparation that is used to stimulate the body's immune response against diseases) for two of five sampled residents (Resident 19 and Resident 20) when:The informed consent for the COVID 19 vaccine, including a discussion of the risks, benefits, and potential side effects for Resident 19, was obtained on 01/07/2026, which was 34 days prior to the administration on 02/10/2026.The informed consent for the COVID-19 vaccine, including a discussion of the risks, benefits, and potential side effects for Resident 20 was obtained on 08/27/2025, which was 21 days prior to the administration on 09/17/2025.These deficient practices violated Resident 19 and Resident 20's rights to make an informed decision at the time of administration. A. During a review of Resident 19's admission Record, the admission record indicated that Resident 19 was initially admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), hyperlipidemia (abnormally high levels of fats in the blood) and hypertension (HTN-high blood pressure).During a review of Resident 19's Minimum Data Set (MDS - a resident assessment tool) dated 03/21/2026, MDS indicated that Resident 19's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 19 required minimal to moderate assistance from staff for activities of daily living (ADLs - toileting hygiene, shower/bathing). During a review of Resident 19's record titled Order Summary indicated a physician's order initiated on 02/10/2026 of COVID-19 Vaccine Inject 1 syringe intramuscularly one time only for vaccine for 1 Day.B. During a review of Resident 20's admission Record, the admission record indicated that Resident 20 was initially admitted to the facility on [DATE], with diagnoses including dysphagia (difficulty swallowing), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and muscle weakness. During a review of Resident 20's MDS dated [DATE], MDS indicated that Resident 20's cognitive skills for daily decisions were intact. The MDS indicated Resident 20 was independent for ADLs.During a review of Resident 20's record titled Order Summary indicated a physician's order initiated on 09/17/2025 of COVID-19 Vaccine Intramuscular Suspension Prefilled Syringe 50 microgram (mcg-unit of measurement)/0.5 milliliter (ml-unit of measurement) Inject 1 syringe intramuscularly one time only for immunization for 1 day.During a concurrent interview and record review on 4/16/2026 at 11:43 a.m. with Infection Preventionist (IPN), Resident 19 and Resident 20 immunization record and vaccine consent form were reviewed. The IPN stated that immunization is vital to prevent severe illness and noted her responsibility for tracking residents' immunizations. The IPN stated that informed consent is crucial for residents to understand the risks, benefits and side effects of getting vaccinated. The IPN stated that informed consent for the covid vaccine for Resident 19 was obtained on 01/07/2026 and it was administered on 02/10/2026. The IPN stated that informed consent for the covid vaccine for Resident 20 was obtained on 08/27/2025 and it was administered on 09/17/2025. The IPN stated the residents could have changed their mind since informed consent for covid vaccine was obtained a month ago for Resident 19 and three weeks ago for Resident 20.During an interview on 4/16/2026 at 8:43 a.m. with Director of Nursing (DON), DON stated obtaining informed consent ensures residents are aware of risks and benefits and have the right to accept or refuse the treatment. DON stated that it is important to respect residents' right to know and decline medications, even those recommended by Medical Doctor.During a review of facility's Policy and Procedure (P&P) titled Coronavirus Disease-Vaccination of Residents, reviewed 3/05/2026, the P&P indicated that, residents or their representatives can accept or decline the COVID-19 vaccine and may change their decision at any time. Education, documentation, and reporting are managed by the infection preventionist. Before vaccination, residents receive information about benefits, risks, and potential side effects. Consent forms are provided in an understandable language and format. The medical record must show that education was given, including material samples, the date, and details of risks and benefits including signed consent.

Based on observation, interview, and record review, the facility failed to ensure a resident's eyeglasses were kept in working condition for one of three sampled residents (Resident 11). This failure resulted in Resident 11 not being able to see adequately and expressing feeling of frustration from not being able to enjoy his preferred activity.During a review of Resident 11's admission Record, the admission record indicated that Resident 11 was initially admitted to the facility on [DATE], with diagnoses including cerebrovascular disease (loss of blood flow to a part of the brain), alcoholic cirrhosis (permanent scarring that damages the liver and interferes with its functioning), and atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart).During a review of Resident 11's Minimum Data Set (MDS - a resident assessment tool) dated 03/12/2026, MDS indicated that Resident 11's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 11 was fully dependent from staffs for activities of daily living (ADLs - toileting hygiene, shower/bathing). The MDS also indicated that Resident 11 has impaired vision with the use of corrective glasses.During a concurrent observation and interview on 4/13/2026 at 10:00 a.m. with Resident 11, Resident 11 was awake, alert, and responsive while watching television up close. Resident 11 stated that his eyeglasses broke two or three months ago and informed the staff , Resident 11 expressed frustration at being unable to see clearly as he enjoys watching television.During a concurrent interview and record review of Resident 11's progress notes record on 4/15/2026 at 10:40 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated that nurses are responsible for ensuring assistive devices are always available to residents and must address any problems as they arise. LVN 4 added that there was no documentation or communication about Resident 11's broken eyeglasses. LVN 4 further stated that eyeglasses are crucial for residents' vision, allowing them to read, watch television, and engage in daily activities without difficulty. LVN 4 added that if Resident 11's vision needs are unmet, the resident could feel sad, neglected, and unheard.During an interview on 4/15/2026 at 11:38 a.m. with the Social Services Director (SSD), the SSD stated that residents should always have access to their assistive devices to support their quality of life and care, ensuring they feel safe and comfortable. The SSD further stated that limited vision poses a safety risk for residents. During an interview on 4/16/2026 at 8:43 a.m. with Director of Nursing (DON), DON stated that the entire team was responsible in ensuring that assistive devices were available to residents and report any issues to the social worker as needed. DON stated that vision is crucial for residents' quality of life and safety, as impaired sight can hinder their needs and communication.During a review of Resident 11's care plan report titled impaired visual function initiated on 7/10/2025, the care plan indicated a goal that resident will maintain optimal quality of life within limitation imposed by visual function. The care plan interventions include arranging eye care consultations as needed and providing suitable visual aids for activity participation.During a review of facility's Policy and Procedures (P&P) titled Resident Rights, dated 4/15/2026, the P&P indicated that the residents have the right to communicate with and access people and services inside and outside the facility; exercise their rights as facility or U.S. residents; receive facility support in exercising these rights; do so without interference, coercion, discrimination, or reprisal; refuse care; and be informed about their rights and responsibilities.

Based on observation, interview and record review, the facility failed to ensure a medication was not left at the bedside without a physician's order for one of two sampled residents (Resident 15). This deficient practice has the potential risk for medication errors and adverse drug events. During a review of Resident 15's admission Record, the admission record indicated that Resident 15 was initially admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), congestive heart failure (CHF-(a condition in which the heart does not pump blood as well as it should) and muscle weakness. During a review of Resident 15's Minimum Data Set (MDS - a resident assessment tool) dated 4/01/2026, MDS indicated that Resident 15's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 15 required moderate to maximum assistance from staffs for activities of daily living (ADLs - toileting hygiene, shower/bathing). During a concurrent observation and interview on 4/13/2026 at 09:00 a.m. with Resident 15, Resident 15 was awake, alert and watching television. There was an opened bottle of pink liquid medication observed on Resident 15 bedside table. Resident 15 stated it was Pepto-Bismol (a medication to treat heartburn, nausea, indigestion and upset stomach) that she takes for gas and bloating. During a concurrent interview and record of Resident 15 on 4/13/2026 at 9:32 a.m. with Licensed Vocational Nurse (LVN) 6, Resident 15's physician order summary report and self-administration evaluation was reviewed. LVN 6 stated there should be a physician's order for all medications, including medication at residents' bedside. LVN 6 stated that Resident 15 had no active order for Pepto-Bismol and was not able to self-administer medication safely per the Medication Self-Administration Evaluation dated 11/24/2025. LVN 6 stated she needed to remove Resident 15's bedside medication due to possible medication interactions, safety concerns, and inability to monitor usage or prevent access by other residents. During an interview on 4/16/2026 at 8:43 a.m. with Director of Nursing (DON), DON stated that staff should routinely check on residents and assess their needs and environment. DON stated that residents may self-administer medication if deemed capable. DON further stated that leaving medication at the bedside is prohibited, as it poses risks to others due to potential interactions and side effects. During a review of facility's Policy and Procedures (P&P) titled Administering Medications, reviewed 3/5/2026, the P&P indicated that residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.

Based on observation, interview, and record review, the facility failed to ensure bed rails zoning was measured for Resident 12 annually or ongoing for bed safety assessments was completed for one of one sampled resident reviewed (Resident 12). This deficient practice had the potential to result in an inability to verify that the bed system remained safe for residents' use and placed the resident at risk for entrapment, injury, and harm.During a record review of Resident 12's admission Record (Face Sheet), the admission record indicated the resident was admitted to the facility on [DATE] with a diagnoses including type 2 diabetes mellitus (high blood sugar due to the body not using insulin properly) , diabetic neuropathy (nerve damage causing numbness or pain, usually in the hands and feet), essential hypertension (chronic high blood pressure without a specific cause), and muscle weakness with abnormalities of gait and mobility (reduced strength and difficulty walking or moving safely). During a record review of the physician's order for Resident 12 dated 01/23/2026 at 2:55 p.m., the order indicated 1/4 side rail X 2 up in bed as enabler to assist with mobility - nonrestraint.During an observation on 04/15/2026 at 8:30 a.m., Resident 12 was observed in bed with bed rails in use. During a record review of the Bed System Measurement Device Test Results Worksheet dated 02/10/2025, it indicated the bed system measurements were completed for Bed ID 24A. During a concurrent interview on 04/15/2026 at 8:45 a.m. and record review of the bedrail measurements with the Maintenance Supervisor (MS), MS stated that the bed rail zone measurements were completed on the time of admission but no follow up. Regarding annual measurements and ongoing reassessment, MS was unable to provide evidence that the annual bed rail zone measurements were completed or reassessment if needed. MS stated Residents that has siderails are at risk for entrapment, or limbs can be caught if not properly assessed.During a concurrent interview and record review on 04/15/2026 at 10:10 a.m., MS stated that while initial measurements are performed at admission, there is no documented evidence of annual measurements or periodic reassessment to ensure continued bed system safety. During a record review of the facility's P & P titled Bedrails dated 2/21/2025, the facility will assure the correct installation and maintenance of bed rails prior to use, the facility will follow the manufacturer's recommendation/instructions regarding bed rail use, the facility will continue to provide necessary treatment and care to the resident who has bed rails in accordance with professional standards of practice and the resident's choices, the assessment must assess the resident's risk from using bed rails, the assessment should assess the resident's risk of entrapment between the mattress and the bed rail or the in the bed rail itself.During a record review of the facility's P & P titled Siderails dated 12/28/2023, the policy stated that the space between the mattress and the side rails will be assessed to reduce the risk of entrapment (the amount of space may vary depending on the type of bed and mattress being used) upon admission when the side rails are required or after admission if side rails are required.

Based on observation, interview and record review, the facility failed to provide behavioral health treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of two sampled residents (Resident 13) by failing to provide an ongoing assessment, monitoring and implementing a person-centered care plan when Resident 13 stated persistent negative feelings related to trauma experience.This deficient practice had the potential to negatively affect the delivery of behavioral health care and services to Resident 13.During a review of Resident 13's admission Record, the admission record indicated that Resident 13 was initially admitted to the facility on [DATE], with diagnoses including hepatic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition a disease in which the functioning of the brain is affected by severe liver disease), schizoaffective disorder, bipolar type (a mental illness that can affect thoughts, mood, and behavior-known as mania and depression) and post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event).During a review of Resident 13's Minimum Data Set (MDS - a resident assessment tool) dated 03/02/2026, MDS indicated that Resident 13's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 13 required mild to moderate assistance from staffs for activities of daily living (ADLs - toileting hygiene, shower/bathing). During a review of Resident 13's history and physical (H&P), H&P indicated that resident 13 had the capacity to make decisions. During a concurrent observation and interview on 4/13/2026 at 11:45 a.m. with Resident 13, Resident 13 was awake, alert and sitting in the wheelchair. Resident 13 reported having history of bipolar disorder, schizoaffective disorder, and PTSD. Resident 13 stated that being independent made him feel satisfied, but he had difficulty getting the staff to listen.During a review of Resident 13's Trauma assessment dated [DATE] and 04/02/2025, it indicated that Resident 13 noted that he was still affected by a combat event and expressed the need for support with his needs and medications.During a review of Resident 13's care plan report, titled past experience of trauma as evidenced by resident reported still be bothered by combat events, initiated on 12/12/2024, indicated the goal for the resident to feel safe in the center, identify stressors, and report them to staff. Interventions included encouraging the resident to recognize personal trauma and triggers and minimize their impact; respecting concerns; involving the resident in decisions; listening without judgment or guilt; and evaluating the need for psychological or behavioral health consultation and referrals as needed.During a concurrent interview and record reviews of Resident 13's order summary report on 4/15/2026 at 08:25 a.m. with Registered Nurse Supervisor (RN 1), RN 1 stated the nursing care for residents with PTSD included engaging resident in alternative activities, providing reorientation, using non-pharmacological interventions, and eliminating triggers. RN 1 stated there was no physician or nursing documentation of behavioral monitoring or assessment of Resident 13's triggers. RN 1 stated a physician order was needed for tally or behavior monitoring of Resident 13 to implement the care plan. RN 1 further stated the importance for ongoing assessment of behavioral health in residents with PTSD to ensure effective treatment and adjust as necessary.During an interview on 4/15/2026 at 11:38 a.m. with Social Service Director (SSD), SSD stated that Trauma Assessments involve questions about residents past experiences, particularly for veterans, including triggers, trauma and abuse. SSD stated that it is important to monitor the resident's behavioral health to minimize behavioral risks, reduce triggers, prevent aggression, and ensure safety and comfort. SSD added that without it may result in residents not receiving necessary care during crucial times, potentially compromising their safety. SSD further stated that the whole team shares responsibility for safeguarding the well-being and ensuring appropriate care of every resident.During an interview on 4/16/2026 at 8:43 a.m. with the Director of Nursing (DON), DON stated that taking care of resident with PTSD included individualized nursing intervention, medication management, redirection and activity engagement are provided. DON stated that social worker conducts trauma assessments with questionnaires for residents with history of behavioral health. DON stated that when there is PTSD diagnosis, adding the resident's monitoring of triggers and side effects of medications are included in the plan of care. DON stated it is to ensure that behavior is monitored for everyone's safety and to ensure residents feel secure.During a review of facility's Policy and Procedure (P&P), titled, Behavior Management, reviewed on 03/05/2026, the P&P indicated that staff must ensure residents with mental disorders or psychosocial difficulties receive appropriate treatment to improve their well-being. Non-pharmacological interventions are the primary approach and included in care plans. The facility monitors identified residents who show behavioral symptoms, implements non-drug interventions first, obtains informed consent, and refers to mental health services when needed.During a review of facility's P&P titled, Trauma Informed Care, dated 3/05/2026, the P&P indicated, that the facility will identify trauma triggers for residents and add trigger-specific interventions to their care plans to reduce exposure and mitigate effects. Common triggers include lack of privacy, loud noises or bright lights, certain sights or objects, sounds, smells, physical touch, and caregivers of the opposite sex. The effectiveness of interventions will be regularly evaluated, involving the resident and their family or representative to ensure open communication and adjustments as needed.

Based on interview and record review, the facility failed to ensure insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) rotation of injection sites for three out of three sampled residents (Resident 61, Resident 9 and Resident 57). This deficient practice had the potential to result in lipodystrophy (partial or complete loss of fat) which affects insulin absorption, potential hyperglycemia (high blood glucose) for Resident 61, 9 and 57. Findings: During a review of Resident 61's admission Record, the admission record indicated Resident 61 was admitted on [DATE] with left-sided hemiparesis/hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), cerebral infarction (a type of brain damage due to a blockage in blood flow), and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of the Minimum Data Set (MDS – a resident assessment tool) dated 1/9/2026 for Resident 61, MDS indicated that Resident 61's cognitive status (thought process) was fully intact. The MDS indicated that Resident 61 was independent for eating; moderate assistance for lower body dressing, and oral hygiene; and maximal assistance for toileting and showering. The MDS indicated that Resident 61 was receiving insulin injections for DM. During an interview on 4/15/2026 at 9:35 a.m. with Licensed Vocational Nurse (LVN 2), LVN 2 stated that insulin injections can be administered in subcutaneous sites (SQ- a fatty layer in between the skin and the muscle), such as the upper arm and abdomen. LVN 2 stated that sites are supposed to be rotated when injecting insulin to prevent lipodystrophy. LVN 2 also stated that the residents who received insulin injections are educated about the need to rotate sites with each injection given. LVN 2 stated the Medication Administration Record (MAR) would indicate where the last administration site was, and that the nurse should choose an alternative site before administering the next injection. During a record review of the physician's orders for Resident 61 dated 7/31/2025, the orders indicated an active Insulin Regular Human Injection Solution, inject as per sliding scale before each meal and bedtime. Rotate Injection Sites. During a record review on 04/15/2026 12:20 p.m. of Resident 61's Location of Administration for Insulin Injections, the following was documented: 3/12/2026 6:30 a.m. and 3/12/2026 at 4:30 p.m. insulin was administered in the left lower quadrant (LLQ) During a record review of the facility's policy and procedure (P & P) titled, Insulin Administration Purpose under, Steps in the Procedure (Insulin Injections via Syringe), dated 3/5/2026, the P & P indicated, Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a record review of Resident's 9 admission record, the admission record indicated admitted on [DATE] with a medical diagnosis of diabetes mellitus [DM, a disease characterized by high blood sugar (glucose) levels, hyperlipidemia, (abnormally high levels of fats (lipids), such as cholesterol and triglycerides, in the blood) During a record review of Resident 9's MDS dated [DATE], The MDS indicated that Resident 9 has a Brief Interview for Mental Status (BIMS a standardized screening tool used in long-term care and post-acute settings to assess cognitive function, specifically memory and orientation) score of 12 cognitively intact. The MDS also indicated that supervision on eating, partial to moderate assistance in toileting hygiene and substantial to maximal assistance with shower. Record review on 04/13/2026 at 11:08 a.m. of Resident 9's medication administration record (MAR) the MAR indicated that during the date and time of 04/12/2026 5:37 p.m.and 04/13/2026 9:30 a.m. insulin was not rotated and administered on Resident 9's right arm on 2 consecutive administrations. During a record review Resident 9 of physician orders for regular insulin as below states to rotate injection sites: Insulin Regular Human Injection Solution Inject subcutaneously before meals and at bedtime . Rotate injection sites. Give no more than 30 mins before meals or give at the beginning of meals (up to 15 mins after the start of meals) and hold the dose if a meal is skipped. b. During a record review of the Resident's 57 admission record, the admission record indicated admitted [DATE] with a diagnosis of anemia (low number of red blood cells), hypertension (high blood pressure), DM. During a record review of Resident 57's MDS dated [DATE], The MDS indicated that Resident 57 has a score of 15 - cognitively intact. The MDS also indicated Resident 57 is independent with eating but requires assistance as setup for oral hygiene, substantial/maximal assistance in toileting hygiene and substantial to maximal assistance with shower. During a review of Resident 57 physician orders identified insulin order Insulin Regular Human Injection Solution, inject subcutaneously before meals and at bedtime. Rotate injection sites. Give no more than 30 mins before meals or give at the beginning of meals (up to 15 mins after the start of meals) and hold the dose if a meal is skipped. During an interview on 04/15/2026 9:35 a.m. with LVN 2, LVN 2 stated that insulin can be administered in subcutaneous sites of the upper arm and abdomen. LVN 2 stated that sites are rotated to prevent lipohypertrophy (fatty lumps). Additionally, the residents are educated about the need to rotate sites. LVN 2 stated the administration site is selected by the medication LVN by reviewing the MAR for last administration site and the staff should choose an alternative site. During a record review, the facility's policy and procedure (P&P) on Insulin Administration Purpose, Revision date March 2025 under the heading Steps in the Procedure (Insulin Injections via Syringe) step #20 directs nursing staff 20. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).

Based on interview and record review, the facility failed to provide the necessary care and treatment for one of one sampled resident (Resident 96) by failing to: a. Reassess Resident 96's ongoing use of Bactrim (a prescription antibiotic combination used to treat bacterial infections) and sacubitril-valsartan (medication for congestive heart failure [CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling]), and notify the physician that the electronic medical records (EMR) system triggered a drug-drug interaction (DDI) alert (an alerts that appear on the screen by flagging potential adverse reactions or duplicate therapies during the prescribing process. These alerts appear during medication search or processing allowing clinicians to cancel or override them) due to concurrent use of Bactrim and sacubitril-valsartan. This combination of medications can significantly increase the risk of hyperkalemia, a condition caused by dangerously high elevated levels of potassium (an essential mineral and electrolyte that helps the body maintain fluid balance, sends nerve signals, and regulates muscle contractions, including the heart). Resident 96 continued to take these medications from 3/12/2026 through 3/16/2026. b. Assess and monitor Resident 96 including the resident's level of consciousness and neuromuscular (nerves and muscles) status - including sensation, strength and movement- as required by the resident's care plan, Risk for complications related to cardiac status due to history of hyperkalemia, when the resident had a high level of potassium of 5.8 mEq/L on 3/13/2026. These failures resulted in Resident 96 not being monitored or assessed, and the resident's hyperkalemia state not being treated, following a documented Change of Condition (COC) first identified on 3/13/2026. On 3/16/2026 and collected at 10:25 a.m., a repeat lab test result showed a critical potassium level of 6.0 mEq/L confirming a worsening and untreated hyperkalemia state, a condition associated with fatal cardiac (heart) arrhythmias (abnormal heart rhythm). Resident 96, who had a Do Not Resuscitate (DNR) status, expired on 3/16/2026 at 11:25 p.m. Findings: During a review of Resident 96 admission record, the admission record indicated the facility admitted Resident 96 on 1/30/2024 with a diagnoses that included anxiety (a mental health condition characterized by excessive, persistent, and unreasonable worry or fear that interferes with daily functioning), hypertension (high blood pressure) dementia (impaired cognitive functioning), anemia (low red blood cells in the blood, dysphagia (difficulty swallowing), presence of a cardia pacemaker (an internally implanted device to support the heart electrical activity), cardiomyopathy (enlarged heart condition) diabetes (high blood sugar level), history of infection of the urinary tract (the body's drainage system for removing waste and extra water, produced as urine), arthritis (joint inflammation) ,and infections of the digestive tract (a tube-like series of organs that runs from the mouth to the anus, acting as the body's food processing center), and acute kidney failure (impairment of the kidneys to rid the body of metabolic [the body's process of turning food and drink into energy to sustain life] waste). During a review of Resident 96's care plan titled Risk for complications related to cardiac status due to history of hyperkalemia initiated 4/10/2024, the care plan goal indicated the resident will display lab results within normal limits and absence of signs and symptoms related to hyperkalemia. The care plan included the following interventions: a) Assess and document the resident's level of consciousness (alertness) and neuromuscular function, including sensation, strength, and movement. b) Monitor serum potassium levels. c) Be aware that cardiac arrest can occur. During a review of Resident 96's care plan titled, Resident is on multiple medications. At risk for ill effects of multiple drug use, initiated 1/31/2026, the care plan interventions included the following interventions: a) Inform and explain to family members/significant others and residents of the risks and benefits of multiple meds. b) Monitor for any signs and symptoms (s/s) of adverse reaction. c) Report to MD (the physician) and family members/significant others for any change of condition. d) Pharmacist review as per policy. During a review of Resident 96's History and Physical (H&P), dated 2/14/2026, the H&P indicated Resident 96 was able to make needs known but had a fluctuating capacity to understand and make medical decisions. During a review of Resident 96's quarterly Minimum Data Set (MDS- a resident assessment tool), dated 3/23/2026, the MDS indicated Resident 96' s cognition (mental process of acquiring, storing, retrieving, and using information) was severely impaired-never/rarely made decisions. The MDS indicated Resident 96 was dependent on staff for all activities of daily living [(ADL) activities such as bathing, dressing, toileting, and hygiene a person performs daily]. The MDS indicated Resident 98 is dependent on staff for mobility such as moving from lying to sitting up in bed and transferring from bed to chair. During a record review of physician's orders for Resident 96, the physician order dated 3/12/2026 indicated an order for sacubitril-valsartan oral tablet 24-26 milligrams (mg, a unit of measurement), to give one (1) tablet by mouth two times a day for congestive heart failure (a chronic, progressive condition where the heart muscle is too weak or stiff to pump blood efficiently), hypertension (high blood pressure) and to hold for systolic blood pressure (SBP, the top number in the blood pressure reading, representing the maximum pressure in the arteries when the heart beats and pushes blood) less than (<) 110 or heart rate (HR)<60. During a review of Resident 96's Interact Change of condition (COC) Evaluation, dated 3/12/2026 at 11 a.m., the COC indicated Resident 96 had vaginal discharge and Nurse Practitioner (NP) 1 ordered Bactrim double strength and laboratory draw orders which included basic metabolic panel ([BMP], a blood test measuring electrolytes and certain metabolites that can help assess kidney problems or dehydration), a urinalysis ([UA], a test that examines the appearance, concentration, and content of urine) and urine culture (a test to identify germ causing infection). During a review of Resident 96's Medication Administration Record (MAR) for March 2026, the MAR showed Resident 96 received twice daily doses of sacubitril/valsartan and Bactrim DS, which was initiated on 3/12/2026 at 5 p.m., and subsequent doses twice daily through 3/16/2026. During a review of Resident 96's Lab Results Report -Basic Metabolic (BMP), reported on 3/13/2026 at 8:55 a.m., the result indicated a high potassium level of 5.8 mEq/L. During a review of Resident 96's Interact Change of condition (COC) Evaluation, dated 3/13/2026 at 2:52 p.m , the COC indicated Resident 96 noted with abnormal lab of potassium level 5.8 mEq/L (milliequivalents per liter ([mEq/L] unit of measure with normal range of 3.5 mEq/L - 5.5 mEq/L). During a review of Resident 96's Nursing Notes, dated 3/13/2026 4:44 p.m. the notes indicated abnormal labs were relayed to the physician and the physician ordered to repeat the lab on 3/16/2026. During a review of Resident 96's Nurse's notes from 3/12/206 to 3/14/2026, the notes indicated no documentation of care plan interventions being implemented. During a review of Resident 96's MAR, the MAR indicated the resident had an advanced directive - not Attempt Resuscitation/CPR Comfort Focused Treatment - primary goal of maximizing comfort. Relieve pain and suffering with medication by any route as needed; use oxygen, suctioning, and manual treatment of airway obstruction. Do not use treatments listed in Full and Selective Treatment unless consistent with comfort goal. DO NOT HOSPITALIZE, NO IV THERAPY NO ARTIFICIAL MEANS OFNUTRITION, INCLUDING FEEDING TUBES. During a review of Resident 96's 3/16/2026 SBAR (Situation, Background, Assessment, Recommendation) nursing notes, dated 3/16/2026, the SBAR indicated that at 11:25 p.m., Unable to obtain vitals (no rise and fall of chest observed). Daughter notified of patient's expiration. The SBAR indicated the physician was made aware and the physician made an order to release the resident. During an interview on 4/15/2026 at 1:29 p.m. with Registered Nurse (RN) 1, RN 1 stated that the EMR will flag and alert staff once staff log in. RN 1 stated it was important to provide up to date information to the physician and elevated potassium level should be reported to physicians as there could be heart concerns heart attack. During a concurrent interview and record review on 4/15/2026 at 1:29 p.m., Resident 96's care plan titled, Risk for complications related to cardiac status due to history of hyperkalemia and the care plan interventions were reviewed with RN 1. RN 1 stated that assessment involved evaluating patients to ensure their bodies and organ systems were functioning properly. RN 1 stated the purpose of assessment was to identify and monitor for any changes from the patient's baseline condition. RN 1 stated residents with hyperkalemia should be monitored at least every shift but more assessments if there are changes in condition. RN 1 stated a change in baseline warrants an assessment, a note, and immediate physician notification. During the interview and record review with RN 1 on 4/15/2026 at 1:45 p.m., RN 1 reviewed the care plan interventions and medical records and stated there was no documented evidence that Resident 96's level of consciousness (alertness) or neuromuscular function -- including sensation, strength, and movement-- was assessed or closely monitored for symptoms of hyperkalemia and potential cardiac arrest at least once every shift for three days. During the interview and record review with RN 1 on 4/15/2026 at 1:45 p.m., Resident 96's change of condition notes, nursing notes, physician notes, acute progress notes, laboratory results, medication administration record and care plans were reviewed. Resident 96's physician orders indicated medication orders of Bactrim DS tablet 800-160 milligrams (a unit of measure), by mouth, one tablet twice a day and sacubitril-valsartan (trade name of Entresto) oral tablet 24-26 milligrams, one tablet by mouth, two times a day. RN 1 stated when Bactrim DS was inputted in the EMR, a DDI alert warning licensed staff of Resident 96's drug-drug interaction for the sacubitril-valsartan and Bactrim DS was noted and the triggered alert was due to a significant risk for hyperkalemia, especially with renal impairment. RN 1 stated it was important not to ignore pop-up warnings for monitoring and to be aware. RN 1 stated the Bactrim DS started on 3/12/2026. During the interview and record review with RN 1 on 4/15/2026 at 1:45 p.m., RN 1 stated upon physician notification on 3/13/2026 (at 4:44 p.m.), the physician ordered repeat labs on 3/16/2026. RN 1 stated there was no documented evidence that the physician was notified of the drug-drug interaction alert generated in the EMR indicating a potential risk of hyperkalemia to Resident 96. RN 1 stated Resident 96 would probably have benefited from cardiac monitoring. RN 1 stated that Do not Resuscitate (DNR) does not stop the facility from providing care and necessary services needed to achieve good quality of care to any residents. RN 1 stated nurses still need to assess and monitor any residents that have COC that are DNR otherwise that can be a neglect. During an interview on 4/16/2026 at 8:59 a.m., with LVN 5, LVN 5 stated when the electronic order for Bactrim was entered a DDI alert appeared on the screen, warning the prescriber of increased risk for hyperkalemia. LVN 5 stated Resident 96's diagnosis of heart problems and renal problems also contributed to the alert to be triggered. LVN 5 stated she did not notify the physician about the DDI alert warning for increased hyperkalemia risk; she just clicked the alert and continued the order. LVN 5 stated the DDI alerts should have been reviewed and discussed with the physician, so the physician can decide to continue or cancel the prescription. LVN 5 stated DDI alert is important as medication can have effect with other drugs. LVN 5 stated if there was an abnormal lab result, the staff should notify the physician of the result, assess the resident, and document in the nursing progress notes. During the interview on 4/16/2026 at 9:31 a.m., the DDI alert in the physician's order and care plan, Risk for complications related to cardiac status due to history of hyperkalemia, was reviewed with the ADON. The ADON stated that LVN's or RN's need to pay attention to Resident 96's history. The ADON stated that the nursing staff did not provide any documentation that will support the assessment and monitoring of Resident 96's level of consciousness and neuromuscular status - including sensation, strength and movement- as required per care plan. The ADON stated that the Interact COC started at 2:52 p.m. (on 3/13/2026), 6 hours from the time the potassium lab result received (at 8:55 a.m. on 3/13/2026). During the interview on 4/16/2026 at 9:31 a.m., the ADON stated that during medication pass, DDI will also prompt nurses to check lab. The ADON stated that it is important to collaborate, address the problem and provide interventions to impact good quality of care. The ADON stated the residents with DNR status still need to get same care, DNR is for resuscitation not changing care. During a telephone interview on 4/16/2026 at 10:27 a.m. with Pharmacy (Pharm) 1, Pharm 1 stated abnormal potassium levels can cause cardiac (heart) arrythmia (irregular heart beat) if not being addressed timely. During an interview on 4/16/2026 10:38 a.m. with the Director of Nursing (DON), the DON stated that potassium is an important electrolyte for heart muscle. During the interview, on 4/16/2026 at 10:38 a.m., The DON stated the medication system has a warning pop-up embedded in the EMR for DDI. The DON stated the nurses, who will see the alert, should let the doctor know of the potential reaction. The DON stated that the nurse should not over-ride the warning without informing the physician and this needs to be documented in EMR. The DON stated Resident 96's EMR assessments were not documented as more frequent than routine vital signs (VS). The DON verbalized that not every intervention is on the medication record. During the interview, on 4/16/2026 at 10:38 a.m., the DON stated that Resident 96's EMR is unable to provide documentation of care plan interventions or implementation of assessments being implemented. The DON stated there was no documentation that the risks and benefits of not correcting hyperkalemia were discussed with Resident 96's family member. The DON stated quality of care is when the facility provides what care is needed to residents. The DON stated DNR does not change any care provided to the residents. The DON defined DNR as it means not resuscitating when the heart stops beating unless there is added restriction. During a telephone interview on 4/16/2026 at 2:27 p.m. with Nurse Practitioner (NP)1 regarding the Bactrim order. NP1 stated she was not working (not present) in the facility at the time and date the order was made, which was 3/12/2026 at 11 a.m. for Bactrim and blood tests. NP 1 stated that it was never brought to her attention about the DDI nor the potassium result. NP 1 stated if she knew about the warning about the medication interaction, she would either change the order or collaborate with the facility staff. NP 1 defined hyperkalemia is something that should be addressed as soon as possible to prevent any complications. During a review of the facility's policy and procedure (P&P) titled, Guidelines for Notifying Physicians of Clinical Problems dated 2/2014, the P&P indicated to help ensure that medical problems are communicated to the medical staff in a timely, efficient and effective manner and all significant changes in resident status are assessed and documented in the medical record. Immediate notification (acute) problems the following symptoms, signs and laboratory values should prompt immediate notification of the physician after an appropriate nursing evaluation. Immediate implies that the physician should be notified as soon as possible either by phone, pager, text messaging or other means.

Based on observation, interview, and record review, the facility failed to ensure re- assessment was done each time Resident 6 has a fall and implementation of fall prevention interventions, including timely post-fall reassessment and revision of the care plan, for 1 of 1 sampled resident (Resident 6) who was identified as high risk for falls.This deficient practice has a potential for Resident 6 to have recurrent falls , sustaining injury from fall compromising residents safety.During a review of Resident 6's admission Record (Face Sheet), the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including hypertension (a condition characterized by persistently elevated blood pressure, which can increase the risk of cardiovascular complications), atherosclerotic heart disease (a condition where plaque builds up in the arteries, reducing blood flow to the heart), benign prostatic hyperplasia (BPH - a non-cancerous enlargement of the prostate that can cause urinary difficulty), history of falls, muscle weakness, and gait instability. During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool) dated 02/11/2026, the assessment indicated the resident required extensive assistance with mobility and activities of daily living (ADL's routine task such as dressing, toileting, and transferring) and was identified as being at risk for falls.During a record review of Resident 6's Care Plan Report Focus Resident is at high risk for falls/injury related to history of repeated falls, poor safety awareness initiated on 6/6/2026, Another care plan initiated on 09/10/2025 with a Focus on resident is at risk for falls due to unsteady gait and poor safety awareness, resident requires assistance with ambulation to ensure safety. Provide physical assistance with ambulation per care plan. During a record review of the Resident's 6 Interdisciplinary Care Conference (IDT-involves professionals to collaborate patient centered-care) dated 7/28/2025 at 1:00 p.m., the IDT indicated that the resident slipped out a wheelchair onto the floor in the hallway while attempting to ambulate without assistance, and Resident's 6 IDT dated 09/04/2025 at 1:00 p.m. , the IDT indicated Resident 6 was observed sitting on a floor mat by an unknown CNA after attempting to ambulate independently without staff assistance. During a review of Resident 6's fall risk assessment dated [DATE], Resident 6 was identified as having a high risk for falls. No other documented fall risk assessment.During an interview on 04/15/2026 at 11:10 a.m. with Minimum Data Set Nurse (MDSN), the MDSN stated that there is no re-assessment done each fall, it is only done on admission. MDSN stated it is important to do re-assessment to check effectiveness of interventions and if there is decline.During an interview on 04/16/2026 at 10:10 a.m., Certified Nursing Assistant (CNA 5), CNA 5 stated that Resident 6 attempted to stand independently from the wheelchair, leaned forward, and subsequently fell.During an interview on 04/16/2026 at 11:30 a.m. with Licensed Vocational Nurse (LVN 2) , LVN 2 stated that Resident 6 was agitated prior to fall and attempted to stand without assistance. LVN 2 stated that post-fall interventions were initiated, including a head-to-toe assessment, neurological check, and monitoring of vital signs. During an interview on 04/15/2026 at 11:27 a.m. with Registered Nurse (RN 1), RN 1 reported that high-risk residents should have interventions such as floor mats, care plans, and assistance with ambulation, and confirmed the residents had a history of falls.During a concurrent interview and record review on 04/15/2026 at 11:17 a.m. with RN 1, RN 1 stated the record indicated Resident 6 had a history of falls and was identified as high risk; however, there was no updated care plan reflecting recent falls or documented reassessment following the most recent fall. RN 1 stated that expected interventions for high-risk residents but were unable to provide evidence that these interventions were updated in the care plan following the fall.During a record review of the facility's policy and procedure ( P&P) titled Fall risk assessment dated 03/2018, the P & P indicated the nursing staff, in conjunction with attending physician, consultant pharmacist, therapy staff and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. The P & P indicated the staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are modifiable

Based on interview and record review, the facility failed to:Inform the Primary Care Physician (PCP) as soon as the facility received Resident 96's abnormal laboratory (lab) result of potassium of 5.8 mEq/L (critical electrolyte that helps nerve function, muscle contraction, and maintaining normal blood pressure normal range 3.5-5.5 milliequivalents per liter, mEq/L, a unit of measure) on 3/13/2026 at 8:55 a.m. The PCP was notified at 1:00 p.m. (almost 4 hours after the facility received the abnormal high lab result) for one of one sampled resident.Notify Resident 96's PCP that Kayexalate (emergency kit -EKIT medication used to treat hyperkalemia [having too much potassium in your blood] by binding potassium in the intestines in exchange for sodium, which is then eliminated via stool) was available at the facility when Resident 96 had a high level of potassium of 5.8 mEq/L (milliequivalents per liter ([mEq/L] unit of measure with normal range of 3.5 mEq/L - 5.5 mEq/L).on 3/13/2026, so the physician could determine if treatment was needed.These failures resulted in Resident 96 not being monitored or assessed, and the resident's hyperkalemia state not being treated, following a documented Change of Condition (COC) first identified on 3/13/2026. On 3/16/2026 and collected at 10:25 a.m., a repeat lab test result showed a critical potassium level of 6.0 mEq/L confirming a worsening and untreated hyperkalemia state, a condition associated with fatal cardiac (heart) arrhythmias (abnormal heart rhythm).Findings:During a review of Resident 96 admission record, the admission record indicated the facility admitted Resident 96 on 1/30/2024 with a diagnoses that included anxiety (a mental health condition characterized by excessive, persistent, and unreasonable worry or fear that interferes with daily functioning), hypertension (high blood pressure) dementia (impaired cognitive functioning), anemia (low red blood cells in the blood, dysphagia (difficulty swallowing), presence of a cardia pacemaker (an internally implanted device to support the heart electrical activity), cardiomyopathy (enlarged heart condition) diabetes (high blood sugar level), history of infection of the urinary tract (the body's drainage system for removing waste and extra water, produced as urine), arthritis (joint inflammation) ,and infections of the digestive tract (a tube-like series of organs that runs from the mouth to the anus, acting as the body's food processing center), and acute kidney failure (impairment of the kidneys to rid the body of metabolic [the body's process of turning food and drink into energy to sustain life] waste).During a review of Resident 96's Lab Results Report -Basic Metabolic (BMP), reported on 3/13/2026 at 8:55 a.m., the result indicated a high potassium level of 5.8 mEq/L. During a review of Resident 96's Interact Change of condition (COC) Evaluation, dated 3/13/2026 at 2:52 p.m., the COC indicated Resident 96 had an abnormal lab of potassium level 5.8 mEq/LDuring a review of Resident 96's Nursing Notes, dated 3/13/2026 4:44 p.m. the notes indicated Resident 96's abnormal lab value was relayed to the physician and the physician ordered to repeat the lab test on 3/16/2026.During a review of Resident 96's Nurse's notes from 3/12/206 to 3/14/2026, the notes did indicate care plan interventions were being implemented for Resident 96 as a result of the COC.During an interview on 4/15/2026 at 1:03 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated that if there is a change of condition (COC), following assessment, the staff should notify the PCP to check if the facility can provide the care or if needed to be transfer to General Acute Care Hospital (GACH). The PCP may order laboratory or other interventions. If the laboratory is ordered, the laboratory will call the facility if there are critical results. The staff at facility will call in a few hours for results. In critical results, once the lab calls, the staff will notify the doctor.During a concurrent interview and record review on 4/15/2026 at 1:03 p.m. with LVN 3, Resident 96's laboratory results (reported on 3/13/2026) were reviewed. The laboratory results indicated Resident 96 had a high potassium level of 5.8 mEq/L. LVN 3 stated if a resident has an elevated potassium, the physician can order Kayexalate (a medication that treats hyperkalemia above 5.0 mEq/L), which was available in the emergency- kit (E-kit) because abnormal potassium can have complications in the heart. LVN 3 stated that for change of condition (COC) it was the responsibility of the charge nurse or the Registered Nurse Supervisor to notify the physician. LVN 3 stated that laboratory results will be available online and it was the responsibility of the LVN or RN to call the physician for any abnormal laboratory result once it was available.During an interview on 4/15/2026 at 1:03 p.m., with LVN 3, LVN 3 stated that lab results were available in the electronic medical records (EMR). LVN 3 stated that Resident 96 should have received appropriate care by ensuring the physician was notified as soon as laboratory results were received, particularly if any abnormalities were identified. LVN 3 stated that this was especially important for residents with a Change of Condition (COC), so that any medical issues can be promptly addressed and complications prevented. LVN 3 stated anyone can help residents by providing and not delaying care.During an interview on 4/15/2026 at 1:29 p.m. with Registered Nurse (RN) 1, RN 1 stated that the EMR will flag and alert staff once staff log in. RN 1 stated that physicians were supposed to be notified of abnormal labs as soon as possible for best care of residents. RN 1 stated, once the physician responds, it should be documented in the progress notes with actions or no actions. RN 1 stated it was important to provide up to date information to the physician and elevated potassium level should be reported to physicians as there could be heart concerns heart attack. During a concurrent interview and record review on 4/15/2026 at 1:29 p.m., Resident 96's care plan titled, Risk for complications related to cardiac status due to history of hyperkalemia and the care plan interventions were reviewed with RN 1. RN 1 stated that assessment involved evaluating patients to ensure their bodies and organ systems were functioning properly. RN 1 stated the purpose of assessment was to identify and monitor for any changes from the patient's baseline condition. RN 1 stated residents with hyperkalemia should be monitored at least every shift but more assessments if there are changes in condition. RN 1 stated a change in baseline warrants an assessment, a note, and immediate physician notification.During the interview and record review with RN 1 on 4/15/2026 at 1:45 p.m., Resident 96's change of condition notes, nursing notes, physician notes, acute progress notes, laboratory results, medication administration record and care plans were reviewed. RN 1 stated Resident 96's potassium level result of 5.8 mEq/L was available on 3/13/2026 at 8:55 a.m. and the physician was notified at 4:44 p.m. RN 1 could not explain why there was a delay in relaying the lab results. RN 1 stated upon identification of Resident 96's abnormal labs, the resident should have been assessed; and a call and a faxed report to the physician should have been made. RN 1 reviewed the care plan interventions and medical records and stated there was no documented evidence that Resident 96's level of consciousness (alertness) or neuromuscular function -- including sensation, strength, and movement-- was assessed or closely monitored for symptoms of hyperkalemia and potential cardiac arrest at least once every shift for three days.During a concurrent interview on 4/16/2026 at 9:31 a.m. with Assistant Director of Nursing and review of Interact COC, dated 3/13/2026 timed 2:52 p.m. and laboratory result dated 3/13/2026 timed 8:55 a.m. were reviewed. The records indicated Resident 96's potassium lab value result was 5.8 mEq/L. The ADON stated that if there is an abnormal lab result, the timeframe to notify the physician (if critical) is right away so physician can give orders or intervention. The ADON stated hyperkalemia is treated with Kayexalate which is available in the E-kit. The ADON stated if the family refused to have Resident 96 receive further treatment, treatment options should be discussed with them (the family), and the risk and benefits documented in the progress notes. The ADON stated there were no documented notes that risks and benefits were discussed with Resident's 96's family, who is so involved with plan of care.During an interview on 4/16/2026 10:38 a.m. with the Director of Nursing (DON), the DON stated the laboratory results are received in EMR and for any abnormal high or critical high, the laboratory will contact the facility and alert the staff. The DON stated that normal or abnormal labs are reported to the physician as soon as it is available in the EMR and any nursing staff has access to EMR. The DON stated the Resident 96's EMR showed blood tests were ordered in response to Resident 96's change in condition on 3/12/2026 and that the lab result of the potassium was 5.8 mEq/L(high). The DON stated that if serum potassium results are on the high side, the facility needs to address it and confirm if the physician will order Kayexalate. The DON stated that potassium is an important electrolyte for the heart muscle. The DON stated the lab report on 3/13/2026 at 8:55 a.m. did not identify the facility's staff's name who was contacted about the abnormal laboratory result, which is usual laboratory practice. The DON stated the nurses will conduct a COC as soon as they can, an important communication to all nurses. The DON stated that if the nurses are busy during the shift, it may delay in initiating the documentation on the form. During the interview, on 4/16/2026 at 10:38 a.m., the DON stated that Resident 96's EMR is unable to provide documentation of care plan interventions or implementation of assessments being implemented. The DON stated there was no documentation that the risks and benefits of not correcting hyperkalemia were discussed with Resident 96's family members. The DON stated quality of care is when the facility provides what care is needed to residents. The DON stated DNR does not change any care provided to the residents. The DON defined DNR as it means not resuscitating when the heart stops beating unless there is added restriction.During a review of the facility's policy and procedure (P&P) titled, Guidelines for Notifying Physicians of Clinical Problems, dated 2/2014, the P&P indicated to help ensure that medical problems are communicated to the medical staff in a timely, efficient and effective manner and all significant changes in resident status are assessed and documented in the medical record. Immediate notification (acute) problems the following symptoms, signs and laboratory values should prompt immediate notification of the physician after an appropriate nursing evaluation. Immediate implies that the physician should be notified as soon as possible either by phone, pager, text messaging or other means.

Based on observation, interview and record review, the facility failed to accommodate the resident's preference to go out on pass (a temporary, therapeutic leave allowing residents to go outside the facility) for one of two sampled residents (Resident 13). This failure resulted in Resident 13's feeling that his concerns were not being heard by staff and had the potential to affect Resident 13's sense of well-being, level of satisfaction with life and feeling of self-worth and self-esteem.During a review of Resident 13's admission Record, the admission record indicated that Resident 13 was initially admitted to the facility on [DATE], with diagnoses including hepatic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition a disease in which the functioning of the brain is affected by severe liver disease), schizoaffective disorder, bipolar type (a mental illness that can affect thoughts, mood, and behavior) and post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event).During a review of Resident 13's Minimum Data Set (MDS - a resident assessment tool) dated 03/02/2026, MDS indicated that Resident 13's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 13 required mild to moderate assistance from staffs for activities of daily living (ADLs - toileting hygiene, shower/bathing). During a review of Resident 13's history and physical (H&P), H&P indicated that resident 13 had the capacity to make decisions. During a concurrent observation and interview on 4/13/2026 at 11:45 a.m. with Resident 13, Resident 13 was awake, alert and oriented to name, time and place. Resident 13 stated difficulty with independence and wishing to go more frequently if possible but facing obstacles. Resident 13 stated he felt that his concerns were not being heard by staff. Resident 13 stated that being able to go out adds meaning and satisfaction to his life. Resident 13 requested a simpler process to pursue his preferences.During a review of Resident 13's care plan titled behavior problem initiated on 12/12/2024, the care plan indicated an intervention as follows: anticipate and meet the resident's needs and provide a program of activities that is of interest and accommodates residents' status. During a review of Resident 13's records titled Elopement Evaluation dated 10/07/2025, it indicated that resident was not at risk for elopement. During a concurrent interview and record review on 4/15/2026 of Resident 13's order summary and care plan report on 4/15/2026 at 10:22 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 explained that when a resident requests to go out on pass, a physician's order is required. LVN 4 stated there was a care plan for Resident 13 to go out on pass, however, there were no active physician orders for out on pass for Resident 13. LVN 4 stated that there was an order on 07/10/2025 but discontinued on 02/28/2026. LVN 4 stated that failure to implement or follow the care plan can negatively affect residents' rights, health, and safety. LVN 4 further stated that residents shouldn't feel confined to staying in this facility- this is their home, and they should have the freedom to go out as they wish. LVN 4 added supporting them helps reduce stress. During an interview on 4/15/2026 at 11:38 a.m. with Social Service Director (SSD), SSD stated that resident 13 was permitted to go out on pass. SSD also stated that escorts cannot be provided every week or twice a week. SSD stated the facility is home to residents, who are free to leave and not restrained to stay.During an interview on 4/16/2026 at 8:43 a.m. with Director of Nursing (DON), DON stated that residents have rights to live normally, have access to what they need safely, receive proper care and treatment, and be treated with respect and dignity. DON also stated that residents may go out on pass with family or a representative or an escort if safety concerns exist. DON further stated that it is important for residents to exercise their rights as it can affect their well-being. DON added that residents are just like us, providing residents with a safe environment outside. It's important that residents don't feel restricted from leaving this place.During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights, dated 4/15/2026, the P&P indicated, that Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include self-determination, support from the facility, freedom from interference or discrimination, and refusal of care.During a review of facility's P&P titled, Out on Pass, undated, the P&P indicated, that the facility is dedicated to enabling residents to participate in family and community life, supporting their well-being. The facility will make reasonable efforts to ensure residents' safety and uphold their rights when they go out on pass.

Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS- resident assessment tool) pain management section for one of three sampled residents (Resident 23).This deficient practice had potential to cause inaccurate care quality measures and triggered care plan will be inaccurate for Resident 23.During a record review of Resident 23's admission record, the admission record indicated Resident 23 was admitted to the facility on [DATE] with diagnoses of lack of coordination (affecting transfers and mobility, may cause falls), mild protein-calorie malnutrition (nutritional imbalance leading to weight loss), diverticulosis of large intestine (pockets in the large intestine that can cause bleeding or infection), diaphragmatic hernia (protrusion of part of stomach, out of normal position from abdominal cavity into chest cavity, causing difficulty in digestion and breathing).During a review of Resident 23's Minimum Data Set (MDS- resident assessment tool) the MDS dated [DATE] indicated Resident 23's Brief Interview for Mental Status (assessment tool for brain's complex mental processes involved in gaining knowledge and comprehension) was 13, meaning the person was cognitively intact (able verbalize needs and comprehend). MDS indicated functional abilities (person's ability to perform activities of daily living such as dressing, standing, sitting, and walking, transfers from bed to chair, toileting) of Resident 23 required supervision or touching assistance (helper provide verbal cues or touching) with activities of daily living (dressing, standing, sitting, and walking, transfers from bed to chair, toileting) and partial/moderate assistance with showering.During a record review Resident 23's MDS dated [DATE] and medication administration record (MAR), the MDS section J Health Conditions - J0100. Pain management indicated discrepancy between MDS and medication administration record (MAR) for 01/ 2026. The MAR indicated that Acetaminophen (pain relieving medication) was given for pain level 3/10 (numeric rating for pain assessment: 1-4 mild pain, 5-7 moderate pain, 8-10 severe pain) on 1/29/2026, which was within five days look-back period of MDS assessment (Assessment Reference Date 1/28/2026-2/2/2026).During a concurrent interview and record review on 04/16/2026 at 12:01p.m. with MDS coordinator Resident 23's MDS dated [DATE] under Section J Pain Management, the MDS indicated Complete for all residents, regardless of current pain level: At any time in the last five days, has Resident 23 Received PRN (Pro re nata, as needed) pain medications OR was offered and declined? the answer selected was No. The MDS coordinator stated they do ask the residents and nurses regarding the pain when they fill out the MDS report.

Based on observation, interview, and record review, the facility failed to ensure the pressure relieving device of a low air loss (LAL) mattress was set according to the manufacturer's recommended guidelines for Resident 71. This deficient practice had the potential to compromise the resident's right to a safe, clean, comfortable, and homelike environment and to place Resident 71 at risk for pressure ulcer development and discomfort while in bed.Findings:During a review of Resident 71 admission record, the admission record indicated admitted on [DATE] with a diagnoses of stroke [cerebral vascular accident (reduction of blood flow to the brain resulting in brain injury), hypertension (high blood pressure), hyperlipidemia (abnormally high levels of fats in the blood), hemiparesis (neurological condition characterized by weakness, numbness, and reduced motor function on one side of the body, often affecting the arm, leg, and face).During a record review of Resident 71's Minimum Data Set (MDS- resident assessment tool) dated 3/18/2026, The MDS indicated that Resident 9 is rarely/never understood. The MDS also indicated that Resident 71 is dependent with eating, toileting hygiene and shower. During an observation on 04/13/2026 12:33 p.m., Resident 71's bed has low air loss overlay (LAL) mattress machine on bed with sticker set at wt. 98 was set approximately 150 lbs. During a concurrent interview and observation on 04/15/2026 10:46 a.m. with certified nursing assistant (CNA) 1 while at the bedside of Resident 71 CNA 1 stated that the setting for the LAL at 150 lbs when the machine indicates set at 98Lbs. CNA 1 stated Treatment Licensed Vocational Nurse (LVN) manage settings for LAL.During a concurrent interview on 04/15/2026 10:52 a.m. and observation of the LAL mattress with LVN 3, LVN 3 stated the settings on the LAL mattress was weight based. LVN 3 stated that settings exceeded the recommended settings. LVN 3 stated that if the mattress is too hard it is not good for the resident's skin and that is the reason why the LAL mattress is ordered.During a review of the facility's policy and procedure (P&P) titled, Support Surface Guidelines, dated 03/05/2026, indicated, guides the facility staff to: Redistributing support surfaces are to promote comfort for all bed- or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction. The P & P indicated elements of support surfaces that are critical to pressure ulcer prevention and general safety include pressure redistribution, moisture control, shear reduction, heat dissipation/temperature control, friction control, infection control, flammability, and life expectancy.

Based on observation, interview and record review, the facility failed to ensure the confidentiality of resident medical records when the medication labels for two of two sampled residents (Residents 1 and 74) were left unattended on a medication cart in the facility hallway. This failure had the potential to violate Resident 1 and 74's right to confidentiality.Findings: During a concurrent observation and interview on 4/16/2026 at 10:46 AM with Licensed Vocational Nurse (LVN) 4 in the facility hallway, two medication labels were left on top of the medication cart. One medication label indicated Resident 1's name, a prescription number, and the name of the medication doxazosin mesylate (a medication to treat high blood pressure) 4 milligram tablet. The second medication label indicated Resident 74's name, a prescription number, and the name of the medication lisinopril (a medication to treat high blood pressure) 10 milligram tablet. LVN 4 stated these labels are from each resident's individual medication package. It is not facility policy to leave these labels on top of the medication cart unattended because the labels contain confidential patient information. Leaving these labels out is a violation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA - a federal law that establishes national standards to protect sensitive patient health information). During an interview on 4/16/2026 at 11:17 AM with the Assistant Director of Nursing (ADON), ADON stated medication labels should not be left out on medication carts. It is important not to leave these labels out because they contain confidential information and that would be a violation of HIPAA and patient confidentiality.During a review of the facility's policy and procedure (P&P) titled, Confidentiality of Information and Personal Privacy, last reviewed 3/5/2026, the P&P indicated the facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. The facility will strive to protect the resident's privacy regarding his or her medical treatments.

Based on interview and record review, the facility failed to ensure the facility's pharmacist consultant's recommendation in the Medication Regimen Review (MRR), which advised adding a pain medication order for mild or severe pain, was reviewed and acted upon for one of five sampled residents (Resident 3)This failure resulted in Resident 3 not receiving recommended adjustments to her pain medication regimen, increasing the risk for Resident 3 to suffer from unmanaged pain. Findings: During a review of Resident 3's admission Record (face sheet), dated 4/15/2026, the face sheet indicated Resident 3 was initially admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including but not limited to Parkinsonism (a general term for brain disorders that cause slowed movements, stiffness, and tremors), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities), bipolar disorder (a chronic mental health condition characterized by intense extreme mood swings that interfere with daily life), and schizoaffective disorder (a chronic mental health condition with symptoms such as hallucinations, delusions, and severe mood swings). During a review of Resident 3's latest Minimum Data Set (MDS - a standardized clinical tool used in nursing homes to evaluate every resident), dated 1/8/2026, the MDS indicated the resident is rarely/never understood and is dependent on staff for all functional abilities. The MDS also indicated the resident has impairment in range of motion to both sides of the upper and lower extremities. During a review of Resident 3's physician's order, dated 1/24/2025, the physician's order indicated to give two tablets of acetaminophen (a medication to treat pain) 325 milligrams every four hours as needed for moderate pain. During a concurrent interview and record review on 4/15/2026 at 1:35 PM with Registered Nurse (RN) 1, the MRR, dated 3/18/2026, was reviewed. The MRR indicated the pharmacist consultant recommended the addition of an acetaminophen order for mild and severe pain for Resident 3. RN 1 stated that based on her review of Resident 3's medical records, there was no physician documentation of acknowledgement or action taken based on this recommendation. RN 1 further stated it is important to keep medications up to date to make sure residents are receiving appropriate medications.During an interview on 4/16/2026 at 7:16 AM with the Director of Nursing (DON), DON stated he looked in Resident 3's medical records and could not find documentation the MRR recommendation was reviewed or executed. DON further stated the physician should have documented whether the acetaminophen orders should be added or not. During an interview on 4/16/2026 at 9:00 AM with DON, DON stated the facility is responsible to ensure the physician reviews the monthly MRR from the pharmacist to ensure the residents receive the care that they need. During a review of the facility's policy and procedure (P&P) titled, Medication Regimen Review, last reviewed 3/5/2026, the P&P indicated upon receiving the MRR report from the pharmacist, the attending physician reviews and responds to the report. The physician documents in the resident's medical record that the pharmacist's recommendations have been reviewed and what (if any) actions were taken to address them.

Based on interview, and record review, the facility failed to ensure adequate documentation of intake and output for one (Resident 8) out of one sampled residents who are on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed).This deficient practice had the potential to cause fluid overload (excess water in the body) or dehydration (insufficient water in the body) for Resident 8.Findings:During a review of Resident 8's admission record, the admission record indicated Resident 8 was originally admitted on [DATE] with diagnoses including, but not limited to polyneuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet); end stage renal disease (ESRD- irreversible kidney failure); chronic (systolic) congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling); and adult failure to thrive (decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity).During a review of the Minimum Date Set, (MDS- a resident assessment tool) dated 3/24/2026, MDS indicated that Resident 8's cognitive status (thought process) was not fully intact. MDS indicated that Resident 8 was independent with eating, moderate assistance with oral hygiene and upper body dressing, and maximal assistance with toileting, bathing, and lower body dressing. During a concurrent interview and record review on 4/14/2025 at 11:30 a.m., Licensed Vocational Nurse (LVN 2) stated that residents receiving dialysis obtain hemodialysis at an outpatient dialysis clinic. LVN 2 reported that Resident 8's most recent dialysis session occurred on 4/11/2026. Documentation for each dialysis treatment is recorded on the Hemodialysis Communication Record, which contains three sections: the top and bottom sections completed by facility staff, and the middle section completed by the dialysis center. LVN 2 stated the facility uploads the completed form into the resident's medical record.During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 4/14/2026 at 12:10 p.m., the ADON stated that management of care for dialysis residents includes completing assessments, following physician orders, and developing care plans. The ADON stated the dialysis center documents the resident's pre and post dialysis weight and records this information on the Hemodialysis Communication Record. The ADON stated that when a resident has physician ordered fluid restrictions, dietary staff and nursing staff coordinate the implementation of those restrictions. The ADON stated Resident 8 has physician orders for fluid restrictions as follows: Fluid restriction 1200ml/24 hours. With a breakdown of:Dietary total 600mL: Breakfast: 240ml, Lunch: 240ml, Dinner: 120ml. Nursing Total: 600ml 7 - 3: 200ml, 3 - 11: 200ml, 11 - 7: 200ml every shift. Start date 3/20/2026 2300. During a continued interview and record review with ADON on 4/14/2026 at 12:10 p.m., ADON reviewed Resident 8's Medication Administration Record (MAR) and stated MAR is marked as completed or not completed each shift. ADON stated there is no place where the specific amount of fluid given to the resident is documented. During a concurrent interview and record review on 4/16/2026 at 9:40 a.m. with the Director of Nursing (DON), the DON stated the dialysis clinic typically obtains the resident's pre dialysis and post dialysis weights. The DON stated the purpose of obtaining the weights for dialysis residents is to determine the resident's fluid status and ensure the resident is not fluid overloaded. The DON stated most dialysis residents have physician ordered fluid restrictions. The DON stated the facility follows the physician's orders for fluid restrictions and that the total daily fluid allowance is divided among the three nursing shifts (7:00 a.m.-3:00 p.m., 3:00 p.m.-11:00 p.m., and 11:00 p.m.-7:00 a.m.). The DON stated there is no specific time and no designated location in the residents' documentation where intake and/or output amounts are consistently recorded for dialysis residents.During a record review of the facility's policy and procedure (P & P) titled Dialysis Care dated on 8/25/2021, the section titled Fluid Restrictions stated Nursing and Dietary Staff will carefully organize the division and distribution of fluid. The P & P indicated, All documentation concerning dialysis services and care of the dialysis resident will be maintained in the resident's medical record. During a record review of the facility's policy and procedure titled, Hydration- Clinical Protocol dated March 2026, the policy indicated physician and staff will monitor fluid and electrolyte imbalances, including assessment of voiding patterns and clinical status.

Based on observation, interview, and record review, the facility failed to ensure the resident's head of the bed was elevated to at least 30 degrees during feedings as ordered for one of three sampled residents (Resident 3), who was receiving nutrition through a gastrostomy tube (G tube, a flexible tube surgically inserted through the abdomen into the stomach for the administration of nutrition, fluids, and medications). This failure had the potential to increase the risk of aspiration (accidentally inhaling food, liquids, stomach acid, or saliva into lungs) in the resident.Findings: During a review of Resident 3's admission Record (face sheet), dated 4/15/2026, the face sheet indicated Resident 3 was initially admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including but not limited to Parkinsonism (a general term for brain disorders that cause slowed movements, stiffness, and tremors), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities), dysphagia (medical term for difficulty swallowing), and gastrostomy status (medical condition of having an artificial, surgically created opening in the stomach wall that allows a feeding tube to be inserted directly into the stomach for nutrition, hydration, and medication).During a review of Resident 3's Minimum Data Set (MDS - a standardized clinical tool used in nursing homes to evaluate every resident), dated 1/8/2026, the MDS indicated the resident is rarely/never understood. The MDS also indicated Resident 3 receives nutrition through a feeding tube and has impairment in range of motion to both sides of the upper and lower extremities. During a review of Resident 3's Nursing Documentation Evaluation, dated 8/23/2024, the evaluation indicated Resident 3 receives nutritional supplements through enteral feeding (a method of delivering liquid nutrition directly into the stomach) via G-tube. During a review of Resident 3's physician's order, dated 1/24/2025, the order indicated Resident 3's head of bed should be elevated to at least a 30-degree angle during enteral feeding and for one hour after feeding. During a review of Resident 3's care plan titled, Resident is at risk for aspiration related to G-tube, created on 1/3/2026, the care plan indicated Resident 3's head of bed should be elevated at least 30 degrees during feeding and for one hour after feeding.During a concurrent observation and interview on 4/13/2026 at 12:59 PM with Assistant Director of Nursing (ADON) in Resident 3's room, Resident 3 was lying nearly flat in bed with the tube feeding machine on. ADON stated Resident 3 is lying flat and the head of bed is at less than a 30-degree angle. ADON stated the facility does not have a measuring device to measure the angle of the resident's head of bed. ADON stated Resident 3's head should be raised higher, to at least a 30-degree angle, while the resident is receiving enteral feedings to prevent the risk of aspiration. During an interview on 4/16/2026 at 9:19 AM with the Director of Nursing (DON), DON stated that aspiration is a complication of enteral tube feeding. The resident's head of bed should be raised to a 30-45-degree angle during feeding to prevent the risk of aspiration to the resident. During a review of the facility's policy and procedure (P&P) titled, Enteral Feeding, last revised 3/5/2026, the P&P indicated the resident's head of bed should be elevated at a 30-degree angle during feedings.

Based on observation, interview, and record review the facility failed to provide the necessary assessments, care, and services for one of three residents (Resident 1) to prevent falls, by failing to ensure two staff transferred Resident 1 from wheelchair (WC) to bed. On 2/25/2024, certified nurse assistant 1 (CNA 1) attempted to transfer Resident 1 from a WC to a bed without the assistance of another staff member. As a result, on 2/25/2024, Resident 1 fell from the WC onto the floor sustaining right eye injury. Resident 1 required emergent transfer to general acute care hospital 1 (GACH 1) via 911 (emergency response telephone number). GACH 1 diagnosed Resident 1 with right orbital (bony cavity that contains the eyeball) displaced fracture (two or more breaks in the bone surrounding the eye causing improper alignment), right retrobulbar hematoma (a collection of blood within the bony orbit and behind the eyeball) with proptosis (bulging) and right periorbital (around the eye) hematoma (clotted blood usually caused by broken blood vessel). On 2/25/2024 was transferred to GACH 2, a trauma center (higher level of care) for emergent ophthalmology (a branch of medicine that deals with the structure, functions, and diseases of the eye) consult. GACH 2 performed canthotomy (a surgical procedure where the lateral corner of the eye is cut to relive the fluid pressure inside or behind the eye) to Resident 1's right eye. Findings: A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 2/2/2024 with diagnoses including dementia (progressive loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Parkinson's disease without dyskinesia (movement disorder), with fluctuations, open angle glaucoma of the left eye (ongoing progressive and irreversible increased pressure in the eye causing progressive visual loss), osteoarthritis (condition of the breakdown of joint cartilage and the underlying bone causing pain and stiffness especially to hips, knees and thumb joint), and history of falling. A review of Resident 1's Prior Stay Assessment- V2 form dated 2/2/2024, indicated Resident 1 had not been admitted to a skilled nursing facility (SNF) in the last 60 days and was authorized for respite care (short term) at the facility from 2/2/2024 to 2/23/2024. A review of Resident 1's Physician Order dated 2/2/2024, indicated physical therapy (PT - the care provided to a patient promote, maintain, or restore health through patient education, physical intervention, disease prevention, and health promotion) and occupational therapy (OT - the use of occupation and meaningful activities with specific goals to help people of all ages prevent, lessen, or adapt to disabilities) to evaluate Resident 1. A review of Resident 1's Lift Transfer Resposition-V2 form dated 2/3/2024, indicated Resident 1 was not able to transfer independently or without supervision. The Lift Transfer Reposition form indicated Resident 1 was not able to bear weight on both legs. The Lift Transfer Reposition form indicated Resident 1 required a total lift (machine used when a resident needs complete assistance to transfer between surfaces) and required two staff for repositioning in bed. A review of Resident 1's care plan titled Resident is at risk for fall/injury r/t (related to) poor balance, Parkinson's disease, hx (history) of fall, use of medications such as (psychotropic [medications that affect the nervous system], analgesic [medications that treat pain and inflammation]), initiated on 2/5/2024, indicated interventions included staff to prevent falls by anticipating and meeting Resident 1's needs. The care plan did not indicate Resident 1's specific needs. A review of Resident 1's MDS dated [DATE], indicated Resident 1's cognition (the mental ability to make decisions of daily living) was not intact. The MDS indicated Resident 1 had not attempted to move from sitting to lying position in bed, lying to sitting on side of the bed, and sitting to standing position due to medical condition or safety concerns. The MDS indicated Resident 1 was dependent on two or more staff to transfer from chair to bed and vice versa. The MDS indicated Resident 1 used a WC for mobility (movement). A review of Resident 1's care plan titled Resident is at risk for fall/injury r/t to poor balance, Parkinson's disease, hx of fall, use of medications such as (psychotropic, analgesic) revised on 2/12/2025, indicated Resident 1 was at risk for fall/injury. The care plan interventions included to ensure staff followed facility's fall protocol. However, the care plan did not include the facility's fall protocol. A review of Resident 1's Change in Condition (COC - a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domain that without intervention, the deviation could lead to significant complications including death) Evaluation form dated 2/25/2024 at 8 p.m., indicated that on 2/25/2024 at 7:40 p.m., Licensed Vocational Nurse 1 (LVN 1), CNA 1, and CNA 2 entered Resident 1's room and saw Resident 1 on the floor with the face down between a window and a bed. The COC indicated LVN 1 observed Resident 1's right eyebrow was cut and bleeding, and the resident's right eyelid was bruised and swollen. The COC indicated LVN 1 asked Resident 1, are you ok and Resident 1 stated, yes. The COC indicated LVN 1 called 911, Resident 1 was transported to GACH 1, and resident's family member 1 (FM 1) was notified. A review of Los Angeles Fire Department (LAFD) Patient Care Report (form emergency transport uses to document assessment and care) dated 2/25/2024 at 7:51 p.m., indicated Resident 1 was picked up and transported to a GACH after a mechanical (external force and or no underlying cause) fall while staff was assisting Resident 1 back to bed. The LAFD patient care report indicated Resident 1 was alert and stable for transport. A review of GACH 1 Emergency Department (ED) Summary Report dated 2/25/2024, indicated Resident 1 arrived with a large right periorbital hematoma. A review of GACH 1 Computerized Tomography Scan (CT - medical imaging technique used to obtain detailed internal images of the body) of maxillofacial (portion of the face from the upper jaw) structures dated 2/25/2024, indicated Resident 1 had, markedly displaced fracture of the right inferior (lower) orbital (eye socket) wall with protrusion of extraconal (sticking out of eye socket) fat through the orbital floor defect. Large right periorbital hematoma with retrobulbar (behind the eyeball) hemorrhage and severe proptosis (bulging from natural position) of the right globe (eye eyeball) and stretching of the right optic nerve (relays messages from your eyes to the brain to create visual images) and extraocular (outside the eye) muscles. Urgent surgical assessment recommended for further management. A review of Resident 1's ED (emergency department) Summary Report dated 2/26/2024 (no time), indicated a call was placed to GACH 2 trauma center on 2/25/2024 at 11:44 p.m., for immediate consultation with ophthalmology for possible lateral canthotomy and facial surgeons. Resident 1 was accepted and transferred to GACH 2 on 2/26/2024 at 12 a.m. The ED summary report under, medical decision making and documented by ED physician, indicated, After evaluation, it is my medical judgement that given patient's medical history, current needs, the medical predictability, and concern that something adverse (negative outcome) is going to happen to the patient given the results of his work up, if they (Resident 1) are not admitted . The complexity required for the (Resident 1's) care, the time requirement for diagnostic procedure and services needed for the patient [Resident 1], the patient will need at least two midnight stays. The ED summary report indicated Resident 1 was treated with Tylenol for pain, updated tetanus injection (vaccine to prevent lock jaw/painful muscle contractions), and ice packs applied to the right eye. Resident 1 received Unasyn (antibiotic - medication to prevent/treat infections)) intravenous (IV - inside a vein) for the facial fractures. During an interview on 2/27/2024 at 8:44 a.m., FM 1 stated the skilled nursing facility (SNF) admitted Resident 1 for respite care for three weeks. FM 1 stated, I was in shock when I got the call (telephone) Sunday night (2/25/2024) that [Resident 1] fell , had a lot of bleeding, and was taken by 911 to the hospital. FM 1 stated, FM 1 contacted the SNF for clarification about Resident 1's fall. FM 1 stated that a nurse (unidentified) told FM 1 that Resident 1 fell when the aid (CAN 1) was transferring Resident 1 from the WC to bed. FM 1 stated, we went to the hospital (GACH 1), and [Resident 1's] right eye was getting larger. The doctor told us they (GACH 1) needed to transfer [Resident 1] to a higher level of care trauma center stat (immediately). FM 1 stated GACH 1 transferred Resident 1 to GACH 2, a trauma center, on 2/25/2024. FM 1 stated, they had to drain blood from [Resident 1] eye and GACH 2 was deciding whether to proceed with reconstructive surgery Resident 1's right eye. FM 1 stated GACH 2 admitted Resident 1 to the intensive care unit (ICU - a unit in a hospital that provides critical care and life support for acutely ill and injured patients), and that Resident 1 received blood transfusion. FM 1 stated Resident 1, is unable to see out of the right eye and that GACH was trying to save the right eyeball. FM 1 stated Resident 1's eyeball detached and was on the side as opposed to being in the right eye socket. FM 1 stated Resident 1 was not able to remember what happened regarding the fall. A review of Resident 2 (Resident 1's roommate) admission record indicated the facility admitted Resident 2 on 2/23/2024 with diagnoses including lumbar vertebra fracture (broken lower back bone), abdominal aortic aneurysm (enlargement of the aorta, the main blood vessel that delivers blood to the body), hyponatremia (low sodium), hypertension (high blood pressure), difficulty walking, and generalized weakness. A review of Resident 2's MDS dated [DATE], indicated Resident 2's cognition was intact. During an interview on 2/27/2024 at 1:05 p.m. Resident 2 stated he recalled a nurse (did not state which nurse) was wheeling Resident 1 to the left side of the room next to the sliding glass door when all of sudden Resident 2 heard the nurse howl (loud cry) and saw Resident 1 lying on the floor. Resident 2 stated, [Resident 1] must have hit his head on the bedside table that was on that side of the bed. Resident 2 stated several staff came in and helped Resident 1 back into the WC. Resident 2 stated Resident 1, had a little bit of bleeding on the right eye. Resident 2 denied witnessing Resident 1's actual fall but did see the nurse behind Resident 1's WC. Resident 2 confirmed and stated there was only one nurse in the room at the time Resident 1 fell . During an interview on 2/27/2024 at 1:25 p.m. CNA 3 stated, CAN 3 was Resident 1's regular CNA I since Resident 1's admission. CNA 3 stated Resident 1 was alert and able to make needs known, could not walk and needed two people to transfer and because, I cannot do it [transfer Resident 1] myself. CNA 3 stated, I help [Resident 1] with transfers because the resident is not strong enough to help with transfers. I always call for help because the resident may fall. CNA 3 stated there were no fall pads (mats) on the floor for Resident 1. During an interview with CNA 4 on 2/27/2024 at 2:59 p.m. CNA 4 stated CNA 4 has provided cared to Resident 1, and that Resident 1 requires two staff for transfers because Resident 1 was stiff, had tremors, could not stand, and was a fall risk. During an interview with CNA 2 on 2/27/2024 at 3:14 p.m. CNA 2 stated, that on 2/25/2024, CNA 4 found Resident 1 already on the floor and did not witness the actual fall. CNA 4 stated Resident 1 was lying on the right side of the bed, facing the bed and was in between the sliding glass door and the bed. CNA 4 stated CNA 1 went to CNA 2 panicking and told CNA 2 that CNA 4 had someone (Resident 1) fall. CNA 2 followed CNA 4 to the room and saw Resident 1 on the floor. CNA 2 stated the WC was next to the foot of the bed, in between the bed and the sliding glass door and facing a dresser located straight ahead. CNA 2 stated the WC was next to the bed because CNA 4 was trying to get Resident 1 back in bed. CNA 2 stated Resident 1's right eyebrow was cut and dripping blood. CNA 2 stated CNA 2 always uses two people when transferring Resident 1 from bed to WC. CNA 2 stated Resident 1, was a fall risk that is why we always used two people to transfer the resident. CNA 2 stated Resident 1 had a yellow wrist band (fall risk band) and was total care (dependent). During an interview with assistant Director of Staff Development (ADSD) on 2/27/2024 at 4:04 p.m., ADSD stated, CNA 1 approached ADSD on 2/26/2024 (a day after the incident) and informed ADSD that on 2/25/2024 Resident 1 fell . ADSD stated CNA 1 said, the last time I transferred the resident alone, there was no problem but when I tried to transfer him yesterday, he fell . The ADSD stated CNA 1 was not Resident 1's regular CAN and that all the nurses in the facility know to call for help when transferring a resident including Resident 1. ADSD stated Resident 1's fall could have been prevented if CNA 1 called for help. ADSD stated Resident 1 was stiff and staff have to be careful. ADSD stated CNA 1 was not familiar with the resident and should have asked for help. During an interview with the physical therapist (PTS) on 2/27/2024 at 4:30 p.m. PTS stated on 2/5/2024, both the PTS and occupational therapist (OT- is a healthcare provider who helps you improve your ability to perform daily tasks) stated Resident was weak and needed a lot of help when sitting up and with transfers. PTS stated PTS had recommended that staff use a lifting device when transferring Resident 1, and for two people to assist when transferring Resident 1. PTS stated PTS further stated Resident 1 was a fall risk because of poor balance and strength. During an interview CNA 1 on 2/28/2024 at 1:30 p.m., CNA 1 stated that on 2/25/2024, CNA 1 was assigned Resident 1. CNA 1 stated that on 2/25/2024 at around 7 p.m., Resident 1 fell when CNA 1 was trying to transfer Resident 1 back to bed without assistance. CNA 1 stated, I saw [Resident 1's] eye towards me moving. I ran into the hallway to get help. CNA 1 stated CNA 2 and LVN 1 came into the room. CNA 1 stated Resident 1 had swelling around the right eye and LVN 1 called 911. CNA 1 stated that on one occasion, someone (unidentified) assisted CNA 1 to transfer Resident 1. CNA 1 stated CN 1 did not know Resident 1 was a fall risk and did not recall seeing a yellow band (fall risk band) on the resident. CNA 1 confirmed and stated two people are needed to transfer Resident because it was the facility's policy. During an interview on 2/28/2024 at 2:20 p.m., LVN 1 confirmed and stated LVN 1 was working on 2/25/2024 and at 7 p.m. LVN 1 stated Resident 1 was sitting in a WC and told CNA 1 that Resident 1 was ready to go back to bed and to get another CNA to help with transferring the resident back to bed. On 2/25/2024 at around 7:40 p.m., LVN 1 stated, I heard a CNA scream and immediately followed [CNA 1 and CNA 2] into [Resident 1's] room and saw [Resident 1] lying on floor, face down in between the bed and the sliding glass door. LVN 1 stated Resident 1 had some bleeding and swelling to the right eye and was not able to open the right eye. LVN 1 stated LVN 1 instructed CNA 1 to apply ice, the bleeding stopped, the paramedics (medical professionals who specialize in emergency treatment) arrived approximately 15 minutes after the fall and transported Resident 1 to GACH 1. LVN 1 stated the way Resident 1, was positioned on the floor, looked like [CNA 1] was attempting to put the resident back to bed. LVN 1 stated CNA 1 told LVN 1 that CNA 1 was trying to put Resident 1 back to bed. LVN 1 stated Resident 1 was dependent for transfers, required two people to assist at all times, and that it is our policy (two persons to assist with transfers). During an interview with the Director of Nursing (DON) on 2/28/2024 at 6:52 p.m., the DON confirmed and stated the facility did not perform/conduct fall risk assessment for Resident 1. The DON stated Resident 1's fall could have been avoided if two staff were present to assist with the transfer. A review of the facility's Inservice Attendance Record Sign in Sheet dated 2/29/2024, regarding the subject of the in-service, indicated, Transfer assist, fall management/prevention transfer assistance IE: 2 person for Hoyer lift (mechanical lifting device) . Staff to identify 1 (one) person or two persons assist and for Hoyer lift always two persons assist at all times. A review of the facility's Safe patient handling lesson plan (no date), regarding CNA- Safely Moving Residents-Lifting and Transferring, indicated, general lifting and transferring tips to help the residents safe included, use teamwork by asking your teammates for help and talking with them about what you do as you plan and while doing it. A review of the facility's policy and procedures (P&P), Fall Management effective 5/26/2021, indicated, patients will be assessed for fall risk as part of the nursing assessment process. This determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Procedure: Identify patient's fall risk by reviewing the nursing documentation. Communicate patient's fall risk status to care givers. Develop individualized plan of care. Review and revise care plan as indicated.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) remained comfortable and free of itching by failing to notify a physician and follow up on a dermatology consult after the facility was aware that Resident 1 continued to itch and that family members 1 and 2 (FM 1 and FM 2) had complained that Resident 1 had been scratching and complaining of discomfort since 7/2023. The facility was aware Resident 1 was continuously itching and scratching for four months despite being treated with hydrocortisone (medication used to treat redness, itching, swelling, or other discomfort caused by skin conditions) and Atarax (medication to treat itching). This failure resulted in Resident 1 experienced flaky scalp (the skin on top of the head), bleeding scalp, hair loss, pain bump to the back of the head, screamed, cried and saying, help me, and was anxious (worry, unease, or nervousness, typically about an imminent event or something with an uncertain outcome) and depressed (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy) because of not sleeping. Cross Reference F600 Findings: A review of Resident 1's admission record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including type 2 diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), hypothyroidism (underactive thyroid [a small, butterfly-shaped gland in the front of the neck]) is when the thyroid gland does not produce adequate thyroid hormones to meet the body's needs), and end stage renal disease (a medical condition in which a person's kidneys (organs in the body that remove waste products from the blood and produce urine) cease to function permanently requiring dialysis [a procedure to remove waste products and excess fluid from the blood when the kidneys stop functioning] or a kidney transplant to maintain/sustain life). A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 10/10/2023, indicated Resident 1 was cognitively intact (mental ability to make decisions of daily living) and required one-person physical assist with bed mobility, dressing, toileting, and personal hygiene. The MDS further indicated Resident 1 required two-person physical assistance for surface transfer. During an interview with a Certified Nursing Assistant 1 (CNA) 1 on 11/3/2023 at 10:30 a.m., CNA 1 confirmed that for two months, Resident 1 had been complaining of itching and skin discomfort and that she had reported to the charge nurses as well as the treatment nurses. CNA 1 stated the charge nurse and the treatment nurses told CNA 1 that they had been applying some type of a cream that did not really provide relief for Resident 1. CNA 1 stated the rash was everywhere (the rash- torso, arms, hands, groin, thighs, leg) on Resident 1. CNA 1 stated Resident 1 was so uncomfortable, and that Resident 1 would often cry and say, help me! while Resident 1 was scratching herself. During an interview and record review with Licensed Vocational Nurse 1 (LVN) 1 on 11/3/2023 at 11:46 a.m., Resident 1's Change in Condition (COC- a deterioration in a resident's physical or mental condition that causes the resident's need for direct care to be re-evaluate) completed by LVN 1 was reviewed. LVN 1 was unaware that Resident 1 had scabies or that she had a history of scabies. LVN 1 confirmed and stated since the mid of 9/2023 (about a month and half), Resident 1 had been scratching herself hard. LVN 1 stated that since 10/18/2023, Resident 1 lost her hair (had a bald spot) from itching and scratching hard. LVN 1 stated the facility was treating Resident 1 with hydrocortisone ointment and Atarax but never got any relief. LVN 1 further stated that a dermatology (a physician trained to diagnose and treat skin, hair, and nail conditions) consult was ordered around mid of 9/2023. LVN 1 stated he was unable to find any documented evidence that the facility contacted a dermatologist to consult with Resident 1. A review of Resident 1's Physician's Order dated 9/22/2023, indicated, to apply Hydrocortisone 2.5 percent (% - unit of measurement) to affected area twice a day as needed for itching and dermatology consult for Resident 1. During an interview with Resident 1's FM 1 and FM2 on 11/3/23 at 1:52 p.m., FM 1 stated Resident 1 had been scratching and complaining of discomfort since 7/2023. FM 1 further stated that she had been reporting to the nurses that Resident 1 itching and that the creams ordered were not helpful at all. FM 2 stated that whenever he visited Resident 1, Resident 1 would be always scratching, crying and that saying that she [Resident 1] could not get the itching to stop. FM 1 further stated that Resident 1 told her that the itching was so bad that she could not sleep which then made her feel anxious and depressed. A review of the Interdisciplinary Team Meeting (IDT- an approach to healthcare that integrates multiple disciplines through collaboration) dated 7/6/2023, indicated for behavior management and Gradual Dose Reduction (GDR- is a method used to reduce the dosage of a specific medication while closely monitoring the Resident 1's progress and potentially incorporating alternative intervention strategies) indicated. The IDT notes indicated Resident 1 was on: 1. Lorazepam (medication used to treat anxiety and sleeping problems related to anxiety) 1 (one) milligram (mg - unit measurement) by mouth (PO) every 12 hours as needed (PRN) for anxiety manifested by (m/b) screaming. 2. Trazodone HCL (an antidepressant used to treat depression, anxiety, and insomnia [lack of sleep]) 100mg, po at bedtime for depression m/b crying spells, agitation, and insomnia. During an interview and record review with the Infection Preventionist Nurse (IPN) on 11/3/2023 at 12:32 p.m., Resident 1's H&P from GACH was reviewed. The IPN stated she was unaware that Resident 1 had a history of scabies. The IPN stated she should have been aware about the scabies diagnosis when Resident 1 was readmitted to the facility on [DATE]. The IPN stated the DON should have informed her that Resident 1 had a history of scabies. The IPN stated the H&P indicated that Resident 1 had possible scabies versus bed bugs. The IPN further stated GACH diagnosed Resident 1 with scabies on 10/25/2023. When asked if the facility has informed the dialysis center that GACH had treated Resident 1 for scabies, the IPN stated it was GACH duty to inform the dialysis center because Resident 1 was not under the facility custody (no longer in the facility). The IPN further stated that she assessed Resident 1 on 11/2/2023 and Resident 1 did not have signs (something that can be observed/measured) and symptoms (evidence of a disease/medical condition) of infection (rash anywhere on her body especially in the webs of her fingers and toes, no burrowing [a tunnel made in or under the skin caused by scabies mite]). During an interview with the DON on 11/3/23 at 4:38 p.m., the DON stated pain assessment for Resident 1 should be documented every shift and pain medication administered as per physician's order. The DON stated any interventions performed on Resident 1, whether pharmacological (relating to the branch of medicine concerned with the uses, effects, and modes of action of drug) or non-pharmacological (therapies that do not involve drugs) must be documented. The DON confirmed and stated that there was documented evidence on pain interventions for Resident 1. During an interview with Resident 1's primary physician (MD2) on 11/4/23 at 4:08 p.m., MD2 stated he was not aware that Resident 1 was unable to sleep because of scratching/itching. MD2 also stated he not aware that Resident 1 was losing her scalp hair from scratching. MD2 stated he had noticed Resident 1 was bleeding on her scalp but did not give/write any orders. A review of the facility's policy and procedures (P&P) titled General Policy Guidelines: Pain Management, effective 8/25/2021 indicated, .: o Maintain the highest possible level of comfort for Residents by providing a system to identify, assess, treat, and evaluate pain. o Design a plan of care to achieve an optimal balance between pain relief and preservation of function, in accordance with Resident directed goals. o Residents will be evaluated as part of the nursing assessment process for the presence of pain upon admission/re- admission, quarterly, with change in condition or change in pain status, and as required by the state thereafter. o Pain management that is consistent with professional standards of practice, the comprehensive person-centered care plan, and the Resident's goals and preferences is provided to Residents who require such services. A review of the facility's P&P titled Guidelines for Notifying Physicians of Clinical Problems revised 2/2014 indicated, the guidelines are to help ensure that medical care problems are communicated to the medical staff in a timely, efficient and effective manner and that all significant changes in resident status are assessed and documented in the medical record. The immediate (acute) and non-immediate (sub-acute) problems listed below are not meant to be all-inclusive. The charge nurse or supervisor should contact the attending physician at any time if they feel a clinical situation requires immediate discussion and management. When contacting the practitioner, especially at night and on weekends ( when physicians not familiar with the residents may be on call), the nurse should have the following information available: 1. Detailed description of current issue or problem, including a chronological story of symptoms and treatment to date, vital signs (blood pressure, heart rate, temperature, and respirations) and results of physical assessment. 2. Active medical problems (problem list). 3. Pertinent information from any recent hospitalization s (hospital discharge summary or admission history and physical form). 4. Current medications (orders). The same P&P indicated, symptoms, signs, and laboratory values (which are not all-inclusive) should prompt immediate notification of the physician, after an appropriate nursing evaluation. Immediate implies that the physician should be notified as soon as possible, either by phone, pager, text messaging, or other means. These situations include unrelieved by measures which have already been prescribed. A review of online Centers for Disease Control and Prevention article, titled Parasites-Scabies dated 6/6/2023, indicated, human scabies is caused by an infestation of the skin by the human itch mite that burrows into the upper layer of the skin where it lives and lays its eggs. The most common symptoms of scabies are intense itching and a pimple-like skin rash. The scabies mite usually is spread by direct, prolonged; skin-to-skin contact with a person who has scabies. Scabies can spread rapidly under crowded conditions where close body contact is frequent. Complications of scabies include intense itching of scabies leads to scratching that can lead to skin sores. The sores sometimes become infected with bacteria on the skin (https://www.cdc.gov/parasites/scabies/index.html).

Based on interview and record review, the facility failed to protect the resident's right to be free from neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress) for one out of seven sampled residents (Resident 1) after Resident 1 and family members 1 and 2 (FM 1 and FM 2) complained of itching and discomfort since 7/2023. The facility was aware Resident 1 was continuously itching and scratching for four months despite being treated with hydrocortisone (medication used to treat redness, itching, swelling, or other discomfort caused by skin conditions) and Atarax (medication to treat itching). This failure resulted in Resident 1 experiencing flaky scalp (the skin on top of the head), bleeding scalp, hair loss, painful bump to the back of the head, screamed, cried and saying, help me, and was anxious (worry, unease, or nervousness, typically about an imminent event or something with an uncertain outcome) and depressed (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy) because of not sleeping. Findings: A review of Resident 1's admission record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including type 2 diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), hypothyroidism (underactive thyroid [a small, butterfly-shaped gland in the front of the neck]) is when the thyroid gland does not produce adequate thyroid hormones to meet the body's needs), and end stage renal disease (a medical condition in which a person's kidneys (organs in the body that remove waste products from the blood and produce urine) cease to function permanently requiring dialysis [a procedure to remove waste products and excess fluid from the blood when the kidneys stop functioning] or a kidney transplant to maintain/sustain life). A review of the Interdisciplinary Team Meeting (IDT- an approach to healthcare that integrates multiple disciplines through collaboration) dated 7/6/2023, indicated for behavior management and Gradual Dose Reduction (GDR- is a method used to reduce the dosage of a specific medication while closely monitoring the Resident 1's progress and potentially incorporating alternative intervention strategies) indicated. The IDT notes indicated Resident 1 was on: 1. Lorazepam (medication used to treat anxiety and sleeping problems related to anxiety) 1 (one) milligram (mg - unit measurement) by mouth (PO) every 12 hours as needed (PRN) for anxiety manifested by (m/b) screaming. 2. Trazodone HCL (an antidepressant used to treat depression, anxiety, and insomnia [lack of sleep]) 100mg, po at bedtime for depression m/b crying spells, agitation, and insomnia. A review of Resident 1's Physician's Order dated 9/22/2023, indicated, to apply Hydrocortisone 2.5 percent (% - unit of measurement) to affected area twice a day as needed for itching and dermatology consult for Resident 1. A review of Resident 1's COC dated 10/18/2023, indicated Resident 1 was observed and evaluated for itchy, flaky scalp with hair loss and painful bump to the right side back of the head. There was no documented evidence that a physician was notified. A review of GACH history and physical (H&P) for Resident 1 dated 10/25/2023, indicated the plan included the following: -Scabies . treated with Elimite (medication used to treat head lice and scabies) previous admission between 7/19/2023 and 7/24/2023. -Status post (S/P) another course of Elimite, we will repeat another course in 72hours from first dose. -S/P one dose of ivermectin (a broad spectrum anti-parasitic agent). -Contact isolation (intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient's environment). - Infectious disease consult (Infectious disease doctors are experts in infections that happen due to bacteria, viruses, fungi, or parasites). A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 10/10/2023, indicated Resident 1 was cognitively intact (mental ability to make decisions of daily living) and required one-person physical assist with bed mobility, dressing, toileting, and personal hygiene. The MDS further indicated Resident 1 required two-person physical assistance for surface transfer. During an interview with a Certified Nursing Assistant 1 (CNA) 1 on 11/3/2023 at 10:30 a.m., CNA 1 confirmed that for two months, Resident 1 had been complaining of itching and skin discomfort and that she had reported to the charge nurses as well as the treatment nurses. CNA 1 stated the charge nurse and the treatment nurses told CNA 1 that they had been applying some type of a cream that did not really provide relief for Resident 1. CNA 1 stated the rash was everywhere (the rash- torso, arms, hands, groin, thighs, leg) on Resident 1. CNA 1 stated Resident 1 was so uncomfortable, and that Resident 1 would often cry and say, help me! while Resident 1 was scratching herself. During an interview with the Admissions Coordinator (AC) on 11/3/2023 at 11:40 a.m., the AC stated that on 11/2/2023 afternoon, she received a call from GACH's social worker (SW) who informed her that Resident 1 was being treated for scabies (is contagious and spreads quickly through close physical contact in a family, school, or nursing home) and also to notify the dialysis center (a hospital-based or independent unit approved and licensed to provide dialysis services) where Resident 1 receives dialysis treatment. During an interview and record review with the Director of Nursing (DON) on 11/3/2023 at 11:36 a.m., Resident 1's medical chart was reviewed. The DON confirmed and stated there was no documented evidence of the dermatology consult for Resident 1. During an interview and record review with Licensed Vocational Nurse 1 (LVN) 1 on 11/3/2023 at 11:46 a.m., Resident 1's Change in Condition (COC- a deterioration in a resident's physical or mental condition that causes the resident's need for direct care to be re-evaluate) completed by LVN 1, was reviewed. LVN 1 stated he was unaware that Resident 1 had scabies or that she had a history of scabies. LVN 1 confirmed and stated since the mid of 9/2023 (about a month and half), Resident 1 had been scratching herself hard. LVN 1 stated that since 10/18/2023, Resident 1 lost her hair (had a bald spot) from itching and scratching hard. LVN 1 stated the facility was treating Resident 1 with hydrocortisone ointment and Atarax but never got any relief. LVN 1 further stated that a dermatology (a physician trained to diagnose and treat skin, hair, and nail conditions) consult was ordered around mid of 9/2023. LVN 1 stated he was unable to find any documented evidence that the facility contacted a dermatologist to consult with Resident 1. During an interview and record review with the Infection Preventionist Nurse (IPN) on 11/3/2023 at 12:32 p.m., Resident 1's H&P from GACH was reviewed. The IPN stated she was unaware that Resident 1 had a history of scabies. The IPN stated she should have been aware about the scabies diagnosis when Resident 1 was readmitted to the facility on [DATE]. The IPN stated the DON should have informed her that Resident 1 had a history of scabies. The IPN stated the H&P indicated that Resident 1 had possible scabies versus bed bugs. The IPN further stated GACH diagnosed Resident 1 with scabies on 10/25/2023. When asked if the facility has informed the dialysis center that GACH had treated Resident 1 for scabies, the IPN stated it was GACH duty to inform the dialysis center because Resident 1 was not under the facility custody (no longer in the facility). The IPN further stated that she assessed Resident 1 on 11/2/2023 and Resident 1 did not have signs (something that can be observed/measured) and symptoms (evidence of a disease/medical condition) of infection (rash anywhere on her body especially in the webs of her fingers and toes, no burrowing [a tunnel made in or under the skin caused by scabies mite]). During a phone interview with the Medical Doctor- Dermatologist 1 (MD1) on 11/3/2023 at 1:36 p.m., The MD1 stated that he did not recall getting a consult request for Resident 1 and therefore did not see Resident 1. MD1 stated the protocol for any resident presenting with symptoms such as for Resident 1, included physical exam. MD1 stated identified concerns would be discussed with the DON or licensed nurses. MD1 stated if ordered treatments such as topical ointments did not help/relieve a resident, then skin scraping, or biopsy is performed to test for scabies. MD1 stated that a negative skin scraping does not rule out scabies. During an interview with Resident 1's family members 1 and 2 (FM 1 and FM2) on 11/3/2023 at 1:52 p.m., FM 1 stated Resident 1 had been scratching and complaining of discomfort since 7/2023. FM 1 further stated that she had been reporting to the nurses that Resident 1 itching and that the creams ordered were not helpful at all. FM 2 stated that whenever he visited Resident 1, Resident 1 would be always scratching, crying and that saying that she [Resident 1] could not get the itching to stop. FM 1 further stated that Resident 1 told her that the itching was so bad that she could not sleep which then made her feel anxious and depressed. During an interview with Resident 1's primary physician (MD2) on 11/4/2023 at 4:08 p.m., MD2 stated he was not aware that Resident 1 was unable to sleep because of scratching/itching. MD2 also stated he not aware that Resident 1 was losing her scalp hair from scratching. MD2 stated he had noticed Resident 1 was bleeding on her scalp but did not give/write any orders. A review of the facility's policy and procedures (P&P) titled Guidelines for Notifying Physicians of Clinical Problems revised 2/2014 indicated, the guidelines are to help ensure that: 1. Medical care problems are communicated to the medical staff in a timely, efficient and effective manner. 2. All significant changes in resident status are assessed and documented in the medical record. The immediate (acute) and non-immediate (sub-acute) problems listed below are not meant to be all-inclusive. The charge nurse or supervisor should contact the attending physician at any time if they feel a clinical situation requires immediate discussion and management. When contacting the practitioner, especially at night and on weekends ( when physicians not familiar with the residents may be on call), the nurse should have the following information available: 1. Detailed description of current issue or problem, including a chronological story of symptoms and treatment to date, vital signs, and results of physical assessment. 2. Active medical problems (problem list). 3. Pertinent information from any recent hospitalization s (hospital discharge summary or admission history and physical form). 4. Current medications (orders). The same P&P also indicated, symptoms, signs, and laboratory values (which are not all-inclusive) should prompt immediate notification of the physician, after an appropriate nursing evaluation. Immediate implies that the physician should be notified as soon as possible, either by phone, pager, text messaging, or other means. These situations include unrelieved by measures which have already been prescribed. A review of the facility's policy and procedures titled Abuse Prohibition Policy and Procedure reviewed on 2/21/2021, indicated, HealthCare Centers prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptoms. Neglect is defined as the failure of the Center, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The actions to prevent abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, will include: Identifying, correcting, and intervening in situations in which abuse, neglect, and/or misappropriation of patient property is more likely to occur.

Based on interview and record review for one of three sampled residents (Resident 1), the facility failed to: 1. Monitor Resident 1 every four hours for Change of Condition (COC - a deterioration in a resident's physical or mental condition) and the check vital signs (temperature, blood pressure, heart rate, pulse, and oxygen saturation [amount of oxygen in the blood]), and immediately provide necessary medical services when Resident 1 had an acute medical COC on [DATE] between 8 a.m. and 8:52 p.m. 2. Implement a physician's order to monitor Resident 1 every four hours for COC. Resident 1 was identified with increased drowsiness/sleepiness on [DATE] between 8 a.m. and 8:52 p.m. 3. Administer intravenous (IV- into a vein [blood vessel]) fluids timely following a physician's order on [DATE] at 11:12 a.m. These deficient practices resulted in Resident 1 being found not breathing and non-responsive to verbal or painful stimuli (a technique used by medical personnel for assessing the consciousness level of a person who is not responding to normal interaction, voice commands or gentle physical stimuli such as shaking of the shoulders) on [DATE] at 8:52 p.m. Resident 1 was transferred to a general acute care hospital (GACH) for evaluation and further care. Findings: A review of Resident 1's Admission Record indicated the facility initially admitted Resident 1 on [DATE] and readmitted Resident 1 on [DATE] with diagnoses including hypothyroidism (a condition when the thyroid gland doesn't make enough thyroid hormone), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). A review of Resident 1's Minimum Data Set (MDS - a standard assessment and care screening tool) dated [DATE], indicated Resident 1 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 1 required extensive two staff assist for bed mobility, dressing and total dependence for transfers. A review of Resident 1's COC document dated [DATE] timed at 11:50 a.m., indicated Licensed Vocational Nurse 1 (LVN 1) documented Resident 1 had gradual (slow progress) altered level of consciousness (AMS - change in mental function that can quickly become life-threatening), and was groaning (deep suffering), weak, drowsy, and responded to verbal and tactile (having to touch) stimuli by moving hands. The COC indicated Resident 1 was offered but pushed away medication, food, and water. LVN 1 documented he (LVN 1) left a message for a physician to call him back and notified Resident 1's family member on [DATE], at 11 a.m. The COC indicated MD (medical doctor) called back (unspecified time) and ordered unspecified IV hydration (fluid) and unspecified blood work to be collected on [DATE] for Resident 1. The COC indicated Resident 1's blood pressure (BP) was ,d+[DATE] millimeters of mercury (mmHg, normal BP -,d+[DATE] mmHg. A review of Resident 1's Order Listing Report dated [DATE] to ,d+[DATE], indicated to monitor abnormal signs/symptoms every shift for . AMS. The order listing report further indicated if . including AMS . increase monitoring to every four hours for Resident 1. A review of Resident 1's physician order dated [DATE] timed at 11:12 a.m., indicated to administer D,d+[DATE]NS (Dextrose and Salt - IV replacement fluid/blood volume expander), at 50 cubic centimeter (cc- unit of measurement) per hour times two liters today ([DATE]) and tomorrow ([DATE]) every shift for hydration until [DATE] . 400 cc per shift (eight hours in a shift). A review of Resident 1's IV Administration Treatment Record for ,d+[DATE], indicated to start D,d+[DATE]NS at 50 cc per hour times two liters today ([DATE]) and tomorrow ([DATE]) for increase in sleepiness every shift for hydration until [DATE] . 400 cc per shift to start on [DATE] at 3 p.m. for Resident 1. The IV administration treatment record indicated X on [DATE] for the day shift (7 a.m. to 3 p.m.) and indicated number 6 and X on [DATE] for the evening shift (3 p.m. to 11 p.m.). The IV administration treatment record chart code X indicated not administered or not ordered for that time frame and number 6 indicated hospitalized for Resident 1. A review of Resident 1's Health Status Note dated [DATE] timed at 3:53 p.m., indicated a RN (Registered Nurse) started new peripheral IV (PIV- away from the center of the body IV) after three attempts to right forearm . with good venous (vein blood) return. The health status note indicated flushed (clear out) IV access with 10 milliliters (ml - unit of measurement) . The health status note did not indicate when and if the IV fluid (D,d+[DATE]NS) was started/administered to Resident 1 or if the RN assessed and recorded Resident 1's vital signs (temperature, blood pressure, pulse, respiration, and oxygen saturation [amount of oxygen in the blood]). A review of Resident 1's Health Status Note dated [DATE] timed at 4 p.m., indicated a RN documented unspecified IV fluid was started at 4 p.m., was infusing (administer into a vein) well for Resident 1. The health status note did not indicate if the RN assessed Resident 1 for COC and recorded Resident 1's vital signs. A review of Resident 1's Health Status Note dated [DATE], did not indicate if a RN assessed Resident 1 or recorded the vital signs for Resident 1 from between 8 a.m. to 8:52 p.m. A review of Resident 1's medical chart, did not indicate if an RN assessed Resident 1 for COC and Resident 1's vital signs on [DATE] between 8 a.m. and 8:52 p.m. A review of Resident 1's Health Status Note dated [DATE] at 8:52 p.m., indicated an RN documented that an unnamed Certified Nursing Assistant (CNA) called the aforementioned RN to check on Resident 1 on [DATE] at 8:30 p.m. The health status note indicated Resident 1 was not breathing and was non-responsive (unconscious, and possibly dead or dying) to verbal or painful stimuli (a technique used by medical personnel for assessing the consciousness level of a person who is not responding to normal interaction, voice commands or gentle physical touch), BP ,d+[DATE] mmHg and paramedics (a trained staff to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) called . The health status note further indicated the paramedics arrived on ,d+[DATE]/ 2021at 8:45 p.m. and assessed Resident 1. The health status note indicated Resident 1 was transported to GACH on [DATE] at 8:45 p.m. A review of Resident 1's GACH ED Notes signed by a Registered Nurse (RN) dated [DATE] timed at 9:38 p.m., indicated Resident 1 Is altered, bradycardic (slow heart rate [pulse]), and hypotensive (low blood pressure) . Left pupil (the center eye through which the light passes through) blown (largely dilated and unresponsive to light) and right pupil pinpoint (remain very small even in bright light). A review of Resident 1's GACH Department of Emergency (ED) Medicine Treatment record dated [DATE] timed at 4:58 a.m., indicated Resident 1 was brought to the ED with complaint of AMS since 6 p.m. The ED medicine treatment note indicated that per Emergency Medical Services (EMS - emergency services that provide urgent pre-hospital treatment and stabilization for serious illness/injuries and transport a person to further care). Resident 1 was bradycardic as low as 35 beats per minute (bpm). The ED medical treatment record further indicated the following interventions were implemented for Resident 1 on [DATE]: -Two (2) liters IV bolus (free flowing) 0.9% NaCL (Sodium Chloride- salt and water) at 9:15 p.m. and 10:32 p.m., -Zosyn (medication to treat infection) IVPB (Intravenous Piggy Bag) 3.375 grams (gm - unit of measurement); and -Vancomycin (medication to treat infection) IVPB 1000 mg at 10:05 p.m. A review of Resident 1's GACH Neurology Consultation Note dated [DATE], indicated Resident 1 was brought in by EMS on [DATE] at 6 p.m. Resident 1 was hypotensive (low blood pressure), obtunded (diminished responsiveness to stimuli), not following commands and a concern for sepsis (the body's extreme response to an infection and is a life-threatening medical emergency) of unknown source and the physician was unable to obtain Resident 1's mental status. Resident 1 was diagnosed with AMS. A review of Resident 1's GACH Neurology Consultation Note dated [DATE], indicated Resident 1 was discharged [DATE] and discharge disposition was Resident 1 expired (died ). On [DATE] at 10:30 a.m., during an interview, the facility's Assistant Medical Records Director (AMRD) stated the facility did not create a care plan for drowsiness/sleepiness based on Resident 1's COC dated [DATE]. The AMRD stated care plans are important for directing and revising care for a resident as needed. On [DATE] at 2 p.m., during a concurrent interview and record review with Licensed Vocational Nurse 1 (LVN 1), Resident 1's COC document dated [DATE] at 11:50 a.m. was reviewed. LVN 1 stated Resident 1 was usually alert, oriented time two to three (name, date/year/ location), was able to feed herself, and enjoyed coloring activity. LVN 1 stated on [DATE] between 8 a.m. and 9 a.m., Certified Nursing Assistant 1 (CNA 1) notified him (LVN 1) that Resident 1 did not eat breakfast and was very sleepy. LVN 1 stated he assessed Resident 1, and Resident 1 was drowsy (sleepy and lethargic- lack of mental alertness), was responding to tactile and verbal stimuli but kept going back to sleep. LVN 1 stated Resident 2 was raising her hands to push food away. LVN 1 stated he did not call 911 (a phone number used to contact the emergency service) to transfer Resident 1 to a GACH because Resident 1 was still responding to tactile and verbal stimuli but kept going back to sleep. LVN 1 stated he contacted and I left a message for Medical Doctor 2 (MD 2 - the on call physician) on [DATE]. LVN 1 stated he informed a supervisor (unidentified) to expect a call back from MD 2. On [DATE] at 10:40 a.m., during a concurrent interview and record review with Assistant Director of Nursing (ADON)., Resident 1's COC dated [DATE] timed at 11:50 a.m., was reviewed. The ADON stated the facility should record vital signs as soon as a resident is identified with COC. The ADON stated the facility's medical director should be contacted and notified of a resident's COC if the primary physician does not call back within 30 minutes. The ADON stated, with a significant change in condition like this (Resident 1's COC), I would immediately send the resident out with paramedics to the hospital. The ADON further stated IV fluids should be started right away as soon as the order is received. The ADON stated Resident 1's COC was identified between 8 a.m., and 9 a.m. on [DATE], after Resident 1 was found collapsed (loss of consciousness) in bed. The ADON stated Resident 1's delayed quality of care was avoidable. The ADON stated Resident 1's progress notes did not indicate if the facility notified the Medical Director that Resident 1 had a COC. The ADON stated, I don't see much documentation. There is no telling what could have happened. There should have been more frequency in documentation for Resident 1. On [DATE] at 2:30 p.m., during an interview, Registered Nurse Supervisor (RNS) stated, IV fluids should be started as soon as I get the order. RNS stated when a resident has COC for AMS we (facility) must call 911 immediately. We don't have to wait for the doctor. A review of facility's Registered Nurse (RN) Job Description revised ,d+[DATE], indicated . the following: 6. Evaluates and monitors residents' condition and provides professional nursing care . 8. Initiates emergency support measures . and physician orders 10. Performs assessment functions including identification changes in the resident's physical or psychological condition (i.e., changes in lab data, vital signs, mental status). 14. Administers medications ordered by the physician. A review of the facility's LVN Job Description updated ,d+[DATE], indicated . Performs interventions and treatments in a timely manner. A review of the facility's policy and procedures (P&P), titled Change of Condition, Resident, revised ,d+[DATE], indicated it is the policy of this facility to identify, inform the physician and resident or resident representative, and intervene to provide medical or nursing care for a resident experiencing an acute medical change of condition in a timely and effective manner. The P&P procedure included: 1. Upon noting or receiving report of a change a resident's physical, mental or psycho social status, the licensed nurse will evaluate the resident's condition. 2. In the event of a life-threatening situation or serious injury, the charge nurse may elect to contact personnel services to assist with care and possible transport to an acute hospital . 6. Continue to monitor and document resident's condition at a minimum of every shift for 72 hours and as needed, until the acute episode has subsided, and the resident is stable.

Based on interview and record review, the facility failed to develop and implement a comprehensive, individualized plan of care for one of three sampled residents (Resident 1), who had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility did not develop a plan of care with the participation of the interdisciplinary team (IDT- A group of experts from various disciplines working together to treat a person's ailment, injury, or chronic [long term] health condition) including the attending physician addressing Resident 1's multiple absences (out of the facility for appointments) which interfered with the administration of antiseizure medications and did not develop interventions such as evaluating Resident 1 for safe self-administration of medications and/or coordinate the scheduled medications with the time of the appointments. Between 8/9/2022 and 9/30/2022, Resident 1 missed 17 doses of [MEDICATION(S)], 22 doses of [MEDICATION(S)], and 12 doses of [MEDICATION(S)] while outside the facility. As a result, Resident 1 experienced falls on 9/7/2022 and 10/1/2022 possibly due to seizures. Resident 1's fall on 10/1/2022, resulted in hospitalization for apparent [CONDITION(S)]. Because of the serious potential harm related to Resident 1's missed medications, on 10/6/2022 at 3:06 pm., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ) Situation (a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) situation on under the 42 Code of Federal Regulations (CFR) S483.21(b) Comprehensive Care Plans (F656) with a scope and severity of J (isolated) in the presence of the Director of Nursing (DON) and the assistant DON (ADON). On 10/7/2022, the facility provided an acceptable Removal Plan. While onsite, the survey team confirmed implementation of the immediate corrective actions through observation, interview, and record review, and on 10/7/2022, at 4:24 pm, the SSA removed the IJ situation in the presence of the DON and the Administrator (ADM). The facility's acceptable IJ Removal Plan included the following: 1. Resident 1 was evaluated by the attending Physician and a Nurse Practitioner (NP) on 10/7/2022. 2. Pharmacy Consultant to review Resident 1's medication regimen on 10/12/2022. 3. On 10/7/2022 Resident 1 was assessed for the ability to self-administer medications and IDT (interdisciplinary Team - professionals from various healthcare disciplines who work in collaboration to care for the residents' needs) determined that Resident 1 was safe to self-administer his own medication while out of the facility with observation of an escort. 4. The IDT met on 10/7/2022 and Resident 1's plan of care was updated to reflect that any time the resident was scheduled to be out of the facility, he (Resident 1) must be escorted by facility staff and if he self-administered medication during this time, it must be observed by the escort. 5. DON/Designee conducted an audit of residents with orders for a temporary leave of absence to ensure that the plan of care reflects alternative interventions are implemented to ensure that medications are administered accordingly and ensure documented in each resident plan of care. 6. DON/Designee provided and will provide all licensed nurses education on care planning addressing medication administration when residents are out of the facility to ensure the continuity of the delivery of pharmaceuticals and that concerns are appropriately escalated and communicated with the pharmacy, the physician and the facility's leadership. 7. All licensed nurses to be re-educated on the facility's policy for developing individualized care plan to ensure residents who go out on pass (OOP) have interventions to ensure alternate medication administration plans are identified. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted Resident 1, on 8/9/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS - a standard assessment and care screening tool) dated 8/13/2022, indicated the resident was able to communicate, make decisions and remember. Resident 1 required supervision with one-person physical assist for bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 1 milligrams (mg- unit dose measurement) give one (1) tablet by mouth two times a day for seizures give two (2) tablets by mouth at bedtime for seizures, [MEDICATION(S)] 100 mg give one (1) tablet by mouth four times a day for seizures; and [MEDICATION(S)] 200 mg give (1) tablet by mouth four times a day for seizures. A review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR further indicated Resident 1 did not receive [MEDICATION(S)] 200 mg 1 tab by mouth on the following dates: 8/9/2022 at 5:00 pm, 8/23/22 at 5:00 pm, 8/24/22 at 5:00 pm, 8/25/2022 at 5:00 pm, 8/26/2022 at 9:00 am, 8/30/2022 at 5:00 pm, 9/8/2022 at 5:00 pm, 9/14/2022 at 5:00 pm, 9/15/2022 at 5:00 pm, 9/22/2022 at 5:00 pm, 9/27/2022 at 5:00 pm; and 9/29/2022 at 5:00 pm. A review of Resident 1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR further indicated Resident 1 did not receive [MEDICATION(S)] 100 mg tablet by mouth on the following dates: 8/9/2022 at 5:00 pm, 8/24/2022 at 5:00 pm, 8/25/2022 at 5:00 pm and 9:00 pm, 8/26/2022 at 9:00 am and 1:00 pm, 8/30/2022 at 5:00 pm, 9/8/2022 at 5:00 pm and 9:00 pm, 9/13/2022 at 1:00 pm, 9/14/2022 at 1:00 pm and 5:00 pm, 9/15/2022 at 1:00 pm and 5:00 pm, 9/22/2022 at 5:00 pm, 9/27/2022 at 1:00 pm and 9:00 pm; and 9/29/2022 at 1:00PM and 5:00 pm. A review of Resident 1's MRA, dated 8/9/2022 to 9/30/2022, indicated 11-off unit and or 9-other/see nurse notes. The MAR further Resident 1 did not receive [MEDICATION(S)] 1mg tablet by mouth on the following dates: 8/9/2022 at 5:00 pm, 8/23/2022 at 5:00 pm, 8/24/2022 at 5:00 pm, 8/25/2022 at 5:00 pm and 9:00 pm, 8/26/2022 at 9:00 am, 8/30/2022 at 5:00 pm, 9/8/2022 at 5:00 pm and 9:00 pm, 9/14/2022 at 5:00 pm, 9/15/2022 at 5:00 pm, 9/17/2022 5:00 pm, 9/18/2022 at 9:00 am and 5:00 pm, 9/22/2022 at 5:00 pm, 9/27/2022 at 5:00 pm; and 9/29/2022 at 5:00 pm., 9/30/2022 at 9:00 pm. A review of Resident 1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 8/23/2022 at 9:00 pm, 8/25/2022 at 9:00 pm, 9/17/2022 at 9:00 pm, 9/8/2022 at 9:00 pm, 9/18/2022 at 9:00 pm; and 9/30/2022 at 9:00 pm. A review of Resident 1's Change of Condition (COC) dated 9/7/2022 timed at 3:35 pm, indicated the resident stated he lost his balance when he got out of bed, fell , and hit the right side of his ribs on the footboard of his bed. The physician was notified, and no new orders were received. A review of Resident 1's COC dated 9/15/2022 at 10:00 pm, indicated Resident 1 reported that he fell on the floor in the hallway trying to sit in his wheelchair after he came back from the doctor's (dr) at around 9:45 pm. Resident 1 was able to help himself up back to the wheelchair unassisted. A Certified Nurse Assistant (CNA) wheeled Resident 1 to his room. Upon assessment, the charge nurse found redness and minimal abrasions on Resident 1's back. Resident 1 complained of pain on his right side of his back from previous fall on 9/17/2022. Medical Doctor was notified. A review of Resident 1's plan of care titled The resident claimed he fell in his room with no injury, poor balance, dated 9/15/2022, indicated the goals included Resident 1 to resume usual activities without further incident through the review date. The interventions included assessing the wheelchair for safety, check Resident 1's range of motion, monitor/document/report to the physician signs and symptoms of pain, bruises (an injury appearing as an area of discolored skin on the body, caused by a blow or impact rupturing underlying blood vessels), change in mental statues, new onset of confusion, sleepiness, inability to maintain posture, and agitation. A review of Resident 1's plan of care titled The resident has [CONDITION(S)] r/t (related to) disease process, dated 9/16/2022, indicated the goal included Resident 1 will be free from injury from [CONDITION(S)] activity through the review date. The interventions included giving the medications as ordered and monitoring/documenting effectiveness and side effects. A review of Resident 1's plan of care titled . warning for use of [MEDICATION(S)] ([MEDICATION(S)]) indication: [CONDITION(S)], dated 9/16/2022, indicated the goal included Resident 1 will not experience side effects/interactions with the use of [MEDICATION(S)] ([MEDICATION(S)]). The interventions included to administer medication as ordered, monitor signs (is something found during a physical exam or from a laboratory test that shows that a person may have a condition or disease) and symptoms of adverse effect (An unexpected medical problem that happens during treatment with a drug or other therapy) and notify the physician if Resident 1 experienced signs of adverse effects from [MEDICATION(S)]. A review of Resident 1's COC dated 10/1/2022 at 12:39 PM, indicated Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) for evaluation due to alleged fall incident. A review of GACH 1's history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 reported falling because he had a [CONDITION(S)] while lying in the bed and rolled off the bed. Resident 1 reported a headache, neck, and back pain. Resident 1 reported he had been missing his [CONDITION(S)] medications while at the facility. Resident 1 appeared to have a breakthrough [CONDITION(S)] (seizures that occur in a person who had previously good consistent control of [CONDITION(S)] documented in the medical records and then gets another [CONDITION(S)]). Resident 1 was instructed to follow up with neurology (branch of medicine dealing with disorders of the nervous system). On 10/3/2022 at 5:20 pm, during an interview, Resident 1 stated he fell three times since his admission to the facility and the falls were related to having seizures because of missing several medications while in the facility. Resident 1 stated he knew when a [CONDITION(S)] is about to happen. Resident 1 stated he fell out of the bed and landed on his back and hit his head on 10/1/2022. Resident 1 stated, he had a brain injury when he was [AGE] years old and currently was prescribed [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)], which have managed his seizures. Resident 1 stated Licensed Vocational Nurses 1, 2, and 3 (LVN 1, LVN 2, and LVN 3) refused to give him his medications when he goes out for doctors' appointments because the medications, are controlled. Resident 1 stated when he returns to the facility and asks the nurses to give him his antiseizure medications, the nurses would not administer his medications because the medications were on a timed schedule. Resident 1 stated he discussed on several occasions with the former ADM and with the DON his concerns with the missing medications and the fact that his attending physician had not come to the facility to see him. Resident 1 stated he has not seen a physician since admission on 8/9/2022. Resident 1 stated this was the reason he was scheduling and coordinating his own medical care outside of the facility. Resident 1 stated he made his own transportation arrangements because the facility refused to help him. On 10/4/2022 at 11:28 am, during an interview, LVN 1 stated she did not administer Resident 1's [CONDITION(S)] medications when he goes out for his appointments. LVN 1 stated, she did not contact or notified Resident 1's physician that the resident had been missing (not administered) his medications. LVN 1 stated the facility did not arrange for Resident 1 to receive/continue taking his antiseizure medications when goes out. On 10/4/2022 at 3:06 pm, during an interview with the DON and concurrent review of Resident 1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON acknowledged Resident 1 had missed multiple doses of [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] medications. The DON stated missing so many doses could result in Resident 1 having seizures and did not follow up with Resident 1's physician. On 10/4/2022 at 3:37 pm, during an interview, LVN 2 stated she did not call Resident 1's physician to come and evaluate Resident 1 and about the missed doses of antiseizure medications. LVN 2 stated missing antiseizure medications could result in seizures. On 10/4/2022 at 5:35 pm., during an interview, LVN 3 stated she did not notify the attending physician or the DON about Resident 1's missed antiseizure medications when he was absent from the facility. LVN 3 stated there was no care plan developed to address the residents' multiple absences from the facility and how to proceed with the medications scheduled when Resident 1 was out. On 10/6/2022 at 11:03 pm, during an interview, the DON stated the LVNs did not communicate to her that Resident 1 had been missing his antiseizure medications. The DON stated, the nurses must notify the medical doctor for any medications that the resident (Resident 1) will be missing, and this did not happen. The DON acknowledged the licensed nurses failed to develop a care plan to ensure Resident 1 did not miss his antiseizure medications whenever Resident 1 was away from the facility. The DON stated she did not inform the physician that Resident 1 leaves the facility for outside appointments and would missing his antiseizure medications. The DON acknowledged and stated that licensed nurses did not coordinate Resident 1's medical care appropriately by failing to develop a care plan to address Resident 1's appointments and missed antiseizure medications. On 10/6/2022 at 1:16 pm, during an interview, the Director of Rehabilitation (DOR) stated Resident 1 was discharged from physical therapy (PT - therapy to preserve, enhance, or restore movement and physical function impaired or threatened by disease, injury, or disability) on 9/15/2022 because Resident 1 met all his physical therapy goals. The DOR stated she was aware Resident 1 had reported about his falls on 9/7/2022 and 10/1/2022. The DOR stated a physical therapist assessed Resident 1 after the fall and determined the resident no longer qualified for PT. The DOR stated she did not believe Resident 1's falls were because of the resident's gait or mobility issues, but a result of seizures. A review of the facility's policy and procedures titled, Care Plan Goals and Objectives dated November 2012, indicated care plans will incorporate goals and objectives which lead to the resident's highest obtainable level of function. Procedure: Goals and/or objectives are resident oriented, behavioral stated, measurable, and within a specific time frame. Goals and/or objectives may be available in the care plan and be reviewed by all staff involved in the resident's care. Goal and/or objectives are reviewed and revised: when there has been a significant change in the resident's condition, when the resident has been readmitted to the facility from a hospital and at least quarterly. A review of the facility's policy and procedures titled, Medication Administration-General Guidelines dated April 2008 indicated medications are administered as prescribed . Medications are administered in accordance with written orders of the attending physician. Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after), except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by a prescriber, routine medications are administered according to the established medication administration for the facility. Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (e.g., the resident is not in the facility at scheduled dose time), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had diagnosis of [CONDITION(S)] (sudden, uncontrolled electrical disturbance in the brain that can cause changes in movements [convulsions] and levels of consciousness [alertness]) received medications as ordered to meet the resident's needs. The facility did not administer or make arrange for Resident 1 to receive [MEDICATION(S)] (clonazepan - anti [CONDITION(S)] medication), [MEDICATION(S)] ([MEDICATION(S)] - antiseizure medication) and [MEDICATION(S)] ([MEDICATION(S)] - antiseizure medication) between 8/9/2022 and 9/30/2022, while Resident 1 was absent (gone for medical appointments) from the facility. Resident 1 missed 17 doses of [MEDICATION(S)], 22 doses of [MEDICATION(S)], and 12 doses of [MEDICATION(S)]. As a result, Resident 1 experienced falls on 9/7/2022 and 10/1/2022 possibly due to seizures, was hospitalized on [DATE], and was at increased risk for breakthrough seizures due to missing aforementioned antiseizure medications. Because of the serious potential harm related to Resident 1's missed medications, on 10/6/2022 at 3:06 pm., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ) Situation (a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) under the 42 Code of Federal Regulations (CFR) S483.45 Pharmacy Services (F755), with a scope and severity of J (isolated) in the presence of the Director of Nursing (DON) and the assistant DON (ADON). On 10/7/2022, the next day, the facility provided an acceptable Removal Plan. While onsite, the survey team confirmed implementation of the immediate corrective actions through observation, interview, and record review, and on 10/7/2022, at 1:27 pm, the SSA removed the IJ situation in the presence of the DON and the Administrator (ADM). The facility's acceptable IJ Removal Plan included the following: 1. Resident 1 was evaluated by the attending Physician and a Nurse Practitioner (NP) on 10/7/2022. 2. Pharmacy Consultant to review Resident 1's medication regimen on 10/12/2022. 3. On 10/7/2022 Resident 1 was assessed for the ability to self-administer medications and IDT (interdisciplinary Team - professionals from various healthcare disciplines who work in collaboration to care for the residents' needs) determined that Resident 1 was safe to self-administer his own medication while out of the facility with observation of an escort. 4. On 10/7/2022 Resident 1's plan of care was updated to reflect that any time resident was scheduled to be out of the facility. Resident 1 must be escorted by facility staff member and that if he self-administers medication during this time, it must be observed by the escort. 5. DON/Designee conducted an audit of residents with orders for a temporary leave of absence to ensure that the plan of care reflects alternative interventions are implemented to ensure that medications are administered accordingly. 6. An audit of residents with orders to go out on pass will be conducted to ensure that each resident care plan include alternates medication administration interventions. 7. The facility will re-educate the licensed nurses on medication administration when residents go out on temporary pass, medication administration, and pharmaceutical policies. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted Resident 1, on 8/9/2022 with diagnoses including traumatic brain injury (brain dysfunction caused by an outside force), seizures, attention-deficit [CONDITION(S)] disorder (a chronic condition including attention difficulty, [CONDITION(S)], and impulsiveness), history of falling, and depression (a mental health disorder characterized by persistently low mood and loss of interest in daily activities). A review of Resident 1's Minimum Data Set (MDS - a standard assessment and care screening tool) dated 8/13/2022, indicated the resident was able to communicate, make decisions and remember. Resident 1 required supervision with one-person physical assist for bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of the Physician's Orders for Resident 1, dated 8/9/2022, indicated the resident to receive the following medications: [MEDICATION(S)] 1 milligrams (mg) give one (1) tablet by mouth two times a day for seizures 1mg give two (2) tablets by mouth at bedtime for seizures; [MEDICATION(S)] 100 mg give one (1) tablet by mouth four times a day for seizures; and [MEDICATION(S)] 200 mg give (1) tablet by mouth four times a day for seizures. A review of Resident 1's Medication Administration Record (MAR) dated for the month of 8/2022 to 9/30/2022, indicated 11-off unit and or 9-other/see nurse notes. The MAR further indicated Resident 1 did not receive [MEDICATION(S)] 200 mg 1 tab by mouth on the following dates: 8/9/2022 at 5:00 pm, 8/23/22 at 5:00 pm, 8/24/22 at 5:00 pm, 8/25/2022 at 5:00 pm, 8/26/2022 at 9:00 am, 8/30/2022 at 5:00 pm, 9/8/2022 at 5:00 pm, 9/14/2022 at 5:00 pm, 9/15/2022 at 5:00 pm, 9/22/2022 at 5:00 pm, 9/27/2022 at 5:00 pm; and 9/29/2022 at 5:00 pm. A review of Resident 1's MAR dated from 8/9/2022 to 9/30/2022, indicated 11-off unit and or 9-other/see nurse notes. The MAR further indicated Resident 1 did not receive [MEDICATION(S)] 100 mg tablet by mouth on the following dates: 8/9/2022 at 5:00 pm, 8/24/2022 at 5:00 pm, 8/25/2022 at 5:00 pm and 9:00 pm, 8/26/2022 at 9:00 am and 1:00 pm, 8/30/2022 at 5:00 pm, 9/8/2022 at 5:00 pm and 9:00 pm, 9/13/2022 at 1:00 pm, 9/14/2022 at 1:00 pm and 5:00 pm, 9/15/2022 at 1:00 pm and 5:00 pm, 9/22/2022 at 5:00 pm, 9/27/2022 at 1:00 pm and 9:00 pm; and 9/29/2022 at 1:00 pm and 5:00 pm. A review of Resident 1's MAR, dated 8/9/2022 to 9/30/2022 indicated 11-off unit and or 9-other/see nurse notes. The MAR further indicated Resident 1 did not receive [MEDICATION(S)] 1mg tablet by mouth on the following dates: 8/9/2022 at 5:00 pm, 8/23/2022 at 5:00 pm, 8/24/2022 at 5:00 pm, 8/25/2022 at 5:00 pm and 9:00 pm, 8/26/2022 at 9:00 am, 8/30/2022 at 5:00 pm, 9/8/2022 at 5:00 pm and 9:00 pm, 9/14/2022 at 5:00 pm, 9/15/2022 at 5:00 pm, 9/17/2022 5:00 pm, 9/18/2022 at 9:00 am and 5:00 pm, 9/22/2022 at 5:00 pm, 9/27/2022 at 5:00 pm, 9/29/2022 at 5:00 pm; and 9/30/2022 at 9:00 pm. A review of Resident 1's MAR dated from 8/9/2022 to 9/30/2022, indicated 11-off unit and or 9-other/see nurse notes. The MAR further indicated Resident 1 did not receive [MEDICATION(S)] 2 mg tablet by mouth on the following dates: 8/23/2022 at 9:00 pm, 9/8/2022 at 9:00 pm, 9/17/2022 at 9:00 pm, 9/18/2022 at 9:00 pm; and 9/30/2022 at 9:00 pm. A review of Resident 1's Change of Condition (COC) dated 9/7/2022 timed at 3:35 pm, indicated the resident stated he lost his balance when he got out of bed, fell , and hit the right side of his ribs on the footboard of his bed. The physician was notified, and no new orders were received. A review of Resident 1's COC dated 9/15/2022 at 10:00 pm, indicated Resident 1 reported to the charge nurse that he fell in the hallway trying to sit in his wheelchair after returning from a medical appointment around 9:45 pm. Resident 1 was able to help himself up back to the wheelchair unassisted. A Certified Nurse Assistant (CNA) wheeled Resident 1 to his room. Upon assessment, the charge nurse found redness and minimal abrasions on Resident 1's back. Resident 1 complained of pain on his right side of his back from previous fall on 9/17/2022. Medical Doctor was notified. A review of Resident 1's COC dated 10/1/2022 at 12:39 PM, indicated Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) for evaluation due to alleged fall incident. A review of GACH 1's History and Physical examination for Resident 1, dated 10/1/2022, indicated the resident presented to the emergency department with neck and back pain after ground level fall. Resident 1 reported falling because he had a [CONDITION(S)] while lying in the bed and rolled off the bed. Resident 1 reported a headache, neck, and back pain. Resident 1 reported he had been missing his [CONDITION(S)] medications while at the facility. Resident 1 appeared to have a breakthrough [CONDITION(S)]) seizures that occur in a person who had previously good consistent control of [CONDITION(S)] documented in the medical records and then gets another [CONDITION(S)]). Resident 1 was instructed to follow up with neurology (branch of medicine dealing with disorders of the nervous system). On 10/3/2022 at 5:20 pm, during an interview, Resident 1 stated he fell three times since his admission to the facility and the falls were related to having seizures because of missing several medications while in the facility. Resident 1 stated he knew when a [CONDITION(S)] is about to happen. Resident 1 stated he fell out of the bed and landed on his back and hit his head on 10/1/2022. Resident 1 stated, he had a brain injury when he was [AGE] years old and currently was prescribed [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)], which have managed his seizures. Resident 1 stated Licensed Vocational Nurses 1, 2, and 3 (LVN 1, LVN 2, and LVN 3) refused to give him his medications when he goes out for doctors' appointments because the medications, are controlled. Resident 1 stated when he returns to the facility and asks the nurses to give him his medications, the nurses would not administer his medications because the medications were on a timed schedule. Resident 1 stated he discussed on several occasions with the former ADM and with the DON his concerns with the missing medications and the fact that his attending physician had not come to the facility to see him. Resident 1 stated he went for a consult outside the facility and the physician gave him Avoay (migraine medication) which he gave to a nurse (unable to recall the nurses name) to keep in the facility's refrigerator and they still have not given me that medication. Resident 1 stated he has not seen a physician since admission on 8/9/2022. Resident 1 stated this was the reason he was scheduling and coordinating his own medical care outside of the facility. On 10/4/2022 at 9:17 AM, during an interview, the DON stated the facility was unable to locate requested medication pharmacy delivery receipts for Resident 1. On 10/4/2022 at 11:28 am, during an interview, Licensed Vocational Nurse 1 (LVN 1) stated she did not administer Resident 1's [CONDITION(S)] medications when he goes out for his appointments. LVN 1 stated, she did not contact or notified Resident 1's physician that the resident had been missing (not administered) his medications. LVN 1 stated the facility did not arrange for Resident 1 to receive/continue taking his anti-[CONDITION(S)] medications when goes out. On 10/4/2022 at 11;28 am, during a concurrent interview and observation, the Evaluator and LVN 1 checked and found Resident 1's [MEDICATION(S)] (preventive treatment of migraine in adults) in the facility's refrigerator. LVN 1 stated she was not aware that [MEDICATION(S)] was in the refrigerator and that there was no physician's order to administer [MEDICATION(S)] to Resident 1. On 10/4/2022 at 3:06 pm, during an interview with the DON and concurrent record review of Resident 1's MAR, the DON stated she was not aware Resident 1 was not receiving anti- [CONDITION(S)] medications. The DON acknowledged Resident 1 had missed multiple doses of [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] medications previously aforementioned. The DON stated missing so many doses could result in Resident 1 having seizures. The DON stated she was aware Resident 1's attending physician had not visited Resident 1 since his admission to the facility. The DON stated she did not follow up with the physician because she delegated the task (to follow up with the physician) to LVN 2. On 10/4/2022 at 3:37 pm, during an interview, LVN 2 stated Resident 1's physician had not visited the resident since admission and Medical Records Department was responsible to contact the residents' medical doctors whenever they did not come to the facility to visit their residents. LVN 2 stated she did not call Resident 1's physician to come and evaluate Resident 1 and about the missed doses of anti-[CONDITION(S)] medications. LVN 2 stated missing anti-[CONDITION(S)] medications could result in seizures. On 10/4/2022 at 5:35 pm., during an interview, LVN 3 stated she did not notify the attending physician, or the DON Resident 1 had missed and was not receiving his anti-[CONDITION(S)] medications whenever Resident 1 was absent from the facility. On 10/6/2022 at 11:03 pm, during an interview, the DON stated the LVNs did not communicate to her that Resident 1 had been missing his anti-[CONDITION(S)] medications. The DON stated, the nurses must notify the medical doctor for any medications that the resident (Resident 1) will be missing, and this did not happen. On 10/6/2022 at 1:16 pm, during an interview, the Director of Rehabilitation (DOR) stated Resident 1 was discharged from physical therapy (PT - therapy to preserve, enhance, or restore movement and physical function impaired or threatened by disease, injury, or disability) on 9/15/2022 because Resident 1 met all his physical therapy goals. The DOR stated she was aware Resident 1 had reported about the resident's falls on 9/7/2022 and 10/1/2022. The DOR stated a physical therapist assessed Resident 1 after the fall and determined the resident no longer qualified for PT. The DOR stated she did not believe Resident 1's falls were because of the resident's gait or mobility issues, but a result of seizures. On 10/20/2022 at 2:05 p.m., during a telephone interview and Resident 1's medication record review, the Pharmacy Consultant (PC) stated the responsibilities of a pharmacy consultant included but are not limited to reviewing all medications, checking storage, educating the nurses, checking on drug interaction. The PC stated she reviewed medications for Resident 1 for the month of August 2022 to date. The PC stated, as far as missed doses, there was a lot of charting gaps. The PC stated, I brought this up with the DON. The PC acknowledged and stated, that there was a very significant amount of missed anti-[CONDITION(S)] medication which places Resident 1 at risk for break through [CONDITION(S)]. On 10/21/2022 at 12:36 p.m., during a telephone interview, the Medical Doctor (MD) stated that one of the responsibilities of the Medical Director is to oversee medical care for the residents. MD 1 stated the facility notified him that a physician had seen Resident 1 and that Resident 1 had requested for a change in the attending physician. MD 1 stated, I am not sure when I was notified that he has not seen a physician I have to look through my records. MD 1 stated, I know what you are trying to get me to say but the physician attested to coming in to see the resident twice and both times he was out for appointments when asked if he (MD 1) had seen Resident 1 after he learnt that Resident 1 had not been seen by a physician. The surveyor notified MD 1 that there was no documented evidence to show that MD 2 ever saw/visited Resident 1, and that licensed staff at the facility had also stated that no physician had seen/visited Resident 1 in the facility. MD 1 stated he (MD 2) attested to coming in to see him (Resident 1) and I believe that. The surveyor informed MD 1 that the only documented evidence was on the progress note by MD 3's Nurse Practitioner (NP) Progress dated 9/22/2022 when CDPH surveyors were onsite to investigate the complaint. The surveyor further informed MD 1 that the NP saw/visited Resident 1 in the interim while Resident 1 waited for a change in physician request to go through/processed. MD 1 stated No because he (Resident 1) had requested for a change in physician. I was one of the options and he didn't choose me. Also, I was his physician at the time of his (Resident 1) admission but he (Resident 1) requested to continue with MD 2 from the hospital and since he was on our physician list, we granted him his request. A review of the facility's policy and procedure titled, Medication Administration-General Guidelines dated 4/2008 indicated medications are administered as prescribed . Medications are administered in accordance with written orders of the attending physician. Medications are administered within 60 minutes of schedules time (1 hour before and 1 hour after), except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by a prescriber, routine medications are administered according to the established medication administration for the facility. Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (e.g., the resident is not in the facility at scheduled dose time), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN (as necessary) documentation. A review of the facility's policy and procedures titled, Change of Condition dated 11/2017, indicated it is the policy of the facility to identify, inform the physician and resident or resident representative, and intervene to provide medical or nursing care for a resident experiencing an acute medical change of condition in a timely and effective manner. The facility must notify the resident's physician of the clinical findings and note/ implement new orders given by the physician. Include information regarding the resident's allergies, advance directives, or level of care wishes., and any other pertinent information as it pertains to the change of condition, when reviewing the change of condition with the physician.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had severely impaired cognition (the person is unable to remember, learn, understand the meaning or importance of things and situations, communicate needs and wants, and make decisions) was not subjected to physical and mental abuse inflicted by Certified Nurse Assistant 1 (CNA 1). On 1/29/2022 between 5 am and 6 am, CNA 1 slapped Resident 1 on her face with an open hand and threatened the resident with taking the resident's eyes out. As a result, Resident 1 was subjected to physical and mental abuse by CNA 1 while under the care of the facility. Based on the reasonable person concept, due to Resident 1's severely impaired cognition and medical condition, an individual subjected to physical assault and threatened with inflicting harm had physical pain and psychological effects including feelings of fear, hopelessness, helplessness and humiliation. Findings: A review of Resident 1's Admission Record indicated the facility readmitted Resident 1 on 12/7/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Quarterly Minimum Data Set (MDS - a standardized assessment and screening tool) dated 1/20/2022 indicated Resident 1 had severely impaired cognition (unable to answer questions) and was totally dependent on staff for personal hygiene, bathing, transfers, and toilet use. A review of the facility's Investigation Summary and Conclusion letter dated 2/3/2022 indicated that on 1/29/2022 the Administrator received a report from a Charge Nurse reporting that one of the CNAs (CNA3 - new staff in orientation) reported observing CNA 1 hitting Resident 1 in the mouth with an open hand during care. CNA 3 described how CNA 1 hit Resident 1 in the mouth as the resident was trying to spit at CNA 1 during care. CNA 3 was assisting CNA 1 to change the resident (resident's garments). CNA 1 made a verbal threat to the resident that if she tried to spit at her again, she would harm the resident. A review of CNA 3's written statement, dated 1/31/2022 and timed at 11:30 am, indicated that on 1/29/2022 around 5 am to 6 am, she was asked to assist CNA 1 to change Resident 1. While CNA 3 was holding the resident's legs and saw Resident 1 trying to spit at CNA 1. CNA 3 heard CNA 1 telling Resident 1, You are not going to spit at me. After that, CNA 3 saw CNA 1 slap Resident 1 on the face with an open hand. CNA 1 and Resident 1 started an argument, and CNA 1 told the resident if she spat at her again, she would take her eyes out. During a telephone interview on 3/21/2022 at 8:40 AM, CNA 3 confirmed witnessing the verbal and physical abuse CNA 1 inflicted on Resident 1 the morning of 1/29/2022 and reporting the abuse to the charge nurse. CNA 3 also stated she (CNA 3) no longer worked at the facility. During an interview on 4/19/2022 at 12:26 PM, the Administrator (ADM) confirmed receiving the report of the verbal and physical abuse inflicted to Resident 1 on 1/29/2022. The ADM stated he interviewed CNA 1, who denied slapping and threatening Resident 1. CNA 1 stated she noticed the resident was trying to spit at her and she quickly reacted and utilized a gown to cover Resident 1's mouth to prevent from spitting. The ADM asked both CNAs (CNAs 1 and 3) to demonstrate how they were situated upon providing care and how the incident happened and CNA 1's demonstration did not make sense. The ADM stated that in his opinion, CNA 3's statement and demonstration was likely to be true. The ADM stated he terminated CNA 1's employment for Resident 1's safety. A review of facility's policy and procedure titled, Abuse Prohibition and Prevention Policy and Procedures, revised on 3/2018 indicated the facility prohibits and prevents abuse, neglect, and exploitation of residents and misappropriation of resident's property. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family member s or legal guardians, friends, or other individuals. All employees and volunteers will be oriented to their role in abuse prevention as mandated reporters and the abuse will not be tolerated in this facility. Orientation program upon hire will include review of facility`s policy on prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property and exploitation, recognizing signs of abuse, reporting abuse and to whom and when staff and others must report their knowledge related to an alleged violation without fear of reprisal, understanding behavioral symptoms of residents, include but not limited to aggressive and/or catastrophic reactions of residents, wandering or elopement type behaviors, resistance to care, outbursts or yelling out, and difficulty in adjusting to new routines or staff, and to recognize signs of burnout, frustration and stress that may lead to abuse.

Based on interview and record review, the facility failed to identify and ensure one of three sampled residents (Resident 1), who was at risk for complications of [CONDITION(S)] (damaged kidneys cannot filter blood as needed causes risks of high blood pressure and heart disease) and [CONDITION(S)] (method of treating kidney disease by using a machine to remove waste material from the kidneys) received care, treatment, and services in accordance with the physician ' s order and policy and procedure by failing to: -Implement the treatment consistent with the physician ' s order by administering Tylenol (a medication used to relieve pain and reduce fever) to Resident 1 for elevated temperature on [DATE] and [DATE], per the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -Implement physician ordered laboratory services on [DATE] to obtain Resident 1 ' s blood culture (a test to detect the presence and identify of bacteria or fungi in the blood and to guide treatment), Complete Blood Count (CBC, a blood test that would help healthcare providers detect a range of disorders and conditions.), and Comprehensive Metabolic Panel (CMP, a group of blood tests that provide an overall picture of the body's chemical balance and metabolism). -Implement the Nephrologist ' s (a physician that specializes in treating diseases of the kidney [an organ found just below the rib cage]) order on [DATE] and the physician ' s order on [DATE] to transfer Resident 1 to the general acute care hospital (GACH). -Implement the facility ' s policy and procedure, titled Change of Condition, to inform the physician (of the resident ' s change of condition) to provide medical care for a resident experiencing an acute (sudden) medical change of condition in a timely (without wasting time) and effective manner. As a result, on [DATE] at 3:14 a.m., Resident 1 was found with a body temperature of 100.6 degrees (?) Fahrenheit (F, normal range is 97.8° F to 99°F), blood pressure (BP) of ,d+[DATE] millimeters of mercury (mmHg, normal BP is ,d+[DATE] mmHg), oxygen saturation of 76% (normal range is between 95 to 100%, measure of how much oxygen is in the blood), and blood sugar level of 26 milligram per deciliter (mg/dl, normal is 70 to 120 mg/dl).Resident 1 was transferred by the paramedics (a healthcare professional whose primary role is to provide advanced emergency medical care for critical and emergent residents or patients) to GACH where Resident 1 required emergency intubation (medical procedure where a flexible tube inserted into the windpipe to help with breathing and connected to a breathing machine), was admitted to the intensive care unit (ICU, a unit in the hospital that provides critical care and life support to patients with serious condition, such as serious infection) and expired on the same day due to bacteremia (presence of bacteria in the circulating blood) at 11:48 p.m. Findings: A review of the Admission Record indicated the facility admitted Resident 1 on [DATE] and readmitted the resident on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the care plan, revised on [DATE], indicated Resident 1 had a potential for complications of [CONDITION(S)] and or [CONDITION(S)] and the care plan interventions indicated to call Nephrologist and Physician for any changes in Resident 1 ' s condition. The interventions also indicated to communicate with the [CONDITION(S)] center staff Resident 1 ' s plan of care, laboratory values, and other changes via resident condition. A review of the Minimum Data Set (MDS, an assessment and care screening tool), dated [DATE], indicated Resident 1 was alert and oriented to year and month and required two or more people for physical assistance with bed mobility. The MDS indicated under health conditions that Resident 1 had a major surgery and a feeding tube. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the History and Physical, dated [DATE], indicated Resident 1 had the capacity to understand and make decisions. According to a review of the Change in Condition (COC) form, dated [DATE] at 10:38 p.m., Resident 1 vomited once, had a temperature of 101.5 degrees Fahrenheit, and the physician was notified at 11 p.m. The COC did not indicate the physician gave orders. A review of the coronavirus disease 2019 (COVID-19, a highly contagious infection affecting the respiratory (breathing) system caused by a virus that can spread from person to person) Nursing Home / Skilled Nursing Facility Daily Communication Worksheet dated [DATE], untimed, indicated Resident 1 had a temperature of 101 degrees F. A COVID-19 rapid test was performed at 9:50 a.m. and indicated a negative result. A review of the [CONDITION(S)] Communication Record / Nurses Note, dated [DATE] at 11:22 a.m., indicated the Nephrologist was aware Resident 1 had a fever and tested negative for COVID, and gave an order to send Resident 1 to GACH after [CONDITION(S)]. A review of the Progress Notes, dated [DATE] at 4:29 p.m., indicated the [CONDITION(S)] center notified the facility that Resident 1 ' s Nephrologist had a concern that Resident 1 may have bacteremia. The Physician was notified and gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation regarding Resident 1 going to the GACH per the Nephrologist ' s order. A review of the Progress Notes, dated [DATE] at 11:35 p.m., indicated Resident 1 returned to the facility at 6 p.m. from [CONDITION(S)] and had a temperature of 101.7 degrees F. Tylenol was given and at 8:30 p.m. the temperature dropped to 100.3 degrees F. The family member (FM 1) requested to speak to the primary physician to ask if Resident 1 can be transferred to GACH 1. A voicemail was left for the Physician. There was no documentation found that the Physician returned the call or there was a follow up call made to the Physician. There was no documentation regarding Resident 1 going to GACH per the Nephrologists order. A review of the Progress Notes dated [DATE] at 9:43 a.m. indicated Resident 1 ' s temperature was 102 degrees F. Tylenol was given, and cooling measures were provided. According to a review of the Progress Notes dated [DATE] at 10:27 a.m., Resident 1 ' s Physician gave an order to transfer Resident 1 to GACH 1 (approximately 18 hours from when the call was first made to the physician [on [DATE] at 4:29 p.m.] and over 23 hours since the Nephrologist indicated Resident 1 may have bacteremia [on [DATE] at 11:22 a.m.]) due to fever, rule out [CONDITION(S)] (a life-threatening medical emergency due to infection). A review of the medical record indicated Resident 1 ' s temperature was not re-assessed on [DATE] from 10:30 a.m. to 1:30 p.m. A review of the Progress Notes, dated [DATE] at 1:25 p.m., indicated a transportation was booked to transfer Resident 1 to GACH 1 with an estimated arrival time between two to three hours. A review of the Progress Notes, dated [DATE] at 1:56 p.m., indicated Resident 1 had a BP of ,d+[DATE] mmHg, pulse 97 beats per minute or bpm (normal pulse is 60 to 80), temperature of 99.2 degrees F. A review of the Progress Notes, dated [DATE] at 2:17 p.m., indicated FM 1 was notified that Resident 1 will be transferred to GACH 1. No other documentation was found regarding any transportation problems (the ambulance did not arrive at the facility), or that the facility called the ambulance company to follow up. No documentation was found that the Physician or family were notified regarding the delayed arrival of the ambulance (approximately 4 hours later). A review of the Progress Notes, dated [DATE] at 3:14 a.m., indicated Resident 1 had a temperature of 100.6 degrees F, pulse rate of 104 bpm, respiratory rate of 16 breaths per minute (normal rate is 12 to 16 breaths per minute), blood pressure of ,d+[DATE] mmHg, oxygen saturation of 76% and blood sugar level of 26 mg/dl. The Notes indicated the paramedics were called. A review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The Notes indicated the Physician ordered stat (with no delay) CBC, CMP and blood culture tests but the tests were not collected from the resident. The Notes indicated on [DATE] at 2 p.m., transportation was coordinated and discussed with Licensed Vocational Nurse 1 (LVN). Resident 1 had an accepting physician at GACH 1, and the plan of care was discussed with the family member who agreed with the transfer. The Notes indicated Resident 1 ' s vital signs were stable and emergency transfer was not indicated. On [DATE], the facility informed the Physician that the transfer (ordered on [DATE]) of Resident 1 to GACH did not happen. Resident 1 was instead transferred to GACH 1 by paramedics (on [DATE]) and admitted to GACH 1 (on [DATE]) in critical condition. The Notes indicated the facility did not notify the physician that the resident was not transferred to GACH on [DATE]. According to a review of the Prehospital Care Report Summary, dated [DATE], Resident 1 had altered level of consciousness (ALOC) due to [CONDITION(S)] (blood sugar drops below a healthy range that can be dangerous requiring immediate treatment). The Report Summary indicated facility staff (LVN 2) was making rounds and found Resident 1 weak with blood sugar level of 26 mg/dl, oxygen saturation of 76% in room air and the resident was given [MEDICATION(S)] (an emergency medicine used to treat severe low blood sugar). The blood sugar increased to 56 mg/dl (after administration of [MEDICATION(S)]). Resident 1 had a temperature of 100.1 degrees F prior to the paramedics ' arrival. The paramedics were informed that Resident 1 was to be transferred to GACH 1 (on [DATE]) .but transport never showed up. The Report indicated Resident 1 was febrile (having a fever) for the last four days (since [DATE]) and facility staff were giving Resident 1 Tylenol. The Report indicated the impression was [CONDITION(S)]. Resident 1 was taken to GACH 1. A review of GACH 1 History and Physical (H&P), dated [DATE] at 11:54 p.m., indicated Resident 1 was brought in by the paramedics from the facility due to [CONDITION(S)] (low blood pressure), [CONDITION(S)], fevers and altered mental state. The H&P indicated Resident 1 was noted to have febrile temperatures for the past week, increasingly altered mental status and minimally responsive. Resident 1 had [CONDITION(S)] and was given sodium chloride (used to replace lost water and salt in the body given by intravenous) bolus (given to the vein as fast as possible) two liters with no improvement. A review of the GACH 1 History and Physical (H&P), dated [DATE] at 11:54 p.m., indicated Resident 1 was emergently intubated due to increased work of breathing and desaturations (drop in oxygen level). Blood culture collected on [DATE] were positive for extended spectrum beta-lactamase Escherichia coli (ESBL E. coli, multidrug-resistant bacteria causing serious hospital and community-acquired infections). Resident 1 ' s treatment included antibiotics (a medication that fights bacteria); she was placed on three pressors (medicine to support blood pressure) and was started on emergent Continuous Renal Replacement Therapy (CRRT, a 24-hour non-stop [CONDITION(S)] therapy used to support patients with renal failure). A review of Resident 1 ' s Certificate of Death dated [DATE] indicated the immediate cause of death was bacteremia. A review of the GACH 1 Discharge Summary Notes, dated [DATE] at 7:29 p.m., indicated Resident 1 had hypotensive fever and [CONDITION(S)]. Throughout the hospital course, Resident 1 ' s status was progressively worsening and was on multiple pressors. After further discussion with FM 1, Resident 1 was placed as do not resuscitate (DNR, not to perform Cardiopulmonary Resuscitation [CPR, uses mouth-to-mouth or machine breathing and chest compressions to restore the work of the heart and lungs when someone's heart or breathing has stopped). Resident 1 was found pulseless and was pronounced dead at 11:48 p.m. on [DATE]. During an interview on [DATE] at 9:59 a.m., Resident 1 ' s medical record was reviewed with LVN 1. LVN 1 stated on [DATE], Resident 1 had a temperature of 101.5 degrees F with nausea and vomiting. LVN 1 stated the physician was notified at 11 p.m. (on [DATE]). There were no (physician) orders found. LVN 1 stated when she came the next day on [DATE], LVN 1 notified the physician who gave order for blood culture, CBC, CMP and Chest x-ray. LVN 1 stated the chest x-ray was done and indicated pulmonary congestion (accumulation of fluid in the lungs). LVN 1 stated the CBC, CMP and the blood cultures were changed to stat and she notified the laboratory. LVN 1 stated the laboratory personnel stated they were short of staff and will not be able to come to the facility to collect blood. During the interview on [DATE] at 9:59 a.m., LVN 1 stated on [DATE], the physician gave an order to transfer Resident 1 to GACH for evaluation. LVN 1 stated she arranged the transport of Resident 1 to GACH and the ambulance (transport) company informed her that transport will arrive in two to three hours, but transport never came to pick up Resident 1. LVN 1 was unable to find documentation that a facility staff called the ambulance company to find out what happened. No documentation that the physician was notified when Resident 1 was not transferred to GACH 1 (on [DATE]). During a telephone interview on [DATE] at 8:44 a.m., LVN 2 stated when the ambulance did not arrive (on [DATE]), LVN 2 called the ambulance company and was informed that they could not come and pick up Resident 1 because they were fully booked. LVN 2 stated she did not notify the Physician or Resident 1 ' s family member. LVN 2 stated she did not document. LVN 2 further stated at about 3 a.m. (on [DATE]), she went to check Resident 1, and the blood pressure was ,d+[DATE] mmHg, heart rate was 103 bpm and she had a hard time taking the resident ' s oxygen saturation. LVN 2 stated she checked Resident 1 ' s blood sugar and it was 21 mg/dl. She informed the RN supervisor who gave Resident 1 [MEDICATION(S)] and called the paramedics. On [DATE] at 9:25 a.m., during a telephone interview, the registered nurse supervisor (RNS 1) stated the ambulance was booked on [DATE] at about 2 p.m. and did not show up. RNS 1 stated she did not call the ambulance company to find out what happened. RNS 1 stated Resident 1 had fever and had low blood sugar level. RNS 1 stated Resident 1 was given [MEDICATION(S)] and the paramedics were called. During an interview, on [DATE] at 12:35 p.m., Resident 1 ' s medical record, including the Progress Notes and MAR, was reviewed with the Director of Nursing (DON). The DON stated on [DATE] Resident 1 had a temperature of 101.5? F and the Physician was notified, and no orders given. On [DATE] the physician gave order for blood culture, CBC and CMP. The DON stated the laboratory was ordered to find out what microorganisms were causing the fever so that appropriate antibiotics and treatment will be given to Resident 1. The DON stated on [DATE] the physician gave an order to transfer Resident 1 to the GACH and was confirmed with the ambulance company and gave an estimated arrival time between two to three hours. The DON was unable to find documentation that the facility followed up with the transportation company. The DON stated the facility should have followed up with the transportation company. During a telephone interview on [DATE] at 11:19 a.m., the [CONDITION(S)] center administrator (ADM 2) stated on [DATE], the [CONDITION(S)] center notified the facility that the nephrologist wanted to transfer Resident 1 to GACH after [CONDITION(S)]. The ADM 2 stated the facility was aware and was going to arrange transportation for Resident 1. During a telephone interview on [DATE] at 3:11 p.m., Resident 1 ' s Physician stated he gave orders for laboratory tests and the facility did not follow through. The physician further stated he was not informed that there were transportation problems, if he had known he would have given an order to transfer Resident 1 by paramedics. On [DATE] at 1:42 p.m., during a telephone interview in the presence of ADM 1, LVN 1, and Infection Preventionist (IP) 2, the DON stated for every COC, the primary physician needed to be notified to get orders and to get the plan of care. The DON also stated if there was a COC and the primary physician was not available, the Medical Director can be notified. During an interview on [DATE] at 3:09 pm, during an interview with the ADM 1, DON, IP 2 and LVN 1, ADM 1 stated the facility was responsible for Resident 1. LVN 1 stated there was no documentation that there were problems with the laboratory personnel and that the physician was notified about any problems with drawing blood. During a telephone interview on [DATE], at 11:40 a.m., Resident 1 ' s January MAR for Tylenol was reviewed with the DON. The DON stated there was no documentation of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility policy and procedure titled, Change of Condition, Resident, with a revised date of ,d+[DATE] indicated to identify, inform the physician and resident or resident representative and intervene to provide medical or nursing care for a resident experiencing an acute medical change of condition in a timely and effective manner. Upon noting or receiving report of a change in resident ' s physical, mental or psychosocial status, the licensed nurse will evaluate the resident ' s condition. After assuring the resident ' s safety, notify the resident ' s physician of the clinical findings and note/implement new orders given by the physician. Keep the resident notified (if cognitively able to understand) and notify the resident representative of the change of condition, new physician orders and/or the need to seek acute medical intervention. Document assessments and interventions on the clinical record. A review of the facility ' s policy and procedure titled, Medication Administration - General Guidelines, dated [DATE], indicated medications are administered as prescribed in accordance with the good nursing principles and practices. The policy indicated medications are administered in accordance with written orders of the physician. The individual who administers the medication dose records the administration on the resident ' s MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . In no case should the individual who administered the medication report off-duty without first recording the administration of any medications. The policy indicated current medications are listed on the MAR. The resident ' s MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Initials on each MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . When as needed (PRN) medications are administered, the following documentation is provided: -date and time of administration, medication, dose, route of administration (if other that oral). -complaints or symptoms for which the medication was given. -results achieved from giving the dose and the time results were noted. -signature or initials of person recording administration and signature or initials of person recording effects.