Alamitos Belmont Health And Rehabilitation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a psychotropic medication (medications that affect brain activities associated with mental processes and behavior) was not used unnecessarily for one of three sampled residents (Resident 13) by failing to define and monitor resident specific, measurable target behaviors related to the use of Zyprexa [an atypical antipsychotic that's used to improve mood, thoughts, and behaviors for people with schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs)]for Resident 13.This deficient practice of failing to ensure antipsychotic medication was used to treat a resident's specific, diagnosed condition, and monitor target behaviors related to the use of psychotropic medication increased the risk that Resident 13 could have experienced adverse effects (unwanted or dangerous medication-related side effects) related to psychotropic medication therapy, such as drowsiness, dizziness, constipation, or increased risk of fall, possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status.Findings:During a review of Resident 13's admission Record, the admission Record indicated, Resident 13 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thought), and cerebral infarction (loss of blood flow to a part of the brain).During a review of Resident 13's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 13 had no capacity (ability) to understand and make decision.During a review of Resident 13's Minimum Data Set (MDS - a resident assessment tool), dated [DATE], the MDS indicated Resident 13 required dependent assistance (Helper does all of the effort) from two or more staff for hygiene, shower, transfer, maximal assistance (Helper does more than half the effort) from one staff for dressing, bed mobility, and setup or clean-up assistance (Helper sets up or cleans up) from one staff for eating. During a review of Resident 13's Order Summary Report (OSR) dated [DATE], the OSR indicated, give Zyprexa 10 milligram (mg) by mouth at bedtime and 2.5mg by mouth in the evening related to schizophrenia manifested by hallucination (an experience involving the apparent perception of something not present) were ordered on [DATE]. The OSR indicated, monitor manifested behavior hallucinations every shift for Zyprexa use related to Schizophrenia was ordered on [DATE].During a concurrent interview and record review on [DATE], at 11:30 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 13's Medication Administration Record (MAR), dated from [DATE] to [DATE] was reviewed. The MAR indicated, monitor behavior manifested by hallucination every shift for Zyprexa use related to Schizophrenia. The MAR indicated, Resident 13 had no hallucinations and there were no hallucinations documented from [DATE] to [DATE]. RNS 1 stated, she did not witness any signs and symptoms of hallucinations for Resident 13. RNS 1 stated, she was not sure what hallucinations that Resident 13 was experiencing because the term hallucinations were very general and not a specific targeted behavior for Zyprexa use. RNS 1 stated, target behavior should be specific and measurable, so psychiatrist or Nurse Practitioner ( a medical practitioner specializing in the diagnosis and treatment of mental illness) could refer to the documentation of behavior occurrences, and medication dosage to consider a Gradual Dose Reduction (GDR- a systematic approach to stepwise tapering of medication dosage to assess if a lower dose can effectively manage symptoms, conditions, or risks, or if the medication can be discontinued entirely). RNS 1 stated, the staff should have clarified with Psychiatric Nurse Practitioner (PNP)1 who prescribed Zyprexa for what specific target behaviors to monitor Resident 13 for. During a phone interview on [DATE], at 5:45 p.m., with PNP1, PNP 1 stated, she ordered Zyprexa for schizophrenia manifested by hallucinations because Resident 13's Family Member (FM) told PNP 1that Resident 13 believed people were pulling her legs to prevent her from getting up from her wheelchair. PNP 1 stated, this was the reason she disagreed with a GDR for Resident 13. PNP 1 stated, clinical documentation should have reflected the resident's condition and monitored target behaviors accurately because a GDR was based on clinical evidence. PNP 1 stated, if accurate target behaviors were not documented and monitored , Resident 13 might receive unnecessary psychotropic medications and would suffer from adverse reaction (an undesired or harmful effect of a drug). PNP 1stated, she was aware that unnecessary medication use could be a chemical restraint (the use of medications to restrict a person's movement or freedom of action, or to control behavior, when the medication is not part of a standard treatment for their condition) as well. During a concurrent interview and record review on [DATE], at 8:53 a.m., with the Minimum Data Set Coordinator (MDSC), Resident 13's Minimum Data Set (MDS), dated [DATE], [DATE], [DATE], [DATE] were reviewed. The MDS indicated, Resident 13 did not have any hallucinations and delusions (misconceptions or beliefs that are firmly held, contrary to reality). The MDS indicated, Resident 13 did not have any physical, verbal, and other behavioral symptoms toward others. The MDSC stated, she did not witness any behavioral issues, hallucinations and delusions for Resident 13. The MDSC stated, the target behaviors should be resident specific and measurable to reflect in clinical documentation.During an interview on [DATE], at 12:07 p.m., with the Director of Nursing (DON), the DON stated, target behavior should be specific and measurable to the resident's diagnosis. The DON stated, hallucinations could be caused by many things, and this should be clarified with PNP 1. The DON stated, monitoring specific target behavior was important, because GDR would be performed based on these data. The DON stated, inaccurate data would lead to delays on treatment, and the residents continuing to receive unnecessary medication. The DON stated, the resident might suffer from unnecessary side effects/adverse reactions. The DON stated, unnecessary medication could be considered as chemical restraint as well.During a review of Resident 13's Psychiatric Visit Progress Report (PVPR), dated [DATE], the PVPR indicated, GDR was contraindicated and no psychotropic medication adjustments needed. The PVPR indicated, continued with same dose of Zyprexa due to schizophrenia management for persistent psychotic symptoms such as auditory and visual hallucinations per daughters.During a review of Resident 13's Care Plan Report (CPR) titled, Resident 13 use psychotropic medication Zyprexa (also known as Olanzapine) related to behavior management for hallucination, initiated [DATE] and revised [DATE], the CPR Goal indicated, Resident 13 will reduce the use of psychotropic medication and will have fewer episodes of hallucination by target date of [DATE]. The CPR Interventions indicated, administer medications as ordered, and monitor and document for side effects and effectiveness. The CPR Interventions indicated, consult with pharmacy and PNP 1 to consider dosage reduction when clinically appropriate.During a review of the facility's Policy and Procedure (P&P) titled, Chemical Restraints and Psychotropic Medication Management, revised 4/2025, the P&P indicated, Policy: It is the policy of this facility to ensure that residents are free from chemical restraints imposed for purposes of discipline or convenience or that are not required to treat a specific condition as diagnosed and documented in the clinical record . Procedure: 3. The Licensed Nurse (LN) shall review the classification of the drug, the appropriateness of the diagnosis, its indication, behavior monitors and related adverse side effects prior to verification of admission orders with the Attending Physician . 8. The facility's Interdisciplinary Team (IDT) will review to ensure; a. Psychotropic medication was prescribed to treat a specific diagnosed condition, as documented in the clinical record; b. Not in excessive dosage; c. Behavior is not related to delirium or other reversible conditions; d. Monitoring for adverse consequences and effectiveness of medications are in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to validate 9 of 9 Registered nurses, 23 out of 23 Licensed Vocational Nurses (LVNs), and 68 out of 68 Certified Nurse Assistants (CNAs)'s competency for what to do when taking care of an unresponsive resident who was not breathing and had no pulse. The deficiency resulted in a delay in initiation of Cardiopulmonary Resuscitation ([CPR] an emergency, life-saving procedure performed when the heart stops beating, to maintain blood circulation to the brain) to one of one resident (Resident 93) and the deficient practice placed 40 residents at risk for a delay in receiving immediate CPR interventions. Findings:During a review of Resident 93's admission Record, the admission Record indicated Resident 93 was admitted to the facility on [DATE] with diagnoses including end stage renal disease ([ESRD], irreversible kidney failure), anemia (a condition where the body does not have enough healthy red blood cells), diabetes mellitus ([DM], a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 93's Minimum Data Set ([MDS], a resident assessment tool), dated [DATE], the MDS indicated Resident 93 was severely cognitively (thinking process) impaired and was dependent on activities of daily living such as hygiene, dressing and putting on footwear. During a review of employee personnel files for CNA1, CNA 2, LVN 1, and LVN 2, the personnel files indicated no documented evidence of facility validation of staff competency on CPR and how to respond to residents who were unresponsive, had no pulse, and had no respirations. During a review of the facility Skills Awareness and Competency form, revised [DATE], the form did not indicate staff CPR skills validation and how to respond to residents who were unresponsive, had no pulse, and had no respirations. During an interview on [DATE] at 8:38 a.m., with LVN 2, LVN 2 stated even though Resident 93 was found cold, unresponsive, with no pulse, and not breathing, LVN 1 and 2 waited to verify each others findings that Resident 93 was indeed not breathing, and had no pulse, then to find out Resident 93's code status (a medical order determining the extent of resuscitation efforts a patient wishes to receive if their heart or breathing stops) by going to the computer before initiating CPR. LVN 1 stated CPR was not started immediately.During an interview on [DATE] at 11:28 a.m., with the Director of Staff Development (DSD), the DSD stated the facility does not ensure or validate staff competency regarding CPR and how to respond to unresponsive residents with no pulse and no respirations. During an interview with the Director of Nurses (DON) on [DATE] at 3:54 p.m., the DON stated the facility did not ensure and validate staff competency for performing CPR timely and how to handle residents who were unresponsive, had no pulse, and had no respirations. During a review of the facility's policy and procedure (P&P) titled, Nursing Staff Competency, Revised 4/2025, the P&P indicated the facility will have appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. The P&P indicated all licensed nurses shall have training in cardiopulmonary resuscitation (CPR). The P&P indicated Director of Staff Development, Nurse Manager or designee must validate all skills listed on the form for competent performance.During a review of the facility's 2025 Facility Assessment, revised [DATE], the facility's assessment indicated during emergency situations, the facility will develop and update annually or as needed an emergency preparedness plan, and the facility will train staff on emergency procedures and their roles during emergencies.Cross reference F678

Based on interview and record review the facility failed to provide documented evidence of all employees, including physicians, COVID-19 (contagious disease) vaccine (medications used to prevent diseases usually given by injection or by mouth) status and the provision of education on benefits and potential side effects and offering of the 2025 to 2026 COVID-19 vaccine. This failure had the potential to result in staff and residents contracting COVID-19 which can cause serious illness, hospitalization, and death. Findings: During a concurrent interview and record review on 1/28/2026 at 12:38 p.m., with the Infection Prevention Nurse (IPN), the facility's Covid Staff Vaccination Status, undated, was reviewed. The IPN stated there was no documented evidence for physician or licensed practitioners' education on benefits and side effects was provided and the offering of 2025 to 2026 Covid-19 booster vaccine. The IPN stated the roster did not include physicians and it should include everyone that has direct access to the residents. During an interview on 1/29/2026 at 12:24 p.m. with the Director of Nursing (DON), the DON stated staff need to be educated and the current COVIE-19 booster should be offered to staff.During a review of the facility's policy and procedure (P&P) titled, Immunizations - Staff, revised 7/2023, the P&P indicated staff includes licensed practitioners.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement infection control measures by failing to:A. Ensure visitors and the staff wore Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) properly for one of three sampled residents (Resident 78) who was on Enhanced Barrier Precaution [EBP-an infection control measures, primarily in nursing homes, requiring staff to wear gowns and gloves during high-contact care for residents with multidrug-resistant organisms or increased risk factors like wounds/devices, expanding beyond Standard Precautions to prevent multidrug-resistant organism(MDRO) spread where direct contact is likely].B. Ensure two of two residents (Resident 10 and 11) were tested for Corona virus disease ([COVID-19] contagious infectious disease) and placed on transmission-based precautions ([TBP] infection control measures used in healthcare settings, in addition to standard precautions, for patients known or suspected of being infected) when they presented with respiratory infection symptoms. These failures had the potential to result in compromised infection control measures and the spread of infection among residents, staff, and visitors. Findings:
A. During a review of Resident 78's admission record, the admission record indicated Resident 78 was initially admitted to the facility on [DATE] and last re-admission was on [DATE] with urinary tract infection (UTI- an infection in the bladder/urinary tract), uterine cancer (a cancer that starts in the uterus, the organ where a fetus grows during pregnancy), Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and chronic kidney disease (the kidneys have become damaged over time).
During a review of Resident 78's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 78 had fluctuating capacity to understand and make decisions.
During a review of Resident 78's Minimum Data Set (MDS-a resident assessment tool), dated [DATE], the MDS indicated Resident 78 required dependent assistance (Helper does all of the effort) from two or more staff for shower/bath, dressing, toilet hygiene, transfer, hygiene, bed mobility, and set up or clean-up assistance (Helper sets up or cleans up) from one staff for eating.
During a concurrent observation and interview on [DATE], at 12:41 p.m., with Licensed Vocational Nurse (LVN) 4 in Resident 78's room, LVN 4 was checking Resident 78's blood pressure and her nursing uniform was touching Resident 78's bed linen. LVN 4 was wearing a mask, but she did not wear a gown and gloves. Resident 78's Family Member (FM) 1 was at the bedside holding Resident 78's hands after LVN 4 finished checking Resident 78's blood pressure. FM 1 did not wear any PPE. There was EBP signage by the entrance for Resident 78. LVN 4 stated, Resident 78 was on EBP, and she should have worn a gown and gloves because checking blood pressure was a high contact resident care activities, and required a mask, gown and gloves to be worn to prevent spreading infection. LVN 4 stated, she should have educated FM 1 regarding wearing PPE while touching Resident 78's hands.
During an interview on [DATE], at 12:45 p.m., with FM 1, FM 1 stated, she has been visiting Resident 78 many times, but the staff did not tell her to wear PPE when/if she was touching Resident 78. FM 1 stated, no one provided her with any education or information regarding wearing PPE in EBP room to prevent infection from spreading.
During an interview on [DATE], at 12:42 p.m., with the Infection Preventionist Nurse (IPN), the IPN stated, the staff should wear mask, gown, and gloves before performing high contact activities with a resident on infection prevention precautions, such as bathing, hygiene care, changing, transferring, and checking blood pressure to prevent cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) when they were caring for the residents who were on EBP. The IPN stated, the staff should have provided education for visitors and asked them to wear PPE as well.
During an interview on [DATE], at 12:07 p.m., with the Director of Nursing (DON), the DON stated, PPE should be worn correctly based on the requirements for different kinds of infections. The DON stated, Resident 78 was on EBP due to having a foley catheter (or indwelling catheter- a thin, flexible tube inserted through the urethra into the bladder to drain urine continuously) which was an invasive line. The DON stated EBP required wearing a mask, a gown, and gloves before performing high contact care that required touching the residents. The DON stated, the staff must wear proper PPE to protect themselves and vulnerable residents.
During a review of Resident 78's Order Summary Report (OSR), dated [DATE], the OSR indicated, place Foley catheter size 16 French (Fr) by gravity drainage ordered on [DATE]. The OSR indicated, place a privacy bag in place for foley catheter and monitor placement every shift ordered on [DATE].
During a review of Resident 71's Care Plan Report (CPR) titled, Resident 78 was at risk for UTI related to Foley Catheter Placement revised [DATE], the CPR Goal indicated, Resident 78 will not have UTI by the target review date of [DATE]. The CPR Interventions indicated, use Enhanced Barrier Precautions.
During a review of the facility's Policy and Procedure (P&P) titled, IPCP Standard and Transmission-Based Precautions, revised 3/2024, the P&P indicated, Policy: It is the policy of this facility to implement infection control measures to prevent the spread of communicable disease and conditions. Procedure: 3. Enhanced Barrier Protection (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gowns and gloves during high-contact resident care activities that provide opportunities for indirect transfer of Multi Drug Resistant Organisms (MDRO infectious organisms that are resistant to different medications)to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. (e.g., residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs).
B. During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was originally admitted to the facility on [DATE] with diagnoses including anemia (a condition where the body does not have healthy red blood cells), sick sinus syndrome (heart rhythm disorder) , atherosclerotic (buildup of fats and other substances in and on the artery walls). heart disease, and atrial fibrillation (irregular heartbeat).
During a review of Resident 10's ([MDS] resident assessment tool), dated [DATE], the MDS indicated Resident 10's cognitive (ability to make decisions of daily living) skills for daily decision-making were intact. The MDS indicated Resident 10 needed set-up assistance when eating, oral hygiene, and substantial assistance (helper does more than half the effort) with personal hygiene, and showering.
During a review of Resident 10's Situation Background Assessment Recommendation (SBAR) Communication Form, dated [DATE], the form indicated Resident 10 presented with a productive cough (also known as a wet cough, brings up mucus [phlegm or sputum] from the lungs to help clear the airways).
During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was originally admitted to the facility on [DATE] with diagnoses including cellulitis (skin condition that causes swelling and redness), asthma (chronic lung condition), and chronic kidney disease (condition where the kidneys become damaged and lose their ability to filter blood, leading to a buildup of waste and fluid in the body).
During a review of Resident 11's MDS, dated [DATE], the MDS indicated Resident 11's cognitive skills for daily decision-making was intact. Resident 11 need set-up assistance when eating, oral hygiene, and substantial assistance with personal hygiene.
During a review of Resident 11's SBAR Communication Form, dated [DATE] at 2:30 p.m., the form indicated Resident 11 presented with mild sore throat.
During a review of Resident 11's SBAR Communication Form, dated [DATE] at 6:18 p.m., the form indicated Resident 11 presented with non-productive dry cough.
During a concurrent interview and record review on with the Infection Prevention Nurse (IPN), Resident 10 and 11's medical records and Medication Administration Records (MARs) were reviewed. Resident 10 and 11's MAR indicated to monitor any Covid-19 signs and symptoms which included cough and sore throat. Resident 10 and 11's MAR indicated no Covid-19 test was conducted. The IPN stated Residents 10 and 11 presented with respiratory symptoms as indicated in the SBAR Communication forms and Residents 10 and 11 should have been tested for Covid-19 for early treatment and mitigation of possible spread. Resident 10 and 11 should have been placed on droplet/contact isolation (TBP to prevent spread of germs) until Covid-19 was ruled out according to Long Beach Public Health guidelines.
During an interview on [DATE] at 12:24 p.m., with the DON, the DON stated the facility should follow the local public health departments' guidelines for residents' safety.
During a review of the facility's policy and procedure (P&P) titled, Covid-19 Testing revised 10/2023, the P&P indicated testing will be performed according to current local and state health departments and Centers for Disease Control and Prevention (CDC) prevention guidelines.
During a review of the facility's untitled P&P, revised 10/2023, the P&P indicated testing will be performed With residence who had symptoms consistent with COVID-19 regardless of vaccination status.
During a review of Long Beach Health and Human Services document titled, Skilled Nursing Facility Covid-19 Guidance, dated [DATE], indicated residents or health care personnel (HCP) with signs or symptoms of Covid-19 like illness, regardless of vaccination status, should be:
Isolated immediately (i.e., HCP sent home, residents remain in current room on transmission-based precautions
Test immediately
If first test was antigen and negative, test again 48 hours after the first test.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility's Quality Assessment and Assurance ([QA&A] develop and implement appropriate plans of action to correct identified quality deficiencies) and Quality Assurance Performance Improvement ([QAPI] takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to identify facility and resident care issues, develop and implement appropriate plans of action to ensure QAA/QAPI committee systemically implemented and evaluated measures to maintain a system to immediately identify residents' code status in an emergency situation that warrants initiation of a resident's CPR without loss of valuable time to implement life saving measures.These deficient practices have the potential to cause delay in life saving measures for 40 current residents who wish to have full treatment in a life-threatening situation.Findings: During a telephone interview on [DATE] at 5:51 p.m., with LVN 1, LVN 1 stated on [DATE], at approximately 5:00 a.m., CNA 1 notified her (LVN 1) that Resident 93 was not responding, and CNA 1 could not wake the resident up. LVN 1 stated she got her stethoscope and asked LVN 2 to come with her to check on Resident 93 in his room. LVN 1 stated she (LVN 1) checked Resident 93's vital signs and the machine could not detect any vital signs. LVN 1 stated she (LVN 1) used her index and middle fingers to feel Resident 93's carotid pulse (the beating of blood flow in the vein that supplies oxygenated blood to the brain) and there was no pulse. LVN 1 stated Resident 93 was a full code, and she (LVN 1) initiated CPR on Resident 93 at approximately 5:30 a.m., (30 minutes after the resident was found unresponsive), until the emergency medical services arrived at 5:45 a.m LVN 1 stated the emergency medical services did not perform CPR. LVN 1 stated the emergency medical staff pronounced Resident 93 dead at 6:00 a.m. During an interview on [DATE] at 8:38 a.m., with LVN 2, LVN 2 stated on [DATE] at approximately 5:15 a.m., LVN 1 informed her she (LVN 1) could not detect any vital signs on Resident 93 and asked her (LVN 2) to verify the lack of vital signs on Resident 93. LVN 2 stated LVN 1 went to check Resident 93's chart for the resident's code status and called the emergency services. LVN 2 stated she (LVN 2) checked his vital signs twice and the machine could not find a reading. LVN 2 stated the second time she (LVN 2) checked Resident 93's vital signs, around 5:40 a.m., LVN 1 was back in the room, and started CPR. LVN 1 asked LVN 2 to go to the front door to wait for emergency medical services to arrive. LVN 2 stated if staff knew the resident's code status, they could have started CPR as soon as Resident 93 was observed unresponsive and without a heartbeat. LVN 2 stated there was a delay in initiating CPR. During an interview on [DATE] at 11:28 a.m., with the Director of Staff Development (DSD), the DSD stated LVN 1, LVN 2 and CNA 1 should have performed CPR on Resident 93, right away when Resident 93 was pulseless and not breathing. The DSD stated staff starting CPR right away would have a higher chance of saving the residents' life. The DSD stated the facility's system was for licensed staff to check a resident's code status in the electronic medical record, and initiate CPR, until emergency medical services personnel take over. During a concurrent interview and record review on [DATE] at 3:25 p.m., with the Director of Nursing (DON), the Nurses Progress Note dated [DATE] was reviewed. The DON stated the Nurses' Progress Note did not indicate the staff members started CPR immediately on Resident 93 when three different staff members, CNA 1, LVN 1 and LVN 2 found the resident unresponsive. The DON stated when CNA 1 found Resident 93 unresponsive and with no knowledge of the resident's code status, CNA 1, LVN 1 and LVN 2 should have tried to find out if Resident 93 was a full code, and initiated CPR right away. The DON stated there was no system in place for emergency situations such as Resident 93's to ensure timely CPR. During an interview on [DATE] at 4:24 p.m. with the Administrator (ADM), the ADM stated he heard about Resident 93 passing during the early morning of [DATE]. The ADM stated staff had to check the resident's code status before initiating chest compressions. The ADM stated the staff did CPR, but staff did not immediately do CPR when they found Resident 93 unresponsive. The ADM stated the QAPI/QA&A committee was not aware of the systemic failure of immediately identifying the resident's code status.During a review of the facility's policy and procedure (P/P) titled QA&A Committee and QAPI Plan dated 2025 indicated to provide excellent quality care to the residents served.meet to exceed the needs, expectations and requirements of our residents while maintaining good outcomes and perceptions of resident care in a cost-effective manner. The principals of QAPI are taught to facility staff and volunteers on an ongoing basis. QAPI activities aim for the highest levels of safety, excellence in Resident Choice, Quality of Life, Clinical Care, Management Practices, Facility Standards, Resident and Family Satisfaction Surveys and Audits.

Based on observation interview and record review the facility failed to handle or store food in a sanitary manner by the following:a. Facility kept 30 salt and pepper shakers without labels, covers, and dates after use in the dry food storage area.b. [NAME] 1 and [NAME] 2 did not wear a hair net to fully cover their hair while handling food.These failure has the potential to increase the risk of cross-contamination and foodborne illness.Findings:a. During a concurrent observation and interview on 1/26/2026 at 9:00 a.m., with the Dietary Supervisor (DS) in the dry food storage area, there were 15 white and 15 black powdery substances inside glass shakers without labels, covers, and dates with holes on the metal tops. The covers fell off from the shakers by being placed upside down. The DS stated those were salt and pepper shakers. The DS stated dietary staff should empty the containers and wash them after every single use before putting them back to store them to prevent foodborne illness. The DS stated they should not store opened and unlabeled food items in the dry food storage area. b. During a concurrent observation and interview on 1/27/2026 at 11:48 a.m., with the Registered Dietician (RD) in the kitchen, [NAME] (CK) 1's hair net did not fully cover her head. The RD stated there were hairs that were not contained in the hair net on both sides and back of CK 1's head. CK 2 was wearing hair cover with exposed hair, confirming hair on both sides and back of her head out of the cover.During an interview on 1/27/2026 at 12:54 p.m., with the DS, the DS stated if staff does not cover hair fully, the hair can fall into the food, and can cause food borne illness.During an interview on 1/29/2026 at 1:51 p.m., with the Director of Nursing (DON), the DON stated kitchen staff need to cover all their hair with hair nets while working in the kitchen to prevent infection control and sanitary reasons.During a review of the facility's policy and procedure(P&P), titled Dress Code, dated 2023, indicated proper dress for staff in food and nutrition services departments are: Hat for hair, if hair is short, which completely covers the hair and hair net for hair, if hair is long (over the ears or longer).During a review of the facility's P&P, titled Storage of food and supplies, dated 2023, indicated dry bulk foods (flour, sugar, dry beans, food thickener, spices, etc.) should be stored in seamless metal or plastic containers with tight covers, or in bins which are easily sanitized. Bins/containers are to be labeled, covered and dated. The P&P indicated dry food items which have been opened, such as pudding, gelatin, biscuit mix, pancake mix, dry cereal, spices, coffee, noodles, etc., will be tightly closed, labeled and dated, open, non-food items are to be tightly closed to prevent exposure to pests. The P&P also indicated All food will be dated - month, day, year.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, failed to follow their policy to replace missing dentures and provide a dentist visit for one of three sampled residents (Resident 15).This Failure had the potential to result in Resident 15 having discomfort while eating or chewing foods that could lead to unintended weight loss and lower self-esteem. Findings:During a review of Resident 15's admission Record, the admission Record indicated, Resident 15 was initially admitted to the facility on [DATE] and last re-admission was on 1/12/2026 with diagnoses including dysphagia (difficulty swallowing), breast cancer ( a disease where cells in the breast grow uncontrollably and form a tumor [abnormal growth]), and dementia (a progressive state of decline in mental abilities).During a review of Resident 15's History and Physical (H&P), dated 1/13/2026, the H&P indicated, Resident 15 had no capacity (ability) to understand and make decisions.During a review of Resident 15's Minimum Data Set (MDS - a resident assessment tool), dated 1/29/2025, the MDS indicated Resident 66 required dependent assistance (Helper does all of the effort) from two or more staff for bed mobility, toilet hygiene, maximal assistance (Helper does more than half the effort) from one staff for dressing, personal hygiene, and supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance) from one staff for eating.During a concurrent observation and interview on 1/26/2026, at 11:27 a.m., with Resident 15 in her room, Resident 15 did not have natural teeth. There were no dentures at the bedside. Resident 15 stated, she did not know where her dentures were. Resident 15 stated, she came in to the facility with both upper and lower dentures upon admission. Resident 15 stated, she asked facility staff to help her locate her dentures but no one has updated her on the status of her dentures. Resident 15 stated, she was having discomfort while she was trying to eat or chew food due to missing dentures. Resident 15 stated, she felt embarrassed when she was talking to other people with no teeth.During a concurrent interview and record review on 1/28/2026, at 11:06 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 15's Resident's Clothing and Possessions (also known as Belongings List) dated on 12/5/2025 and 1/12/2026 were reviewed. The Resident's Clothing and Possessions indicated, Resident 15 had dentures on 12/5/2025 upon initial admission, but had no dentures on 1/12/2026 upon readmission from the General Acute Care Hospital (GACH). RNS 1 stated, Resident 15 lost her dentures during the hospitalization, and she should have notified the Social Service Director (SSD) for replacement. RNS 1 stated, if the resident did not have proper fitted dentures, the resident might have unintended weight loss.During a concurrent interview and record review on 1/28/2026, at 11:59 a.m., with the Social Service Director (SSD), Resident 15's Social Service Summary (SSS), dated from 1/16/2026 was reviewed. The SSS indicated, Resident 15 had upper and lower dentures. The SSD stated, she was not aware of the missing dentures. The SSD stated, the missing dentures should have been replaced as soon as possible to prevent unintended weight loss and discomfort while eating. The SSD stated, the nursing staff did not notify her regarding missing dentures, and she believed Resident 15 had the dentures when she visited her on 1/16/2026. The SSD stated, Resident 15 should be seen by dentist for missing dentures within three days.During an interview on 1/29/2026, at 12:07 p.m., with the Director of Nursing (DON), the DON stated, the SSD should have arranged a dental visit for Resident 15, to get the missing dentures replaced as soon as possible. The DON stated, the nursing staff should have communicated with the SSD regarding the missing dentures. The DON stated, providing dentures in a timely manner was important because it could affect Resident 15's ability to eat, and it could lead to social isolation.During a review of Resident 15's Order Summary Report (OSR), dated 1/12/2026, the OSR indicated, provide dental consultation and treatment as needed was ordered on 1/12/2026.During a review of Resident 15's Care Plan Report (CPR), titled Resident 15 had oral/dental health problems related to edentulous (no natural teeth) and the dentures were lost in the GACH, initiated 1/20/2026, the CPR Goal indicated, Resident 15 will be free from infection, pain or bleeding in the oral cavity. The CPR Interventions indicated, coordinate arrangements for dental care as needed.During a review of the facility's Policy and Procedure (P&P) titled, Ancillary Services, revised 12/2023, the P&P indicated, Policy: It is the policy of this facility that Social Services staff will coordinate ancillary services to promote residents' optimal well-being. i.e. Dental, Optometry, Ophthalmology, Audiology, Podiatry evaluations for residents. Procedures: 1. Social Services will maintain a system to monitor ancillary services . 4. Social Services staff member will request that nursing obtain a physician's order for evaluation(s) prior to scheduling of appointments.During a review of the facility's Policy and Procedure (P&P) titled, Dental Services, revised 4/2025, the P&P indicated, Policy: It is the policy of this Facility to ensure that its residents who require dental services on a routine or emergency basis have access to such services without barrier. It is likewise the policy of the Facility to repair or replace the dentures of a resident except in those situations where the loss or damage directly results from the action of an alert and oriented resident who is responsible for his/her own medical decisions. Procedure: 2. In the event that a Facility resident requires emergency dental services, for the repa1r or replacement of dentures or otherwise, the Facility will: Promptly and, in any event, no later than three (3) business days from the date of loss/damage, refer to the resident for dental services. Assist the resident in making the necessary dental appointments, when necessary or requested. 3. If a referral for dental services does not occur within three (3) business days from the date of loss/damage, the Facility will: Document what actions were taken to ensure the resident could eat, drink and communicate (if applicable) adequately while awaiting dental services. Document the nature of the extenuating circumstances which led to the delay.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: a. Ensure one of three resident's (Resident 10) Potassium Chloride Oral Solution (mineral and electrolyte that regulates fluid balance, sends nerve signals, and regulates muscle contractions) was administered in the correct form.b. Ensure Licensed Vocational Nurse (LVN) 2 indicated the date and time a Lidocaine patch (medication for pain) was applied for one of one resident (Resident 39).c. Document the correct remaining quantity of Morphine Sulfate (potent pain medication), for one of one resident's (Resident 78)The deficient practices had the potential to result in medication errors including residents' diagnoses not being treated, or too much medication being administered.Findings:
a. During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was originally admitted to the facility on [DATE] with diagnoses including weakness, and peripheral vascular disease (circulation disorder where blood vessels outside the heart and brain narrow or become blocked, reducing blood flow to the limbs).
During a review of Resident 39's Minimum Data Set ([MDS] resident assessment tool), dated 12/26/2025, the MDS indicated Resident 39's cognitive skills (functions your brain uses to think, pay attention, process information, and remember things) for daily decision-making were moderately impaired. Resident 39 needed assistance with eating and supervision with other activities of daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily).
During a review of Resident 39's Order Summary Report, the Order Summary Report indicated Lidocaine HCl External Patch 4 %, apply to bilateral knee topically one time a day, ordered 12/17/2025.
During an observation on 1/26/2026 at 9:24 a.m., with LVN 2, in Resident 39's room, LVN 2 applied the Lidocaine patches on Resident 39's knees without labeling the patches with a date and time.
b. During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was originally admitted to the facility on [DATE] with diagnoses including anemia (a condition where the body does not have healthy red blood cells), sick sinus syndrome (heart rhythm disorder) , atherosclerotic (buildup of fats and other substances in and on the artery walls), heart disease, and atrial fibrillation (irregular heartbeat).
During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10's cognitive skills for daily decision-making were intact. The MDS indicated Resident 10 needed set-up assistance when eating, oral hygiene, and substantial assistance (helper does more than half the effort) with personal hygiene, and showering.
During a review of Resident 10's Order Summary Report, the Order Summary Report indicated Potassium Chloride Oral Solution, Give 15 milliliters by mouth two times a day for potassium supplement on Lasix (water pill used to treat edema associated with heart failure) dated 1/23/2026.
During an observation on 1/26/2026 at 9:45 a.m., with LVN 2, in Resident 10's room, LVN 2 administered the Potassium in pill form not liquid form (as indicated in the dated 1/23/2026) to Resident 10.
During an interview on 1/27/2026 at 3 p.m., with LVN 2, LVN 2 stated the wrong potassium form was administered; the liquid form and not the pill form should have been administered to Resident 10. LVN 2 stated she did not indicate the date and time on the Lidocaine patch for Resident 39.
During an interview on 1/29/2026 at 12:24 p.m. with the Director of Nursing (DON), the DON stated Resident 39's medication orders need to be administered in the correct form as ordered by the physician for resident safety. The DON stated Resident 10's lidocaine patch needs to be removed when it is time, but there was not time and date of when it was administered. The DON stated the lidocaine patches could not stay on the Resident 10's knees all day and the facility needs to follow pharmacy policies and procedures.
During a review of the facility's policy and procedure (P&P) titled, Medication Administration- General Guidelines, dated 5/2022, the P&P indicated medications shall be administered as prescribed in accordance with good nursing principles and practices. The right drug is applied for each medication.
During a review of Resident 78's admission Record, the admission Record indicated Resident 78 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 78's diagnoses included anemia (a condition where the body does not have enough healthy red blood cells), diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension ([HTN]-high blood pressure).
During a review of Resident 78's History and Physical (H&P), dated 9/4/2024, the H&P indicated Resident 78 had fluctuating capacity to understand and make decisions.
During a review of Resident 78's MDS, dated [DATE], the MDS indicated Resident 78 was rarely/never understood. The MDS indicated Resident 78 was dependent on facility staff for activities of daily living such as hygiene, showering, dressing, putting on/taking off footwear.
During a review of Resident 78's Order Summary Report, dated 1/16/2026, the Order Summary Report indicated morphine sulfate oral solution 20 mg/mL (milligram per milliliter, a unit of measurement for medication) give 0.25 mL orally every 2 hours as needed for mild pain (1-3 pain level) or shortness of breath with respiration rate between 21-25 breaths per minute (BPM) 0.25 mL equal 5 mg and give 0.5 mL orally every 2 hours as needed for moderate pain (4-6 pain level) or shortness of breath with respiratory rate of 26- 30 BPM 0.5 mL = 10 mg and give 0.75 mL orally every 2 hours as needed for severe pain (7-10 pain level) or shortness of breath with respiratory rate of more than 30 per minute, 0.75 mL equals 15 mg.
During a concurrent observation, interview and record review on 1/28/2026 at 9:47 a.m., with Licensed Vocational Nurse (LVN) 4 with the East Station Medication Cart 4, Resident 78's morphine sulfate oral medication bottle, and the facility's liquid controlled medication tracking system for morphine sulfate oral medication were reviewed. Resident 78's morphine sulfate medication bottle contained approximately 10 mL's. The facility's controlled medication tracking system indicated a quantity of 10.50 mL remaining on 1/27/2026 at 11:03 a.m.(the previous day) with the last dose administered on 1/28/2026 at 1:24 a.m. with no indication of how much was left in the bottle. LVN 4 stated the licensed nurses were pulling the medication out from the bottle but did not indicate how much was left in the bottle on the tracking form. LVN 4 stated there was 15 mL in the bottle to start, minus each dose taken out of the bottle according to the tracking form came to 9.25 mL that should be left in the bottle but the tracking form indicated there was 10.50 mL left on 1/27/2026 and no indications of how much was in the bottle with the last administration date of 1/28/2026 at 1:24 a.m. LVN 4 stated licensed nurses should be documenting how much was pulled out and how much was left in the bottle consistently and accurately on the tracking form. LVN 4 stated pulling out the medication and not documenting it accurately can leave the next licensed staff confused with how much was in the bottle and the count would not be correct.
During an interview on 1/29/2026 at 11:55 a.m., with the Director of Nursing (DON), the DON stated when licensed staff are giving pain medications like morphine, licensed staff should document accurately on the tracking form and the electronic Medication Administration Record (eMAR). The DON stated licensed staff should be writing the amount taken out of the bottle and the amount that's left in the bottle onto the tracking form. The DON stated the importance of accurate documentation of the amount of medication taken out of the bottle and the amount that's left in the bottle was to be accountable of the medication so there was no confusion on how much was left in the bottle when the next licensed staff draws up the medication from the bottle. The DON stated the staff should be pulling out the dosage ordered and documented how much was given to the residents, and how much was left in the bottle, staff should be doing the math. DON stated the licensed staff should not be looking at the bottle and eyeing it to see how much was left in the bottle, that was not the correct way to do it because not all licensed staff will see the same amount.
During a review of the facility's policy and procedures (P&P) titled Preparation and General Guidelines of Controlled Substances, dated May/2022, indicated, medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. accurate accountability of the inventory of all controlled drugs is always maintained.when a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record (CDR) and the medication administration record (MAR) such as date and time of administration (MAR, and Accountability Record), the amount administered (Accountability Record), the remaining quantity (Accountability Record), and initials of the nurse administering the dose, completed after the medication is actually administered (MAR, and Accountability Record).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to measure and document one of two sampled resident's (Resident 9) Stage II (Partial-thickness loss of skin, presenting as a shallow open sore or wound) pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) on the sacrococcygeal (tailbone) area at least on a weekly basis after being admitted on [DATE]. The deficient practice resulted in poor tracking of the pressure ulcer's healing progress and had the potential to result in delayed care and services.Findings:During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was originally admitted to the facility on [DATE] with diagnoses including chronic kidney disease (long-term, irreversible, and gradual loss of kidney function, often causing waste and fluid buildup in the body), anemia (a condition where the body does not have enough healthy red blood cells), and protein calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function).During a review of Resident 9's Minimum Data Set ([MDS] resident assessment tool), dated 12/15/2025, the MDS indicated Resident 9's cognitive skills (functions your brain uses to think, pay attention, process information, and remember things) for daily decision-making were intact. Resident 9 needed set-up assistance with eating, oral hygiene, substantial assistance (helper does more than half the effort to complete the task) with personal hygiene, dependent on staff (helper does all the effort) with toileting hygiene and showering. The MDS indicated Resident 9 was at risk for developing pressure injuries and had one unhealed Stage II pressure injury present on admission.During a review of Resident 9's Clinical admission [DATE] at 11:11 p.m., the admission form indicated Resident 9 had a Stage II pressure injury in the sacrococcygeal area measuring 4 centimeters in length by 3 centimeters in width, and 0 depth, 100 percent granulation tissue (new, moist, red, or pink connective tissue with new capillaries on the surface of a wound) and with light serosanguinous exudate (thin, watery, pink-to-light-red wound drainage).During a concurrent interview and record review on 1/28/2026 at 10:26 a.m., with Licensed Vocational Nurse (LVN)3, Resident 9's medical records were reviewed. LVN 3 confirmed and stated the only wound measurement of Resident 9's Stage II was conducted on admission [DATE]. LVN 3 stated as of 1/28/2026 (28 days) the pressure injury had not been measured to monitor progress. LVN 3 stated measurements and description of pressure injury need to be conducted on at least a weekly basis to track its progress. During an interview on 1/29/2026 at 12:24 p.m., with the Director of Nursing (DON), the DON stated the pressure injuries need to be measured minimally on a weekly basis to track the wound's progress. During a review of the facility's policy and procedure (P&P) titled, Skin and Wound Monitoring and Management dated 4/2025, the P&P indicated the resident with a pressure injury will receive necessary services to prevent infection, and prevent new, avoidable pressure injuries from developing. The P&P indicated a licensed nurse will assess/ evaluate at least weekly each area of alteration should include but not limited to measuring the skin injury.

Based on observation, interview, and record review, the facility failed to ensure appropriate coordination with the hospice (care focused on providing comfort and support to people who are in the final stages of a terminal illness, rather than trying to cure the disease) provider for one of two sampled residents (Resident 44).This failure had the potential to result in gaps in monitoring, and unmet hospice-related care needs for residents.Findings:During a review of Resident 44's admission Record, the admission Record indicated the facility admitted Resident 44 on 9/22/2025 with diagnoses including atherosclerotic heart disease (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery) and phimosis (a condition where the foreskin is too to be tight to be pulled back over the head of the penis) During a review of Resident 44's History and Physical (H&P), dated 9/26/2025, the H&P indicated, Resident 44 had fluctuating capacity to understand and make decisions. During a review of Resident 44's Minimum Data Set (MDS- a resident assessment tool), dated 12/28/2025, the MDS indicated Resident 44' cognition (think, pay attention, process information, and remember things) was severely impaired. The MDS indicated Resident 44 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating, moderate assistance (helper does less than half the effort to complete the task) with oral hygiene, maximal assistance (helper does more than half the effort to complete task) with dressings, personal hygiene, dependent with toileting hygiene, showering and putting on/taking off footwear. During a review of Resident 44's Order Summary Report, dated 9/22/2025, the Order Summary Report indicated an order to admit Resident 44 to hospice with an admitting diagnosis of atherosclerotic heart disease. During a review of Resident 44's care plan titled Hospice, revised 12/30/2025, the care plan indicated interventions to work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs were met and work with nursing staff to provide maximum comfort for the Resident 44. During a review of Resident 44's hospice Client Calendar Report and Sign-In/Notes for December 2025 and January 2026, the report and notes indicated the corresponding hospice visit records did not match the scheduled visits on 12/18/25, 12/22/2025, 12/25/2025, 1/1/2026 for aide (certified nursing assistant) hospice visits and on 1/19/2026 for Registered Nurse hospice visit . There was no documentation indicating that the visits were rescheduled, completed later, or otherwise accounted for. During an interview on 01/28/2026 at 11:48 a.m., with the Social Service Director (SSD), the SSD stated her role in hospice coordination was limited to contacting the hospice provider to invite them to care planning meetings. During a concurrent interview and record review on 1/28/2026 at 12:05 p.m., with Registered Nurse Supervisor (RNS) 1, Resident 44's medical records were reviewed. RNS 1 stated hospice coordination is generally handled by social services and nursing. RNS 1 stated corresponding hospice visit sign-in documentation (indicating the hospice agency staff came to see the patient) did not match the scheduled visits on the hospice calendar, and there was no documentation indicating that missed visits were rescheduled or completed. RNS 1 stated lack of coordination and oversight of hospice resulted in interruption of hospice care goals and unmet resident needs. During an interview on 01/29/2026 at 1:51 p.m. with the Director of Nursing (DON), the DON stated facility is expected to coordinate with the hospice agency, including monitoring scheduled visits and ensuring services are provided as arranged to meet hospice residents' needs. During a review of the facility and the hospice provider's hospice services agreement (HSA), dated 2/1/2023, the HSA indicated clinical record should contain information including complete documentation of all services and events.During a review of the facility and the hospice provider's HSA, signed 9/23/2025, the HSA indicated, they have to facilitate cooperative efforts in performance of their respective obligations under this agreement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to follow it's policy and procedures (P&P) titled Cardiopulmonary Resuscitation ([CPR] an emergency lifesaving procedure performed when the heart stops beating), which indicated the facility will provide CPR, to any resident requiring such care prior to the arrival of the emergency medical personnel, in the absence of an advance directives or a do not resuscitate (DNR) order for one of three sampled Residents (Resident 93).The Facility failed to:Activate the EMS system by paging or yelling loudly for Code Blue ( an emergency alert signaling that a person was experiencing a life-threatening situation, typically cardiac (heart) or respiratory arrest, requiring immediate resuscitation) on [DATE] at 5:00 a.m., when Resident 93 was observed by Certified Nurse Assistant (CNA) 1 unresponsive (not reacting to touch, sound or smell), not breathing, and without a pulse (heartbeat) in bed.Call 911 within five minutes after Resident 93 was observed unresponsive on [DATE] at 5:00 a.m.Ensure Certified Nursing Assistant (CNA) 1, Licensed Vocational Nurse (LVN) 1 and LVN 2 initiated CPR as soon as Resident 93 was observed unresponsive and without a pulse on [DATE] at 5:00 a.m. This deficient practice resulted in a delay of life-saving CPR for Resident 93, who was pronounced dead on [DATE] at 6:15 a.m. and placed 40 current residents, who had a full code (residents' choice of level of life saving treatment if found unresponsive) status of not receiving life saving measures immediately without loss of valuable time for being successfully revived.On [DATE] at 4:59 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation had cause, or is likely to cause serious injury, harm, impairment, or death to a resident) was called due to the facility's failure to ensure CNA 1, LVN 1 and LVN 2 performed CPR without delays after finding Resident 93 unresponsive, in the presence of the Administrator (ADM) and the Director of Nursing (DON). On [DATE] at 3:35 p.m., the ADM submitted an acceptable IJ removal plan ([IJRP], an intervention to immediately correct the deficient practices). After verification of the IJRP's implementation through interview, and record review, the IJ was removed on [DATE] at 4:29 p.m., in the presence of the ADM. The IJRP included the following: 1.The interdisciplinary team (IDT healthcare team composed of various specialties') implemented a wristband identification system for code status for all residents Black dot: Do Not Resuscitate (DNR resident wishes no life saving measures if found with nor heart beat and not breathing), No dot : Full Code; If a resident is found unresponsive, staff will immediately initiate CPR. 2. The DON and the Director of Staff Development (DSD) will in-service all Registered Nurses (9), LVN's (23) and CNA's (68) regarding indications for CPR and American Heart Association (AHA) recommendations by [DATE].3. The in-services included the wristband identification system to immediately identify code status, and the updated CPR policy. 4. On [DATE], the IDT, including Social Services, Medical Records, DSD, and MDS, reviewed and verified all Physician Orders for Life-Sustaining Treatment (POLST is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) POLST forms and code status orders in the electronic medical records system to update the resident wristbands. All 77 residents' wristbands were updated.5.The admission Nurse will place a wristband indicating code status on each new admission. 6. The Treatment Nurse or Designee will conduct a follow-up daily review of new admission code status orders to verify the wristbands. 7. The DSD or Designee will in-service staff upon hire, annually, and as needed regarding the wristband identification system to immediately identify code status and the updated CPR policy 8. The Medical Records Director or Designee will conduct a daily review of the code status report to compare it to the resident wristbands. Any identified discrepancies will be immediately updated and reported to the DON. 9. The DON or Designee will report the progress of the monitoring to the Quality Assurance and Performance Improvement (QAPI a systematic, interdisciplinary, and comprehensive method for improving safety, quality of care, and resident quality of life) Committee monthly for 6 months or until substantial compliance has been achieved. Findings:During a review of Resident 93's admission Record, the admission Record indicated Resident 93 was admitted to the facility on [DATE] with diagnoses including end stage renal disease ([ESRD], irreversible kidney failure), anemia (a condition where the body does not have enough healthy red blood cells), diabetes mellitus ([DM], a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities).During a review of Resident 93's Minimum Data Set ([MDS], a resident assessment tool) dated [DATE], the MDS indicated Resident 93 was severely cognitively (thinking process) impaired . The MDS indicated Resident 93 was dependent on staff for activities of daily living (ADL) such as hygiene, getting dressed and putting on footwear.During a review of Resident 93's physician order for life sustaining treatment ([POLST], a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) dated [DATE], the POLST indicated Resident 93 was a full code with resuscitation/CPR, trial period of artificial nutrition including feeding tube (a flexible, medical device used to deliver liquid nutrition, fluids, and medication directly into the stomach or small intestine when a person cannot eat or swallow safely).During a record review of Resident 93's Nurses Progress Notes dated [DATE], at 7:03 a.m., the Nurses Progress Notes indicated on [DATE] at 5:30 a.m., CNA 1 found Resident 93 cold to touch (indicating heart stopped circulating blood) and unresponsive. The Nurses Progress Notes indicated CNA 1 left Resident 93 and went to find LVN 1 to assess Resident 93. The Nurses Progress Notes indicated LVN 1 found Resident 93 with no heartbeat upon auscultation (listening for a heartbeat using a stethoscope [device used to detect and listen to heartbeat). The Nursing Progress Notes indicated Resident 93 had no detectable vital signs (measurements of the body's basic function, heartbeat, respiration rate [breathing], and blood pressure that indicate the state of a patient's essential body functions), no rise and fall of chest (not breathing). The Nursing Progress Notes indicated before being found unresponsive Resident 93 was last seen by CNA 1 around 4:30 a.m., coughing. The progress note indicated Resident 93 was a Full Code. The Nursing Progress Notes indicated emergency medical Technician (EMT)'s arrived at 5:45 a.m., and called Time of Death at 6:00 a.m.During a review of the EMT's run sheet (official document completed by EMT for every dispatched (sent) call dated [DATE], the run sheet indicated the EMT's were dispatched at 6:05 a.m., arrived at the facility at 6:10 a.m. and Resident 93 was pronounced dead at 6:15 a.m.During a telephone interview on [DATE] at 5:51 p.m., with LVN 1, LVN 1 stated on [DATE], at approximately 5:00 a.m., CNA 1 notified her (LVN 1) that Resident 93 was not responding, and CNA 1 could not wake the resident up. LVN 1 stated she got her stethoscope and asked LVN 2 to come with her to check on Resident 93 in his room. LVN 1 stated she (LVN 1) checked Resident 93's vital signs and the machine could not detect any vital signs. LVN 1 stated she (LVN 1) used her index and middle fingers to feel Resident 93's carotid pulse (the beating of blood flow in the vein that supplies oxygenated blood to the brain) and there was no pulse. LVN 1 stated Resident 93 was a full code, and she (LVN 1) initiated CPR on Resident 93 at approximately 5:30 a.m., (30 minutes after the resident was found unresponsive), until the emergency medical services arrived at 5:45 a.m LVN 1 stated the emergency medical services did not perform CPR. LVN 1 stated the emergency medical staff pronounced Resident 93 dead at 6:00 a.m.During an interview on [DATE] at 8:38 a.m., with LVN 2, LVN 2 stated on [DATE] at approximately 5:15 a.m., LVN 1 informed her she (LVN 1) could not detect any vital signs on Resident 93 and asked her (LVN 2) to verify the lack of vital signs on Resident 93. LVN 2 stated LVN 1 went to check Resident 93's chart for the resident's code status and called the emergency services. LVN 2 stated she (LVN 2) checked his vital signs twice and the machine could not find a reading. LVN 2 stated the second time she (LVN 2) checked Resident 93's vital signs, around 5:40 a.m., LVN 1 was back in the room, and started CPR. LVN 1 asked LVN 2 to go to the front door to wait for emergency medical services to arrive. LVN 2 stated if staff knew the resident's code status, they could have started CPR as soon as Resident 93 was observed unresponsive and without a heartbeat. LVN 2 stated there was a delay in initiating CPR.During an interview on [DATE] at 11:28 a.m., with the Director of Staff Development (DSD), the DSD stated LVN 1, LVN 2 and CNA 1 should have performed CPR on Resident 93, right away when Resident 93 was pulseless and not breathing. The DSD stated staff starting CPR right away would have a higher chance of saving the residents' life. The DSD stated the facility's system was for licensed staff to check a resident's code status in the electronic medical record, and initiate CPR, until emergency medical services personnel take over. During a concurrent interview and record review on [DATE] at 3:25 p.m., with the Director of Nursing (DON), the Nurses Progress Note dated [DATE] was reviewed. The DON stated the Nurses' Progress Note did not indicate the staff members started CPR immediately on Resident 93 when three different staff members, CNA 1, LVN 1 and LVN 2 found the resident unresponsive. The DON stated when CNA 1 found Resident 93 unresponsive and with no knowledge of the resident's code status, CNA 1, LVN 1 and LVN 2 should have tried to find out if Resident 93 was a full code, and initiated CPR right away. The DON stated there was no system in place for emergency situations such as Resident 93's to ensure timely CPR. During a review of the American Heart Association [DATE] CPR and Emergency Cardiovascular Care (ECC) Guidelines (https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/adult-basic-life-support), the guidelines indicated after identifying an individual that was not responsive and not breathing, the rescuer should activate the emergency response system first, then immediately begin CPR, beginning with chest compressions at a rate of 100 to 120 a minute and delivering 2 breaths in between compressions. The guidelines indicated immediate chest compression was critical to improve the individual's outcomes by providing high-quality CPR.During a review of the American Red Cross Training Services Program article (https://www.redcross.org/take-a-class/cpr/performing-cpr/what-is-cpr), the article indicated CPR increased the likelihood of surviving cardiac arrest, when the heart stopped beating or and fails to circulate (to move in a circle) blood to the brain and other vital organs. CPR can double or triple the chance of survival by giving continuous chest compressions.During a review of the facility's policy and procedures (P&P) titled Cardiopulmonary Resuscitation (CPR), revised 12/2023, the P&P indicated it was the policy of this facility to provide basic life support (BLS), including CPR, to any resident requiring such care prior to the arrival of emergency medical personnel in the absence of an advance directive. The P&P indicated staff should check for responsiveness, quality of breathing and pulse simultaneously and if the Resident was unresponsive, not breathing (occasional gasps are not breathing) and no pulse, activate EMS system:1. Page or yell loudly for Code Blue to the area2. Call 9113. Designate an individual to bring code cart and if available, bring Automated External Defibrillator (AED a portable life-saving device used in emergencies when someone is experiencing sudden cardiac arrest) to unresponsive person, start CPR per American Heart Association guidelines for any resident in cardiac or respiratory arrest.

Based on interview and record review the facility failed to create a comprehensive person-centered care plan in a timely manner for one of three sampled residents' (Resident 7) Stage II (Partial-thickness loss of skin, presenting as a shallow open sore or wound) pressure ulcer (damage to the skin and underlying tissue caused by constant, long-term pressure, usually on bony areas like the hips, heels, or tailbone) on the sacrococcygeal (tailbone) area.This failure had the potential to result in delays with the necessary care and services to address Resident 7's wound care needs.During a review of Resident 7's admission Record, the admission Record indicated the facility readmitted Resident 7 on 11/28/2025 with diagnoses including metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance from underlying illness) and Stage II pressure ulcer of sacral (tailbone) region. During a review of Resident 7's Minimum Data Set (MDS- a resident assessment tool), dated 12/4/2025, the MDS indicated Resident 7's cognition (functions your brain uses to think, pay attention, process information, and remember things) was moderately impaired. The MDS indicated Resident 7 required supervision assistance (helper provides verbal cues and/ or touching/ steading and/or contact guard assistance as resident completes activity) with eating, moderate assistance (helper does less than half the effort to complete the task) with personal hygiene, maximal assistance (helper does more than half the effort to complete task) with getting dressed and putting on/taking off footwear, dependent (helper does all of the effort) with oral hygiene and toileting hygiene. During a concurrent interview and record review on 1/29/26 at 12:00 p.m., with Registered Nurse Supervisor (RNS) 1, Resident 7's care plan titled, Potential for Pressure Ulcer development/ skin breakdown, created 11/28/2025 was reviewed. RNS 1 stated, Resident 7 was readmitted with a stage 2 pressure ulcer on her sacrococcyx on 11/28/2025. RNS1 stated the care plan did not indicate and have interventions for Resident 7's pressure ulcer upon admission. RNS1 stated the care plan did not address Resident 7's stage 2 pressure ulcer until 12/8/2025. RNS 1 stated the sacrococcyx pressure ulcer care plan was not developed in a timely manner, timely care plan development was essential as it guides staff in providing appropriate care and addressing patient needs and failure to have an updated care plan may result in unmet patient needs. During an interview on 1/29/2026 at 1 p.m., with the Director or Nursing (DON), the DON stated developing a comprehensive person-centered care plan promptly upon noticing the concerns, rather than waiting 10 days, is crucial. The DON stated this care plan is what the staff will follow. During a review of the facility's policy and procedure titled Skin and Wound Monitoring and Management, revised 4/2025, the P&P indicated facility nursing staff will identify and document in the resident's clinical records, the condition and pressure injury risk factors related to the development of unavoidable pressure injury. The P&P indicated this identification and implementation of a plan of care will begin at admission with the initial care plan and be completed throughout assessment process for developing a comprehensive plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During interview and record review the facility failed to ensure safe and appropriate discharge planning for one of three sampled resident (Resident 1) by arranging a transfer to an assisted living facility without verifying that the receiving facility could meet the resident's needs and without confirming the accuracy of the discharge destination.This failure to confirm the appropriateness of the discharge and the receiving facility's capability placed Resident 1 at risk for an unsafe and inappropriate transfer, jeopardizing the resident's health, safety, and continuity of care.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of but not limited to Stage 5 chronic kidney disease (the final stage where kidneys fail requiring dialysis[a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed]) , diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities) with anxiety (emotion characterized by feelings of tension, worried thoughts ) and multiple healing broken bone to the back. During a review of Resident 1's History and Physical (H&P), dated 8/1/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 9/20/2025, the MDS indicated Resident 1 was dependent on nursing staff for toileting, showering, dressing, putting on and taking off footwear, personal hygiene and transferring. During a concurrent interview and record review on 12/13/2025 at 11:13 a.m. with the Social Services Director (SSD), Resident 1's Physician Orders dated 12/12/2025 were reviewed. The orders indicated that Resident 1 was scheduled for discharge on [DATE] at 2:00 p.m. to an assisted living facility (a housing option that provides personal care and support services to residents who need help with daily tasks but do not require 24/7 medical care). The SSD confirmed that Resident 1 was being discharged to an assisted living facility and stated that the facility used a placement referral to make arrangements for this discharge. During a telephone interview on 12/13/2025 at 11:44 a.m. with the Administrator (ADM) of the assisted living facility, the ADM stated that the name of her facility was different from the one listed in Resident 1's Physician Orders. The ADM further stated that her facility was located in a different city and was an independent living facility that accepts residents who were very independent, require minimal care, and are ambulatory. The ADM explained that the facility typically does not accept residents with dementia. The ADM stated she had never heard of the facility name listed in the Physician Orders and was not expecting any admission on [DATE]. Additionally, the ADM confirmed she was not aware of any resident by the name of Resident 1. During an interview on 12/13/2025 at 1:09 p.m. with the Social Services Director (SSD), the SSD stated that typically, the assisted living facility visits their facility and communicates with nursing staff regarding residents' medications and diagnoses. The SSD stated she spoke with the assisted living facility's Administrator on 12/12/2025 regarding transportation arrangements. When asked to search for the assisted living facility online, the SSD stated she was unable to locate the facility. The SSD then contacted the Administrator of the assisted living facility, who explained that she had another resident scheduled for admission and initially thought Resident 1 was that individual with a similar name. The Administrator further stated she was confused about the situation and was not expecting Resident 1's admission. The SSD stated Resident 1 would not be discharged to the assisted living facility because it was not considered safe, and the discharge would be delayed.During a record review of Resident 1's Physician Orders, dated 12/13/2025 at 2:34 p.m., Resident 1 had an order to discontinue the discharge order to assisted living.During a review of the facility's policy and procedure (P&P), titled Criteria for Transfer and Discharge, date revised 4/2025, It is the policy of this Facility that each resident will remain in the Facility, and not be transferred or discharged unless the discharge or transfer is appropriate as per the existing criteria. When the Facility transfers or discharges a resident, the Facility shall ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to inform one of one sample resident ( Resident 1) that Resident 1's insurance would not cover the cost of a board and care facility ( a small, residential setting that provides housing, meals, and personal care assistance to a limited number of residents).
This deficient practice compromised Resident 1's ability to make an informed decision, potentially leading to financial hardship and psychosocial distress.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hypertension ( high blood pressure) and repeated falls.
During a review of Resident 73's History and Physical (H& P) dated 3/13/2025, indicated Resident 1 does have the ability to make own decisions.
During a review of Resident 73's Minimum Data Set ([MDS] resident assessment tool) dated 6/6/2025, the MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with toileting hygiene and personal hygiene.
During a telephone interview on 6/17/2025 at 10:30 a.m. with Resident 1, Resident 1 stated that he was currently residing at the board and care facility. Resident 1 stated that he was informed of the location prior to his discharge from the facility by the Social Service Staff (SSS-unknown). Resident 1 stated that he asked SSS would his insurance pay for his stay at the board and care, SSS replied yes. Resident 1 stated that once he arrived at the board and care, he was informed by the business office that his social security check would be used to pay for his stay at the board and care. Resident 1 stated that he does not mind where he was currently residing, however he does wish that he was informed about his financial obligation prior to transferring so that he could have made an informed decision. Resident 1 stated that he had experienced psychosocial harm (stress and anxiety) from being discharged , because he does not receive enough money from his social security check to cover the entire amount and that he would have a share of cost (is a monthly amount individuals must pay towards their medical expenses before Medi-Cal begins to cover the remaining costs). Resident 1 stated that he would not like to return to the facility because he feels as though the facility did not want him there.
During a concurrent interview and record review on 6/18/2025 at 9:08 a.m. with Social Service Director (SSD), the SSD stated that she was responsible for assisting residents with transfers and discharges. SSD stated that she had not explained to Resident 1 the cost of the board and care and that she should have explained the cost prior to the resident being discharged to the board and care. SSD stated Resident 1 had the right to be informed because he had been able to decide if he wanted to go there. SSD stated that she does not know why she did not explain the financial aspects prior to Resident 1's discharge. SSD stated that Resident 1 probably felt betrayed and upset.
During an interview on 6/18/2025 at 9:54 a.m. with the Director of Nursing (DON), the DON stated that before residents were discharged or transferred to another facility, SSD should inform residents' with written notice, reason for the discharge, location, their appeal rights, and payment expectations. The DON stated the residents should be informed of all those things in order for them to be able to make an informed decision. The DON stated the Resident 1 probably felt upset.
During an interview on 6/18/2025 at 10:30 a.m. with the Administrator (Admin), the Admin stated that the facility had been trying to find placement for Resident 1 and when the board and care facility accepted him that they acted immediately to discharge Resident 1.
During a review of the facility's policy and procedure (P&P) titled Criteria for Transfer and Discharge, dated 4/2025, the P&P indicated, It is the policy of this Facility that each resident will remain in the facility and not be transferred or discharged unless the discharge or transfer is appropriate as per the existing criteria. When the Facility transfers or discharges a resident, the facility shall ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately assess, monitor the effectiveness of current pain management, and reassess the pain for one of six sampled residents (Resident 47) who was receiving pain medications.
This deficient practice had the potential for resident 47 to experience unnecessary pain.
Findings:
During a review of Resident 47's admission Record, the admission Record indicated Resident 47 was admitted to the facility on [DATE] with diagnoses of depression (a mental illness that causes persistent sadness and loss of interest), Parkinson's Disease (a chronic brain disorder that causes movement problems, and can also affect mental health, sleep, and pain), and malignant neoplasm of the prostate (prostate cancer).
During a review of Resident 47's Order Summary Sheet, Resident 47 had an order placed on 11/2/2023 for Percocet (a pain medication that can treat moderate to moderately severe pain) 5-325 milligrams (mg, a unit of measurement) oral tablet give 2 tablets by mouth twice a day for pain management. An order was placed on 9/17/2024 for Tylenol (a pain medication, that treats minor aches and pains) oral tablet 325 mg (give 2 tablets= 650 mg) by mouth one time a day for pain management. The Order Summary Sheet indicated an order for pain management consult was ordered on 11/14/2024 with the Rehabilitation (a medical specialty that helps patients regain their independence after an injury or illness) physician (MD 3) with new orders post evaluation on 11/14/2024 for Cyclobenzaprine HCl (muscle relaxer, used with rest, physical therapy, and other measures to relax muscles and relieve pain and discomfort caused by strains, sprains, and other muscle injuries.) tablet 5mg give 0.5 tablet (2.5 mg) by mouth twice a day for muscle pain for 21 days, and gabapentin (treats nerve pain) oral capsule 100 mg, give 2 capsules (200mg) by mouth three times a day for pain management.
During a review of Resident 47's untitled care plan initiated on 3/30/2024 and updated on 11/14/2024, the care plan indicated Resident 47 had acute (a short-term pain that has a known cause, such as an injury, surgery, or infection) and chronic (persistent pain that lasts longer than 3 to 6 months, or beyond the typical recovery time for an injury or health condition) pain of the back, spine, and left hip. The care plan indicated pain was not relieved by current pain medications. The goals for Resident 47 included Resident 47 voicing adequate relief of pain or the ability to cope with incompletely relieved pain. Interventions for Resident 47 included evaluating the effectiveness of pain medications, follow the pain scale (a tool that helps people describe how much pain they are feeling), to medicate as ordered, and monitor and record pain characteristics (quality, severity, location, onset, duration, aggravating factors, and relieving factors).
During a review of Resident 47's minimum data set (MDS, a resident assessment tool) dated 9/19/2024, the MDS indicated Resident 47 was cognitively intact (a person was able to think, learn, remember, use judgment, and make decisions without significant impairment).
During a review of Resident 47's Medication Administration Record (MAR) for the month of 11/2024, the MAR indicated the following pain follow up codes, U= unknown, I= ineffective, and E= Effective. The following was documented in the MAR:
1.) Resident 47 received Tylenol 650 mg one time a day on 8 occasions and the effectiveness was Unknown between 11/1/2024 and 11/14/2024.
2.) Resident 47's pain level on a scale of 1-10 (0= no pain, 1-3 mild pain, 4-6 moderate pain, 7-10= severe pain) was documented daily, every shift (3 times a day) as 0, no pain from 11/1/2024 through 11/14/2024.
3.) Resident 47 was given Percocet 5-325 mg (2 tablets) twice daily every day from 11/1/2024 through 11/14/2024, with a documented pain level of 0 and there was no record in the MAR that Resident 47 was reevaluated for pain after the pain medication was given.
4.) Resident 47's MAR did not indicate his pain characteristics were being monitored.
During a review of Resident 47's progress notes- nursing note dated 11/14/2024, the progress note indicated Resident 47 was assessed for pain and reported the Percocet he had been receiving only brings his pain down to a pain level of 3 (pain scale 0-10, 0 being no pain and 10 being most severe pain you can experience). Resident's physician (MD 2) was informed of the pain level and ordered for Resident 47 to be seen and evaluated by MD 3.
During a review of Resident 47's pain management review dated 11/14/2024, the review indicated Resident 47 had a change of condition related to pain, his pain during a review was a 10 out of 10 and Resident 47 endorsed almost constant pain during the 5 days prior to the pain management review. Resident 47 complained of back pain, bone pain, neck pain, and joint pain during all hours of the day.
During an interview on 11/13/2024 at 8:54 a.m., Resident 47 stated he experienced extreme pain (8-10) while he walked with the Restorative Nursing Assistant (RNA - nursing aide program that helps residents maintain their function and joint mobility)s and suffered from chronic back pain.
During an interview on 11/14/2024 at 1:45 p.m., Resident 47 stated the nurses gave him his pain medication because it was scheduled but never asked him his pain level or where his pain was and never came back after his pain medication was given to see if he was still in pain.
During an interview on 11/14/2024 at 3:47 p.m., Resident 47 stated a pain specialist (MD 3) came to see him that day and he thought that was weird because he had been complaining of pain since he arrived at the facility, and it was the first time he was offered to see a pain specialist.
During an interview and concurrent record review of Resident 47's MAR on 11/15/2024 at 11:57 p.m., the director of staff development (DSD) stated nurses were only documenting the pain score (0-10) in the MAR and not the characteristics of pain. The DSD stated Resident 47 was receiving Percocet pain medication twice daily which is usually used for severe pain with a documented pain scale of 0. The DSD stated the physician (MD 2) should have been notified if Resident 47's pain level was constantly 0 for reevaluation of pain medications. The DSD stated there was no reevaluation for pain in Resident 47's chart after pain medication was given and Resident 47 should have had an evaluation 30 minutes to 1 hour from when he received the pain medication. The DSD stated if it was not documented in the chart, it was not done. The DSD stated the nurses were not documenting a full pain assessment that included pain characteristics per Resident 47's care plan. The DSD stated an accurate pain assessment was important to see if the resident needed the pain medication and to evaluate if the resident's current pain regimen was effective. The DSD stated pain reassessment was important to ensure the pain medication given was effective.
During an interview on 11/15/2024 at 12:23 p.m., Resident 47 stated he felt so much better today and the muscle relaxer (Cyclobenzaprine) they gave him was helping his joints feel less stiff and overall, his body felt better. Resident 47 expressed that he finally felt better that the facility was paying attention to him because he was seen by MD 3 for pain. Resident 47 stated the nurse that gave his pain medication that morning (licensed vocational nurse- LVN 3) asked a lot of questions about his pain prior to receiving the medication and came back after the medication was given to see if it was effective and that was the first time the nurse had done that.
During an interview on 11/15/2024 at 12:28 p.m., LVN 3 stated prior to 11/14/2024, Resident 47 would request more Percocet but did not report pain and it was more of a routine for him. LVN 3 stated Resident 47 did not have a physician's order to reassess pain, but they should have been reassessing pain within the hour that the medication was given. LVN 3 stated they did not document the characteristics of pain because it was a chronic pain, and they would only document the characteristics of pain if there were any abnormalities or changes in pain.
During a review of the facility's policy and procedure (P/P) titled Pain Recognition and Management dated 12/2023, the P/P indicated the pain medication received, refused and the response to the medication was to be documented in the resident's MAR. The P/P indicated if the pain management program was not effective, the licensed nurse was to contact the resident's physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff wore personal protective equipment ([PPE], clothing or equipment that protects the wearer from injury or illness) while providing direct resident care for one of three sampled residents (Resident 70) who was on enhanced barrier precaution/protection ([EBP], infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms).
This failure had the potential to result in the transmission of infectious microorganisms and increase the risk of causing an outbreak in the facility.
Findings:
During a review of Resident 70's admission Record, the admission Record indicated Resident 70 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of metabolic encephalopathy (a brain disorder that occurs when an underlying condition causes a chemical imbalance in the blood that affects the brain), gastrostomy tube ([G-Tube], a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension ([HTN], high blood pressure).
During a review of Resident 70's Minimum Data Set ([MDS] a resident assessment tool), dated 8/29/2024, the MDS indicated Resident 70 was moderately impaired in cognitive skills (thought process) for daily decision-making and was dependent (helper does all of the effort to complete the activity or the assistance of two or more helpers is required) on mobility such as rolling left and right, sit to lying position, lying to sitting on the side of the bed and self-care abilities such as eating, toileting, oral and personal hygiene.
During a review of Resident 70's Order Summary Report, the Order Summary Report indicated enhanced barrier precautions, PPE required for high resident contact care activities. Indication was G-Tube every shift.
During an observation on 11/12/2024 at 9:26 a.m., inside of Resident 70's room, the Certified Nursing Assistant (CNA) 1 did not have on proper PPE when tending to Resident 70's care in the room. The signage on the doorway indicated Resident 70 was on EBP and PPE needed to be worn when resident care was provided. CNA 1 only had gloves on when picking up Resident 70's blanket from the bed and adjusting the blanket on Resident 70. CNA 1 then stepped out of Resident 70's room and did not perform hand hygiene.
During an observation on 11/12/2024 at 10:01 a.m., in Resident 70's room, Resident 70 was lying in bed in a supine (on the back) position. Resident 70 did not want to be interviewed and asked to be left alone. Resident 70 had a pillow underneath her right arm, a walker at the end of the bed and tube feeding machine next to the patient.
During an interview on 11/15/2024 at 10:52 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 70 was on EBP because Resident 70 had a G-Tube for feedings. LVN 2 stated residents with any openings in the body such as wounds, a foley catheter (a flexible tube that drains urine from the bladder into a collection bag), or G-Tube are on EBP. Staff are to wear PPE to protect other residents and themselves from infection. Staff who do not wear proper PPE when providing care to the residents are at risk for spreading infection and soiling their clothes when in contact with the openings from the residents. Infections can spread from resident to resident, resident to staff or resident to visitors.
During an interview on 11/15/2024 at 2:47 p.m., with the Director of Nursing (DON), the DON stated the purpose of EBP was to protect the resident and staff from possible infections. The DON stated residents with wounds or devices such as a foley catheter, G-tube, or if the resident had a history of infection are on EBP. The proper PPE staff should have on are gloves, gown, mask when encountering anything that may belong to the resident such as their personal belongings or anything at the bedside. The DON stated when staff are not following PPE guidelines, infections can spread and be passed on to other staff members, residents and even visitors which can cause an outbreak. The correct way of donning (putting on) PPE was gown, mask, gloves. Gloves are put on last and should cover the sleeves of the gown. The correct way of doffing (taking off) PPE was gloves, gown, and mask and the perform hand hygiene. The DON stated all staff should perform hand hygiene before going into a resident's room and after leaving a resident's room.
During a review of the facility's policy and procedure (P/P) titled IPCP Standard and Transmission-Based Precautions, revised 3/2024, indicated enhanced barrier protection used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothes then indirectly transferred to residents or from resident to resident (e.g. residents with wounds and indwelling medical devices are at especially high risk of both acquisition and colonization with MDROs) examples of high contact resident care activities requiring gown and glove use for EBP include dressing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use like central vascular line, indwelling urinary catheter, feeding tube, tracheostomy/ventilator.
During a review of the facility's P/P titled, Hand Hygiene, dated 12/2022, indicated five moments of hand hygiene are before patient contact, before aseptic procedure, after patient contact, after body fluids, secretions contact, and after environment contact health care personnel must perform hand hygiene when it is needed during each five moments of hand hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the nursing staff and physician were notified in a timely manner when one out of six residents (Resident 47) presented with decreased range of motion (ROM- full movement potential of a joint) of the bilateral (both) ankles.
As a result of this deficient practice, Resident 47 had a delay in services including being seen and evaluated by physical therapy (PT - profession aimed in the restoration, maintenance, and promotion of optimal physical function) to see what services he required.
Findings:
During a review of Resident 47's admission Record, the admission Record indicated Resident 47 was admitted to the facility on [DATE] with diagnoses of depression (mental illness that causes persistent feelings of sadness and loss of interest), Parkinson's Disease (a chronic brain disorder that causes movement problems, and can also affect mental health, sleep, and pain), and malignant neoplasm of the prostate (prostate cancer).
During a review of Resident 47's untitled care plan, the care plan initiated 4/11/2024 indicated Resident 47 required assistance for positioning and ambulation due to limited mobility. The care plan goal was to maintain Resident 47's current level of function in mobility. On 11/14/2024 the care plan was updated to include bilateral ankle limitations in ROM. Interventions updated on 11/14/2024 requesting a physical therapy (PT) and occupational therapy (OT- profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) evaluation and Resident 47 being seen by the rehab physician (MD 3) on 11/14/2024 for evaluation.
During a review of Resident 47's Joint Mobility Assessment (JMA - a diagnostic procedure that evaluates a joint's mobility and muscle strength) dated 8/13/2024, the JMA indicated Resident 47 did not have any ROM limitations (100% intact ROM) in any of his joints and to continue with the current RNA program.
During a review of Resident 47's Order Summary Sheet, the Order Summary Sheet indicated Resident 47 had orders dated 9/11/2024 for Restorative Nursing Assistant (RNA - nursing aide program that helps residents maintain their function and joint mobility) orders for bilateral lower extremity (BLE-legs, ankles, and feet) and bilateral upper extremity (shoulders, arms, wrists, and hands), exercise bike as tolerated followed by ambulation (walking) in parallel bars (the bars provide support for patients who have difficulty standing or walking on their own) as tolerated three (3) times a week.
During a review of Resident 47's minimum data set (MDS, a resident assessment tool) dated 9/19/2024, the MDS indicated Resident 47 was cognitively intact (a person was able to think, learn, remember, use judgment, and make decisions without significant impairment). The MDS indicated Resident 47 had no impairments in his lower extremities.
During a review of Resident 47's Progress Note: type Restorative Nursing dated 10/18/2024, the note indicated Resident 47 was able to tolerate RNA treatment with maximum (full assistance by RNAs) assistance and there were no new changes to report.
During a review of Resident 47's JMA dated 11/14/2024, the JMA indicated Resident 47 had minimum (75-100% of range intact) ROM limitations on his bilateral ankles.
During an observation and concurrent interview on 11/13/2024 at 8:51 a.m., Resident 47 was laying in bed, his right ankle was observed inverted (opposite position, order, or arrangement from usual) in towards his left leg. Resident 47 attempted to move his feet and ankles but only slight movement was observed, Resident 47 was unable to make his right ankle straight. Resident 47 stated both his ankles are stiff, but his right ankle is slightly stiffer. Resident 47 stated it was torture when he had to stand up and walk during therapy because his ankles are stiff. Resident 47 stated he walks on his toes and facility staff tell him not to walk that way, but he physically can not put his feet flat on the floor.
During an interview on 11/14/2024 at 2:08 p.m., restorative nursing assistant (RNA 1) stated around mid-October 2024 (unknown date) she noticed Resident 47's right ankle was tighter when he was trying to walk. RNA 1 stated she informed Physical Therapist (PT 1) about Resident 47's right ankle feeling tighter, but he no longer works at the facility, so she was not sure what he did with the information. RNA 1 stated she did not inform anyone from nursing about the increased stiffness because PT 1 was in the facility gym at the same time as herself and Resident 47 when she noticed the increased stiffness of the right ankle.
During an interview on 11/14/2024 at 2:56 p.m., the director of rehab (DOR) stated she performed a JMA on Resident 47 on 11/14/2024 (same day as interview) and she noticed a change in Resident 47's ROM of his bilateral ankles. The DOR stated she was going to contact the physician to request an authorization for Physical Therapy (PT) and Occupational Therapy (OT). The DOR stated Resident 47 did have a decline in his bilateral ankle ROM since the last JMA (8/13/2024). The DOR stated, if an RNA noticed a decline in a resident's ROM, they were to inform rehab staff as well as nursing staff so the resident could be reassessed for new needs and services. The DOR stated the physician should be notified the same day a decline in ROM is identified. The DOR stated nursing and rehab has a meeting every month with the RNAs and RNA 1 did not mention the decline in Resident 47's ROM during the October meeting. The DOR stated if she knew about Resident 47's increased stiffness earlier, the physician could have been contacted sooner and she could have assessed for any new interventions therapy could work on for Resident 47. The DOR stated there was no record in Resident 47's chart that PT 1 had been informed about the decline in ROM.
During an interview on 11/15/2024 at 11:57 a.m., the director of staff development (DSD) stated it was the responsibility of the RNAs to report any change of condition (COC) or decline in a resident's ROM to the rehab staff and nursing staff right away. The DSD stated the importance of reporting the decline right away was to ensure all the resident's needs were being met and ensure the physician was notified right away by either the rehab staff or nursing staff so they can place new order's if needed.
During a review of the facility's Restorative Nursing Assistant (RNA) Job Description dated 12/17/2021, the job description indicated it was the responsibility of the RNA to inform the nurse supervisor or charge nurse of any changes in the resident's condition so that appropriate information can be entered on the resident's care plan.
During a review of the facility's policy and procedure (P/P) titled Significant Change of Condition, Response dated 12/2023, the P/P indicated if, at any time it is recognized by any one of the team members that the condition or care needs of the resident have changed, the licensed nurse or nurse supervisor should be made aware. The P/P indicated an example of a change of condition was a change in the ability or decline in physical function. The P/P indicated the nurse was to notify appropriate departments for prompt evaluation and the physician was to be contacted in a timeframe that was based on the urgency of the situation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow up on a level 2 Preadmission Screening and Resident Review (PASRR, Level 2 Evaluation helps determine the most appropriate placement of an individual, considering the least restrictive setting, and whether specialized services are needed) evaluation for one of six sampled residents (Resident 47) who had a diagnosis of depression (a mood disorder that can affect a person's thoughts, feelings, behavior, and sense of well-being).
This deficient practice had the potential to cause a delay in services for Resident 47.
Findings:
During a review of Resident 47's admission Record, the admission Record indicated Resident 47 was admitted to the facility on [DATE] with diagnoses of depression, Parkinson's Disease (a chronic brain disorder that causes movement problems, and can also affect mental health, sleep, and pain), and malignant neoplasm of the prostate (prostate cancer).
During a review of Resident 47's minimum data set (MDS-a resident assessment tool) dated 9/19/2024, the MDS indicated Resident 47 was cognitively intact (a person is able to think, learn, remember, use judgment, and make decisions without significant impairment) and was taking an antidepressant (a class of prescription medications that treat depression and other mental health conditions).
During a review of Resident 47's PASRR Level I (involves completion of an evaluation to determine if an individual has, or is suspected of having, a PASRR condition, i.e., serious mental illness (SMI), intellectual disability (ID), developmental disability (DD), or related condition (RC)) Screening dated 10/5/2024, the PASRR Level 1 indicated Resident 47 was diagnosed with a serious Mental Illness (i.e., depression). The PASRR Level 1 was positive and indicated Resident 47 required a Level 2 PASRR.
During a review of Resident 47's Notice of Attempted Evaluation letter (Level 2 PASSR) dated 10/5/2024, the evaluation letter indicated a level 2 PASRR was unable to be completed for evaluation of serious mental illness because facility staff were unresponsive to two or more attempts of communication within 48 hours of the level 1 PASRR. The evaluation letter indicated the case was closed and to reopen the case the facility needed to complete a new level 1 Screening.
During an interview and concurrent record review on 11/15/2024 at 10:03 a.m., with the Director of Nursing (DON), Resident 47's Notice of Attempted Evaluation letter (Level 2 PASSR) dated 10/5/2024 was reviewed. The DON stated she supervised completing the level 1 PASRRs and receiving the determination letters for level 2 PASRRs. The DON reviewed Resident 47's level 2 PASRR Notice of Attempted Notification letter dated 10/5/2024 and stated the letter indicated the evaluation was unable to be completed. The DON stated she was unaware that there was an attempt to contact the facility for evaluation until this review. The DON stated the Medical Records department must have received the letter and uploaded it into the electronic medical record (EMR) but she was not informed so she did not follow up to complete a new level 1 screening to reopen the case. The DON stated the importance of a level 2 PASRR was to ensure the facility was meeting all of the resident's needs while in the facility. The DON stated the potential outcome of Resident 47 not receiving his level 2 PASRR evaluation right away was a delay in services if there were new recommendations upon completion of the evaluation.
During a review of the facility's policy and procedure (P/P) titled Resident Assessment, PASRR) dated 12/2021, the P/P indicated It was the policy of this facility to ensure that each resident was properly screened using the PASRR specified by the State. Based upon the assessment, the facility was to ensure proper referral to appropriate state agencies for the provision of specialized services to residents with Serious Mental Illness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of six sampled residents (Resident 8) received her Insulin (a medication that regulates blood sugar levels and is essential for life) as ordered by the physician.
This deficient practice had the potential for Resident 8 to become hypoglycemic (occurs when blood sugar level drops too low).
Findings:
During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes (a common condition that occurs when your body doesn't use insulin properly, resulting in high blood sugar levels) and chronic kidney disease (CKD, a long-term condition that occurs when the kidneys are damaged and can't filter blood properly. This can lead to a buildup of waste and excess fluid in the body).
During a review of Resident 8's untitled care plan initiated 8/22/2024, the care plan indicated Resident 8 had diabetes with goals for Resident 8 to be free from any signs or symptoms of hypoglycemia. The interventions for Resident 8 included receiving diabetes medications as ordered by the doctor.
During a review of Resident 8's minimum data set (MDS - a resident assessment tool) dated 8/26/2024, the MDS indicated Resident 8 had moderately impaired cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and was receiving hypoglycemic (medications to lower sugar) agents including insulin.
During a review of Resident 8's Order Summary Report, the Order Summary Report indicated the following orders were placed 9/28/2024:
1.) Insulin Glargine (is an injection that treats diabetes by increasing insulin levels in your body. This decreases your blood sugar) Solution 100 units/ milliliter (ml, a unit of measurement)- inject 14 units subcutaneously (situated or applied under the skin) one time a day at bedtime for diabetes. Hold if blood sugar is less than 150 milligrams (mg, a unit of measurement) per deciliter (dL, a unit of measurement) or if patient refused dinner.
2.) Insulin Glargine Solution 100 units/ml- inject 20 units subcutaneously one time a day (9 a.m.) for diabetes, hold if blood sugar is less than 150 mg/dL or if patient refused Breakfast.
During a review of Resident 8's MAR for the month of 10/2024 and 11/2024 the following was indicated:
1.) Insulin Glargine 14 units at bedtime, hold if blood sugar was less than 150 mg/dL was given on the following dates with the following blood sugars:
10/7/2024, blood sugar 125, given in the abdomen (stomach)
10/17/2024, blood sugar 124, given in the abdomen.
2.) Insulin Glargine 20 units one time a day (9 a.m.), hold if blood sugar was less than 150 mg/ dL was given on the following dates with the following blood sugars:
10/3/2024, blood sugar 94mg/ dL, in the abdomen
10/4/2024, blood sugar 139mg/ dL, in the abdomen
10/13/2024, blood sugar 149 mg/dL, in the abdomen
10/18/2024, blood sugar 122 mg/dL, in the abdomen
10/19/2024, blood sugar 132 mg/dL, in the abdomen
10/26/2024, blood sugar 139 mg/dL, in the left arm
11/2/2024, blood sugar 141 mg/dL, in the abdomen
During an interview and concurrent record review on 11/15/2024 at 10:41 a.m., with the director of nursing (DON), Resident 8's MAR was reviewed. The DON stated Resident 8 had physician's order for insulin Glargine (hold if blood sugar less than 150 mg/dL). The DON stated it was important to follow physician's parameters because it indicated if the medication was needed or not needed. The DON stated the parameters were a physician's order and it was important to follow physician's orders because they were there to prevent any adverse effects (an undesirable or harmful outcome) to the medication. The DON stated insulin was a high-risk medication (drugs that can cause significant harm or death to a patient if used incorrectly or misused) and could cause hypoglycemia. During a review of Resident 8's MAR for 10/2024 and 11/2024, the DON acknowledged that Insulin Glargine was given on the dates noted above when the blood sugar was less than 150 mg/dL. The DON stated giving Insulin Glargine below the parameters (insulin dosage based on blood sugar reading) given by the physician posed a risk for hypoglycemia, a change in mental status, jitters (shakiness), sweating, and the resident could lose consciousness. The DON stated the importance of following physician's orders was patient safety and her nurses were not following physician's orders by giving insulin Glargine to Resident 8 below the specified parameters.
During a review of the facility's policy and procedure (P/P) titled Preparation and General Guidelines dated 10/2019, the P/P indicated the nurse was to administer medication in accordance with written orders of the attending physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Cross Reference: F658
Based on interview and record review, the facility failed to ensure one out of six sampled residents (Resident 8) was free from a significant medication error by failing to follow the physician's ordered parameters (specific instructions) when administering insulin (a hormone medication that regulates blood sugar levels and is essential for life).
This deficient practice had the potential for Resident 8 to become hypoglycemic (occurs when your blood sugar level drops too low).
Findings:
During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes (a common condition that occurs when your body doesn't use insulin properly, resulting in high blood sugar levels) and chronic kidney disease (CKD, a long-term condition that occurs when the kidneys are damaged and can't filter blood properly. This can lead to a buildup of waste and excess fluid in the body).
During a review of Resident 8's care plan initiated on 8/22/2024, the care plan indicated Resident 8 had diabetes with goals for Resident 8 to be free from any signs or symptoms of hypoglycemia. Interventions for Resident 8 included receiving diabetes medications as ordered by the doctor.
During a review of Resident 8's minimum data set (MDS, a resident assessment tool) dated 8/26/2024, the MDS indicated Resident 8 had moderately impaired cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and was receiving hypoglycemic (medications to lower sugar) agents including insulin.
During a review of Resident 8's Order Summary Report, the Order Summary Report indicated the following orders were placed on 9/28/2024:
1.) Insulin Glargine (is an injection that treats diabetes by increasing insulin levels in your body. This decreases your blood sugar) Solution 100 units/ milliliter (ml, a unit of measurement)- inject 14 units subcutaneously (situated or applied under the skin) one time a day at bedtime for diabetes. Hold if blood sugar is less than 150 milligrams (mg, a unit of measurement) per deciliter (dL, a unit of measurement) or if patient refused dinner.
2.) Insulin Glargine Solution 100 units/ml- inject 20 units subcutaneously one time a day (9 a.m.) for diabetes, hold if blood sugar is less than 150 mg/dL or if patient refused Breakfast.
During a review of Resident 8's MAR for the month of 10/2024 and 11/2024 the following was indicated:
1.) Insulin Glargine 14 units at bedtime, hold if blood sugar was less than 150 mg/dL was given on the following dates with the following blood sugars:
10/7/2024, blood sugar 125, given in the abdomen (stomach)
10/17/2024, blood sugar 124, given in the abdomen
2.) Insulin Glargine 20 units one time a day (9 a.m.), hold if blood sugar was less than 150 mg/ dL was given on the following dates with the following blood sugars:
10/3/2024, blood sugar 94mg/ dL, in the abdomen
10/4/2024, blood sugar 139mg/ dL, in the abdomen
10/13/2024, blood sugar 149 mg/dL, in the abdomen
10/18/2024, blood sugar 122 mg/dL, in the abdomen
10/19/2024, blood sugar 132 mg/dL, in the abdomen
10/26/2024, blood sugar 139 mg/dL, in the left arm
11/2/2024, blood sugar 141 mg/dL, in the abdomen
During an interview and concurrent record review on 11/15/2024 at 10:41 a.m., with the director of nursing (DON), of Resident 8's MAR was reviewed. The DON stated Resident 8 had physician's parameters (insulin administration dosage based on blood sugar levels) for insulin Glargine (hold if blood sugar less than 150 mg/dL). The DON stated it was important to follow physician's parameters because it indicated if the medication was needed or not needed. The DON stated the parameters were a physician's order and it was important to follow physician's orders because they were there to prevent any adverse effects (an undesirable or harmful outcome) to the medication. The DON stated insulin was a high-risk medication (drugs that can cause significant harm or death to a patient if used incorrectly or misused) and could cause hypoglycemia. During a review of Resident 8's MAR for 10/2024 and 11/2024, the DON acknowledged that Insulin Glargine was given on the dates noted above when the blood sugar was less than 150 mg/dL. The DON stated giving Insulin Glargine below the parameters given by the physician posed a risk for hypoglycemia, change in mental status, jitters (shakiness), sweating, and loss of consciousness. The DON stated the importance of following physician's orders was patient safety and her nurses were not following physician's orders by giving insulin Glargine below the specified parameters.
During a review of the facility's policy and procedure (P/P) titled Preparation and General Guidelines dated 10/2019, the P/P indicated the nurse was to administer medication in accordance with written orders of the attending physician.

Based on observation, interview, and record review the facility failed to follow the menu and did not meet the nutritional needs of 46 of 81 residents on regular texture diets (diets with no restriction) when the residents did not receive three (3) ounce ([oz] unit of measurement) portions.
This failure had the potential to result in decreased intake of nutrients resulting in unintended (not done on purpose) weight loss.
Findings:
During a review of the facility's daily spreadsheet titled Menus Cycle 4, dated 11/12/2024, the spreadsheet indicated residents on regular diet textures would get 3 oz of Meatloaf.
During an observation on 11/12/2024 at 11:03 a.m., at the tray-line area (an area where meals were assembled on the trays), the meatloaf on the steam table varied in portion sizes.
During a concurrent observation and interview on 11/12/2024 at 11:13 a.m., with [NAME] 1, [NAME] 1 weighed random pieces of meatloaf using the facility food scale. [NAME] 1 stated the first piece of meatloaf was 2.6 oz, the second piece was 3.6 oz, and the last piece was 2.5 oz. [NAME] 1 stated the portion size of the meatloaf should be 2 oz and she weighed the meatloaf once and increased the portion sizes because there were too many complaints from the residents that the portions were small.
During an interview on 11/12/2024 at 11:20 a.m., with [NAME] 1, [NAME] 1 stated the portion sizes for meatloaf was 3 oz and not 2 oz after checking the menu spreadsheets.
During an interview on 11/12/2024 at 11:25 a.m., with the Dietary Supervisor (DS), the DS stated the staff referred to menu spreadsheet to check the correct portion sizes of the food served in tray-line. The DS stated it was not okay for the meatloaf to be inaccurate in portion size and staff needed to follow the spreadsheet to ensure residents were getting an adequate amount of nutrition.
During an interview on 11/12/2024 at 11:54 a.m., with the Registered Dietitian (RD), the RD stated it was important to check and follow the menu spreadsheet for portion sizes of the food to ensure they were providing adequate nutrition to the residents. The RD stated residents who got lesser portions would not get adequate nutrition which could lead to weight loss and residents who got bigger than recommended portions could gain weight as a potential outcome.
During a review of the facility's standardized recipe titled Meatloaf (S-B/T), undated, the standardized recipe indicated Suggested portion size: 3 oz. Procedure: Slice into 3 oz portions. Top with gravy. (Should get 20 portions per pan).
During a review of the facility's Policies and Procedures (P&P) titled Food Preparation, dated 2023, the P&P indicated, Procedure: (1) The facility will use approved recipes, standardized to meet the resident census. This count is kept current so that an accurate amount of food is prepared. (2) Recipes are specific as to portion yield, method of preparation, quantities of ingredients, and time and temperature guidelines.
During a review of the facility's P&P titled Portion Control, dated 2023, the P&P indicated, Policy: To provide specific portion control information. Procedure: To be sure portions served equal sizes listed on the menu, portion control equipment must be used. A variety of portion control equipment should be available and utilized by employes portioning food. (3) A diet scale should be used to weigh meats. A scale that will weigh over two pounds or less accurate for weighing food in ounces. It is not always necessary to weigh every slice of meat, but test weighing should be done periodically to ensure accuracy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance when:
a.
The buttered carrots had no butter flavor.
b.
The mashed potatoes were bland in taste and had no flavor.
This failure had the potential to result in 80 of 81 facility residents, getting food from the kitchen including Residents 27, 42,78, and 82 at risk of unplanned weight loss, a consequence of poor food intake.
Findings:
During a review of Resident 42's admission Record, the admission record indicated the facility admitted Resident 42 on 10/17/2024 with diagnoses including, but not limited to, chronic kidney disease ([CKD] a long term condition where the kidneys are damaged and cannot filter blood properly), chronic obstructive pulmonary disease ([COPD] a common lung disease that makes it difficult to breathe and protein-calorie malnutrition (a nutritional status where the body is lacking nutrients leading changes in the body composition and functions).
During a review of Resident 42's Minimum Data Set (MDS, a resident assessment tool), dated 10/23/2024, the MDS indicated Resident 42' cognition (process of thinking and reasoning) was moderately intact for daily decision making. The MDS indicated Resident 42 required partial or moderate assistance (helper does less than half the effort) when eating.
During a review of Resident 42's Order Summary Report, dated 11/3/2024, the order summary report indicated an order for a fortified (adding food items on the tray to provide additional nutrients) diet, no added salt([NAS] no salt packet served on the tray) with regular texture and thin liquid (fluids with no restriction) consistency.
During an interview on 11/12/2024 at 11:44 a.m., with Resident 42, Resident 42 stated the food was bland.
During a review of Resident 82's admission Record, the admission record indicated the facility admitted Resident 82 on 10/16/2024 with diagnoses including, but not limited to, dysphagia (difficulty swallowing), and protein calorie malnutrition.
During a review of Resident 82's MDS, dated [DATE], the MDS indicated Resident 82 was able to understand and make decisions. The MDS indicated Resident 82 required set up and clean-up assistance when eating.
During a review of Resident 82's Order Summary Report, dated 11/5/2024, the order summary report indicated Resident 82 was ordered NAS, mechanical soft chopped texture (foods that are soft and easy to chew), thin liquid consistency diet.
During an interview on 11/12/2024 at 11:44 a.m., with Resident 82, Resident 82 stated the food was horrible.
During a review of Resident 78's admission Record, the admission record indicated the facility admitted Resident 78 on 8/30/2024 with diagnoses including, but not limited to, chronic systolic (congestive) heart failure (a serious condition that occurs when heart cannot pump enough blood to meet the body's needs), acute respiratory failure ([ARF], a serious medical condition occurs when the body's is unable to provide enough oxygen to the blood and organs or remove enough carbon dioxide from the body) and ascites (a condition where fluid builds up in the abdomen that covers the abdominal organs.).
During a review of Resident 78's MDS, dated [DATE], the MDS indicated Resident 78 was able to understand and make decisions. The MDS indicated Resident 78 required set up and clean-up assistance when eating.
During a review of Resident 78's Order Summary Report, dated 8/30/2024, the order summary report indicated an order for NAS, regular texture, thin liquids diet.
During an interview on 11/12/2024 at 10:19 a.m., with Resident 78, Resident 78 stated the food sucks and it's like poison. Resident 78 stated the kitchen offered alternative like sandwiches, but it was not good.
During a review of Resident 27's admission Record, the admission record indicated the facility admitted Resident 27 on 10/5/2024 with diagnoses including, but not limited to, dysphagia, obstructive and reflux uropathy (a blockage in the urinary tract that prevents urine from draining causing it to back up into the kidneys), and essential hypertension ([HTN] high blood pressure).
During a review of Resident 27's MDS, dated [DATE], the MDS indicated Resident 27 was not able to understand and make decisions. The MDS indicated Resident 27 required set up and clean-up assistance when eating.
During a review of Resident 27's Order Summary Report, dated 10/5/2024, the order summary report indicated an order for a NAS, regular texture, thin liquid consistency diet.
During an interview on 11/12/2024 at 10:25 a.m., with Resident 27, Resident 27 stated the food was not good.
During a review of the facility's daily spreadsheet titled Menus Cycle 4, 2024 dated 11/12/2024, the spreadsheet indicated residents on regular diet (diet with no restriction) and NAS would get the following food items:
Meatloaf four (4) ounces (oz, unit measurement)
Mashed potato half (1/2) cup (cup, household measurement)
Gravy
Buttered carrots ½ c
Roll 1 each
Margarine 1 each
Winter fruit cup 3 ¼ oz
Beverage 8 oz
During a concurrent observation and interview on 11/12/2024 at 12:20 p.m., of the test tray (a process of checking the temperature, tasting, and evaluating the quality of food) with the Dietary Supervisor (DS) and Registered Dietitian (RD), the DS stated the buttered carrots did not seem to have a butter flavor and the mashed potatoes were bland in taste. The DS stated the cook maybe did not follow the recipe. The DS stated the residents may not eat the food and would not be happy with the food if was not flavorful.
During a review of the facility's Policies and Procedures (P&P) titled Food Preparation, dated 7/19/2024, the P&P indicated, POLICY: Food shall be prepared by methods that conserve nutritive value, flavor, and appearance. PROCEDURE: (1) The facility will use approved recipes, standardized to meet the resident census. (3) Prepared food will be sampled. The Food and Nutrition Services employee who prepares the food will sample it to be sure the food has a satisfactory flavor and consistency. Use a clean spoon or put a small portion of the food in a dish and taste from the dish. (4) Poorly prepared food will not be served-such food is to either be improved, prepared again, or replaced with an appropriate substitution. Note that increased amounts of herbs and spices (not salt) may be added, since potency of products may vary.
During a review of the facility's standardized recipe titled Buttered Carrots, undated, the standardized recipe indicated Ingredients: sliced carrots, salt, black pepper, melted margarine. If using butter buds instead of margarine: prepare the butter buds liquid by combining the warm water with the butter buds. Mix well.
During a review of the facility's standardized recipe titled Mashed Potatoes, undated, the standardized recipe indicated Ingredients: water, potato pearl, margarine, salt, black pepper.

Based on observation, interview and record review, the facility failed to prepare foods in a form designed to meet individual needs when residents on puree level four (4) diet (diet consisted of food that are soft with pudding like consistency) received meatloaf that could not hold its shape and puree carrot were weeping water.
This failure had the potential to result in coughing, choking (to keep from breathing the normal way) and death for eight (8) of 81 residents on the puree diet.
Findings:
During a review of the facility's daily spreadsheet titled Menu Cycle 4, dated 11/12/2024, the spreadsheet indicated residents' meals on puree level 4 diet would include the following foods on the tray:
Puree meatloaf half (1/2) cup ([c] household measurement)
Mashed potato with gravy ½ c
Puree buttered carrots 1/3 c
Puree bread 1 piece (pc)
Margarine 1 pc.
Puree winter fruit cup 1/3 c
Beverage 8 oz.
During a concurrent observation and interview on 11/12/2024 at 10:31 a.m., with [NAME] 1 in the tray-line (an area where foods were assembled on the trays) area, [NAME] 1 stated she already prepared the puree foods. The puree carrots in the steamtable appeared watery with a runny consistency and the puree meat looked like it would not hold its shape.
During a concurrent observation and interview on 11/12/2024 at 12:27 p.m., with Dietary Supervisor (DS) and Registered Dietitian (RD), of the test tray (a process of checking the temperature, tasting, and evaluating the quality of food), the DS stated the puree meatloaf was spread out on the plate while the other puree food held its shape. The DS then read the diet manual definition of puree diet and stated, puree diet should be lump free, not firm and sticky, should hold it shape in place and no liquids seeping from the food. The DS stated the puree meatloaf did not hold its shape on the plate and there was liquid coming out from the puree carrots. The RD stated the puree diets are for residents with dysphagia (difficulty swallowing) and for those without teeth. The RD stated residents could aspirate (when something you swallowed enters the airways and lungs) especially for those residents with difficulty swallowing as a potential outcome of eating foods that were no prepared in the proper textures. The RD stated another potential outcome is that residents may not enjoy their food.
During an interview on 11/13/2024 at 1:35 p.m., with [NAME] 1, [NAME] 1 stated puree food was a difficult texture to make and the meat was always watery.
During a review of the facility's Diet Manual titled Dysphagia Diets, Puree IDDSI Level 4, dated 1/2022, the diet manual indicated Definition: A diet used in the dietary management of dysphagia with the food texture prepared lump-free, not firm or sticky ad holds its shape on the plate. The diet requires no biting or chewing. Any liquids must not separate from the food and the food can fall off a spoon a spoon intact. The food is more easily swallowed and prevents aspiration. All prepared pureed recipes should be tested prior to service to ensure the texture meets the International Dysphagia Diet Standardization Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) guidelines.
During a review of the facility's recipe titled Meatloaf (S-B/T) not dated, the recipe indicated, Puree: Place portion needed from regular prepare recipe into a food processor process to a fine texture. For every five portions needed, prepare a slurry with 1 tablespoon thickener and ½ cup hot liquid. Mix well with a wire whip. Add ½ of the slurry to the meat. Process for 1 minute. If too dry, add more slurry until meat is pudding consistency.
During a review of the facility's recipe titled Buttered Carrots not dated, the recipe indicated, Puree: take drained portions needed from regular prepared recipe and place in a food processor. Process until fine. For every 5 portions, add 3 tablespoon thickener and ¼ cup liquid. Process until smooth, scrape down sides of the bowl. Reprocess 30 second. Reheat to 165°F and serve with #12 scoop.
During a review of IDSSI website titled IDDSI dated 7/2019, the IDSSI website indicated, Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:
a.
Staff improperly labeled food products.
1.
Jello was not labeled with product name.
2.
Dry potato was improperly labeled.
3.
Resident's food from outside was not labeled with the resident's name.
b.
Three (3) dented cans were stored with non-dented cans.
c.
There was chipped, cracked, and rusted kitchen utensils and equipment.
1.
Chopping boards had scratches and had sauce splatter stored in the clean area.
2.
Fruit cutter had rust.
3.
Potato container cover had chips.
4.
Can opener had chips.
5.
48 of 48 resident's tray were cracked.
d.
Kitchen equipment and food preparation surfaces were not cleaned and sanitized.
1.
Clean area for storing pots and pans had crumbs and food particles.
2.
Pans had food residue, spill and burnt surfaces.
3.
Toaster had breadcrumbs residue.
4.
Tray-line (an area where foods were assembled on the trays) top had rust and brown dirt particles.
5.
Microwave had food splatter and dry sauces.
e.
Cook did not check the food temperature prior to tray-line service.
f.
Mashed potato in the steamtable was 125 degrees Fahrenheit ([°F] a scale of temperature).
g.
Staff did not perform hand hygiene.
1.
Cook touched the garbage cover then put on new gloves.
2.
Cook picked up a paper towel off the floor then proceeded plating food in tray-line.
3.
Staff picked up two pieces of paper towel off the floor then proceeded working.
h.
Resident's freezer temperature was not monitored and checked.
These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 80 of 81 medically compromised residents who received food and ice from the kitchen.
Findings:
a.
1. During an observation on 11/12/2024 at 8:42 a.m., of the reach-in freezer, a green food item was not labeled with name.
During an interview on 11/12/2024 at 9:11 a.m., with the Dietary Supervisor (DS), the DS stated their process of labeling and dating foods were as follows:
(1)
Label with product name.
(2)
Label with the date the product was made.
(3)
Label with expiration date.
The DS stated they label food with the product name so that cooks could identify the food items and they label it with the date so that the staff could know the shelf life (length of time which a food item remains usable) of the product. The DS stated if food was not labeled with product name, the staff would not know the food product and could cause cross-contamination as a potential outcome to residents.
2. During an observation on 11/13/2024 at 9:27 a.m., of the dry potato container, the label indicated a use by date of 11/11/2024 and an expiration date of 11/9/2024.
During an interview on 11/13/2024 at 9:55 a.m. with the DS, the DS stated the dry potato label was a typographical error and the expiration year was 2025 instead of 2024.
3. During a concurrent observation and interview on 11/13/2024 at 10:24 a.m. with Licensed Professional Nurse 1 (LVN 1), LVN 1 stated the residents' food inside the Resident Refrigerator was not labeled with the resident's name that the food item belonged to. LVN 1 stated it was important to label outside food with resident's name to make sure they were giving the right food to the right resident to comply with diets and food allergies. LVN 1 stated potential outcome to the residents could be allergic reactions and incorrect diets given to the residents.
During a review of facility's Policies and Procedures (P&P) titled Labeling and Dating of Foods, dated 2023, the P&P indicated, POLICY: All food items in the storeroom, refrigerator, and freezer need to be labeled and dated based on established procedures for either food safety or product rotation (FIFO- First In-First Out). Once daily, the PM cook and or PM diet aide will be responsible to inspect the refrigerators and discard perishable foods that are TCS in order to ensure food safety. Working containers holding food or food ingredients that are removed from their original packages for use in the food facility, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar, shall be identified with common name of the food, except that containers holding food that can be readily and unmistakably recognized, such as dry pasta, need not be identified.
During a review of facility's Policies and Procedures (P&P) titled Foods Brought by Family or Visitors, dated 7/21/2023, the P&P indicated It is the policy of the facility that food(s) brought to a resident by family/visitors must be accepted by the resident; inspected before facility storage and stored and served in accordance with food safety professional standards. The use of outside foods is a possible intervention for residents with low intake, distinct food preferences, cultural/ethnic preferences, etc. This intervention preserves the resident right to self-determination as much as possible. (5) Resident food shall be stored in the following locations: Resident refrigerator or in the kitchen. Resident food stored in the facility kitchen will be easily distinguishable from facility food. All foods shall be labeled with the resident name, location, and date.
During a review of Food Code 2022, the Food Code 2022 indicated, 3-501.17 Commercially processed food, open and hold cold, (B) except specified in (E) - (G) of this section, refrigerated, ready-to-eat time/temperature control for food safety food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacture's use-by- date if the manufacturer determined the use-by date based on food safety.
b.During a concurrent observation and interview on 11/12/2024 at 9:50 a.m. in the dry storage room with the DS, there were three (3) dented cans stored with the undented cans. The DS stated they separated dented cans in a designated area as dented cans could get a hole that the naked eye could not see and spoil, and it was bad for resident's consumption and residents could get sick from botulism (a rare but serious illness that occurs when the body's nervous system is attacked by a toxin produced by the bacteria).
During a review of facility's P&P titled Food Storage-Dented Cans, dated 2023, the P&P indicated, POLICY: Food in unlabeled, rusty, leaking, broken containers or cans with side seam dents, rim dents, or swells shall not be retained or used by the facility. PROCEDURE: All dented cans (defined as side seam or rim dents) and rusty cans are to be separated from remaining stock and placed in a specified labeled area for return to purveyor for refund. All leaking cans are to be disposed immediately.
During a review of Food Code 2022, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of §3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard.
c.During an observation on 11/12/2024 at 10:10 a.m., the chopping boards had scratches with dried up sauce spilled, the large white chopping board was chipped, the fruit slicer had rust and the container cover for the potatoes was chipped.
1.2.3. During a concurrent observation and interview on 11/12/2024 at 12:40 p.m., with the DS, the DS stated the chopping boards had scratches, and the potato container cover had cracks. The DS stated it was not okay to have kitchen equipment with cracks and scratches as the cracked pieces could get in the food and it would be a cross-contamination issue. The DS stated the slicer looked rusted, needed to be thrown away and should not be used in the kitchen due to cross-contamination. The DS stated the large chopping boards had chips and stains. The DS stated the large chopping boards should not be used and needed to be replaced.
4. During an observation on 11/13/2024 at 9:18 a.m., of the can opener, the can opener metal shelving had a chip.
5. During an observation on 11/13/2024 at 9:33 a.m., of the dishwashing process, 48 of 48 resident's meal trays had cracks and chips.
During an interview on 11/13/2024 at 9:52 a.m., with the DS, the DS stated the can opener was just replaced last month and it should not have any chips as the particles could go in the can of food resulting in cross-contamination.
During a concurrent observation and interview on 11/13/2024 at 10:06 a.m., with the DS, the DS stated the resident's tray had exposed metals and had cracks and chips. The DS stated they needed to get rid of them as residents and staff could get injured and it could be a physical contaminant to the resident's food. The DS stated cross contamination would be the potential outcome to the residents for having cracked and chipped trays.
During a review of the facility's P&P titled Sanitation, dated 2023, the P&P indicated, (11) All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas. (12) Plastic ware, china, and glassware that becomes unsightly, unsanitary, or hazardous because of chips and cracks, or loss of glaze shall be discarded. Plastic ware is bleached as necessary to prevent staining. (20) Separate chopping boards are to be used for preparing meats and vegetables. After each use, chopping boards shall be thoroughly cleaned and sanitized.
During a review of Food Code 2022, the Food Code 2022 indicated, 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints.
d.During an observation on 11/12/2024 at 10:24 a.m. in the pots and pans storage area, the clean pots and pans had dirt, crumbs, and food debris on them. The Pans had food spillage and burnt surfaces. The Bread toaster was covered with plastic and had breadcrumbs and tray-line roof had rust and brown dirt particles.
1. During a concurrent observation and interview on 11/12/2024 at 12:37 p.m., with the DS, the DS stated the preparation areas and other areas in the kitchen were cleaned after each meal. The DS stated the clean storage area for pots and pans had food debris from breakfast and it was not okay due to cross-contamination. DS stated if there was cross-contamination, residents could get sick with stomach issues like vomiting and stomach pain as a potential outcome.
2.3.4. During a concurrent observation and interview on 11/12/2024 at 12:43 p.m., with the DS, the DS stated the bread toaster had crumbs and it should have been cleaned after each use. The DS stated this was a cross-contamination issue. The DS stated the tray-line roof was cleaned after every meal however, it looked dirty and rusted due to the steam coming out from the steamtable. The DS stated it was not acceptable due to cross-contamination of food in the tray-line. The DS stated residents could get sick with stomach pain and diarrhea as a potential outcome of the cross-contamination.
5. During an observation on 11/13/2024 at 9:20 a.m. of the microwave, the microwave had food splatters and dry sauces.
During a concurrent observation and interview on 11/13/2024 at 9:52 a.m., with the DS, the DS stated the microwave was cleaned every after use, however, there was dried up spillage and food inside. The DS stated it was not acceptable to have dried up food spillage in the microwave due to cross-contamination.
During a review of facility's P&P titled Sanitation, dated 2023, the P&P indicated, POLICY: The Food and Nutrition Service Department shall have equipment of the type and in the amount necessary for the preparation, serving and storing of food. There shall be adequate equipment for cleaning and disposal of waste and general storage. All equipment shall be maintained as necessary and kept in working order. (16) The kitchen staff is responsible for all the cleaning with the exception of ceiling vents, light fixtures, and the hood over the stove, while will be cleaned by maintenance staff.
During a review of the facility's job task assignment log titled AM/PM Cooks Job Assignments, undated, the log indicated a schedule to clean all counter tops after use for AM cooks and cover, toaster, cutting boards for PM cooks.
During a review of Food Code 2022, the Food Code 2022 indicated, 4-601.11 (E) Except when dry cleaning methods are used as specified under § 4-603.11, surfaces of utensils and equipment contacting food that is not time/temperature control for safety food shall be cleaned: (1) At anytime when contamination may have occurred; (2) At least every 24 hours for iced tea dispensers and consumer self-service utensils such as tongs, scoops, or ladles; (3) Before restocking consumer self-service equipment and utensils such as condiment dispensers and display containers; and (4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverage and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specification, at a frequency necessary to preclude accumulation of soil or mold.
e.During an observation on 11/12/2024 at 11:03 a.m., of the tray-line, [NAME]
1 started plating the food from the steamtable to the plates and trays without checking the temperature of the foods.
During an interview on 11/12/2024 at 11:25 a.m., with the DS, the DS stated staff took the food temperature before plating the food in the tray-line to ensure food was hot and not undercooked. The DS stated the food temperature record log was blank.
During a review of facility's P&P titled Meal Service, dated 2023, the P&P indicated, POLICY: Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner and served at the appropriate temperatures. (2) Food and Nutrition Services staff member will take the food temperatures prior to service of the meal with a thermometer prior to service of the meal with a thermometer that has been cleaned and sanitized.
f.During an observation on 11/12/2024 at 11:03 a.m., [NAME] 1 took the mashed potatoes temperature in the steamtable and it was 125°F.
During an interview on 11/12/2024 at 11:25 a.m., with the DS, the DS stated the holding temperature of food was 140°F, and if the mashed potatoes was not at 140°F, the residents could complain that the food was cold.
During a review of facility's P&P titled Meal Service dated 2023, the P&P indicated (3) The food will be served on tray-line at the recommended temperatures indicated below and recorded on the daily therapeutic menu in the temperature column of regular food and next to the food item under the therapeutic diet column of each food served. Hot food serving temperature must be at or above minimum holding temperature of 140°F. the temperatures may also be recorded on a temperature log. The temperature of foods should be periodically monitored throughout the meal service to ensure proper hot or cold holding temperature.
g.1. During an observation on 11/12/2024 at 11:06 a.m., [NAME] 1 touched the lid of the garbage can and put on new gloves without performing hand hygiene.
2. During an observation on 11/12/2024 at 11:20 a.m., [NAME] 1 touched the lid of the garbage can then went back to plating food for the residents.
During an interview on 11/12/2024 at 4:06 p.m., with the DS, the DS stated staff must wash their hands as soon as they enter the kitchen, touched their face, hair and when they were coming back from their break. The DS stated staff must not touch the cover of the garbage can or wash their hands after their hands were in contact with dirt on the garbage can because of cross-contamination.
During an observation on 11/13/2024 at 9:17 a.m., Dietary Aide 1 (DA 1) picked up two (2) pieces of paper towel off the floor then went back to work without handwashing.
During an interview on 11/13/2024 at 1:28 p.m., with [NAME] 1, [NAME] 1 stated she needed to wash hands every time she started working and thought that it was okay to not wash hands as long as she could change her gloves. [NAME] 1 stated it was not oaky to touch the garbage lid then go back to work as the bacteria could be on the trash can and it could go to her hands and transfer to the food she handled. [NAME] 1 stated residents could get sick with diarrhea as a potential outcome.
During a review of the facility's P&P titled Handwashing Procedure, dated 2023, the P&P indicated Hand washing is important to prevent the spread of infection. When to wash hands: (8) Touching trash can or lid.
During a review of Food Code 2022, the Food Code 2022 indicated 2-301.14 When to Wash. Food employees shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in food preparation including working with exposed [NAME], clean equipment and utensils, and unwrapped single- service and single-use article and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling service animals or aquatic animals as specified in 2-403.11(B); P (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco products, eating, or drinking; (E) After handling soiled equipment or utensils;(F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; G) When switching between working with raw food and working with ready-to eat food; (H) Before donning gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the hands.
h.During a concurrent observation and interview on 11/13/2024 at 10:20 a.m., with LVN 1, LVN 1 stated the 11-7 nurse shift monitored the temperature of the residents' refrigerator however the freezer temperature was not monitored, and they did not have a log. LVN 1 stated she did not know the reason why the freezer was not monitored because there was ice cream stored in there. LVN 1 stated they monitored the refrigerator and freezer for infection control purposes to ensure food was not spoiled and contaminated. LVN 1 stated residents could get sick with diarrhea and stomach issues if food was not in their proper temperatures.
During a review of the facility's P&P titled Sanitation, dated 2023, the P&P indicated 21. Correct temperatures for the storage and handling of foods are used. Thermometers will be used to check temperatures of refrigerators, freezers, and food storeroom. Thermometers will be also used to check the food at mealtimes.
During a review of the facility's P&P titled Cold Storage Temperature Monitoring and Record Keeping, dated 2023, the P&P indicated Food and Nutrition Services staff shall review and record temperatures of all refrigerators and freezers to ensure the correct temperatures for food storage and handling. Freezer temperature standards are 0°F or below.
During a review of the facility's P&P titled Foods Brought by Family or Visitor, dated 2023, the P&P indicated (8) The temperature of the refrigerator and freezer will be monitored and logged by Nursing/Food Services staff in accordance with the facility professional food safety standards. Any deviations from the correct temperature standards will be reported to the Maintenance Department and/or the DSS for guidance and correction.

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly by not ensuring two (2) of the dumpster's (a large trash metal container designed to be emptied into a truck) were not overflowing with trash, and the dumpster lids remained closed.
This failure had the potential to result in attracting birds, flies, insects, pest and possibly spread infection to 80 of 81 facility residents.
Findings:
During an observation on 11/12/2024 at 3:58 p.m., at the dumpster area, 2 dumpsters were overflowing with trash and the lids could not close.
During a concurrent observation and interview on 11/12/2024 at 4:02 p.m., with the Dietary Supervisor (DS), the DS stated staff threw all the food trash into those dumpsters. The DS stated the dumpsters were overflowing with trash and were open and it was not okay as it could attract pest and rodents that could come in the facility. The DS stated rodents could carry diseases and could pass the disease to the resident as a potential outcome.
During a concurrent observation and interview on 11/12/2024 at 4:09 p.m., with the Environmental Services Director (EVSD) at the dumpster area, the EVSD stated their trash vendor collected their trash once a day and would usually come around 3PM to 3:30 p.m., however they were late today because it was holiday yesterday. The EVSD stated the dumpster was overflowing and it was not okay that it was not closed as it could attract flies and the environment would smell. The EVSD stated this practice was not safe for the resident as it could get resident sick as a potential outcome.
During a review of facility's Policies and Procedures (P&P) titled Miscellaneous Areas, dated 2023, the P&P indicated, Procedure: (1) All food waste must be placed in sealed leak-proof, non-absorbent, tightly closed containers (i.e. plastic bags) and shall be disposed of as necessary to prevent a nuisance or unsightliness. (2) Garbage and trashcan must be inspected daily that no debris is on the ground. or surrounding area, and that the lids are closed. The trash collection area is a potential feeding ground for vermin and rodents and must be kept clean.
During a review of Food Code 2022, indicated, 5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refused are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage of breeding place for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source of contamination of food, equipment, and utensils. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide Restorative Nursing Aide program (RNA, nursing aide program that helps residents maintain their function and joint mobility) to one of three sampled residents (Resident 1) when Resident 1 was not discharged home on 2/6/2024 and continued to stay in the facility until 3/6/2024. Resident 1 did not start receiving RNA services until 2/19/2024.
This deficient practice placed Resident 1 at risk for a decline in ambulation and range of motion ([ROM] how far you can move or stretch a part of your body, such as a joint or a muscle).
Findings
During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted on [DATE] with the diagnosis of history of falling and weakness.
During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 1/27/2024, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact and Resident 1 required partial to moderate assistance (helper does less than half the effort to assist the resident) for activities of daily living (ADLs- eating, dressing, walking, and toileting).
During a review of Resident 1's History and Physical (H & P) dated 1/22/2024, the H &P indicated Resident 1 has capacity to make decisions.
During a review of Resident 1's untitled care plan, dated 1/24/2024, the care plan indicated Resident 1 had ADL self-care performance deficit related to general weakness. Under this care plan Resident 1 had the goal of increasing their current level of function in ADL through the review date (3/4/2024). The care plan had the interventions including monitoring/documenting/reporting to physician as needed any changes and any potential for improvement.
During a review of Resident 1's Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Discharge Summary with dates of service of 1/23/2024 to 2/5/2024, the summary indicated discharge recommendation of home health services and restorative programs were not indicated at this time.
During a review of Resident 1's Discharge Summary, the summary indicated a discharge date of 3/4/2024.
During a review of Resident 1's Nursing Progress Note dated 2/17/2024, the note indicated the physician requested resident to be placed on the RNA program.
During a review of Resident 1's Physician Order dated 2/19/2024, the order indicated RNA program for bilateral lower extremities and bilateral upper extremities omni cycle (leg exerciser) as tolerated, followed by sit to stand transfer training with left lower extremity non weight bearing daily five times a week.
During a review of Resident 1's Physician Order dated 3/1/2024, the order indicated RNA for ambulation with front wheel walker as tolerated five times a week with weight bearing as tolerated on left lower extremity five times a week.
During an interview on 4/5/2024 at 1:08 p.m. with the Director of Rehabilitation ([DOR]overseer of rehabilitation [restoring function] services), the DOR stated RNA was not recommended for Resident 1 because Resident 1 was supposed to be discharged home with home health Services. The DOR stated Resident 1 was started on RNA on 2/19/2024 when Resident 1 requested to start RNA. The DOR stated if RNA services were not provided to a resident they could experience a change in ROM, the resident's level of functioning could stay the same or they could experience a decline. The DOR stated the goal of RNA was to maintain the resident's functional level.
During an interview on 4/5/2024 at 3:28 pm with the Director of Nursing (DON), the DON stated the goal of RNA was to maintain the strength of the resident. The DON stated residents were transitioned to RNA after completing therapy. The DON stated if a resident does not receive RNA services, it could affect a resident's ROM or decrease the resident's strength.
During a review of the facility's policy titled Range of Motion, undated, the policy indicated the facility will provide resident care and services to achieve or maintain or improve level of self-care or mobility. The policy indicated a resident will be assessed if physical/occupational therapy or maintenance ROM program will be appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise the comprehensive resident centered care plan interventions for one of three sampled residents (Resident 1), who had a history of frequent falls between the hours of 4 am and 8 am due to the need to urinate.
This failure resulted in Resident 1 sustaining multiple falls on 12/12/2023, 12/18/2023, 1/10/2024, and 1/16/2024 which had the potential to injury.
Findings:
During a review of Resident 1's admission Record (face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] with difficulty walking, muscle weakness and aphasia (loss of ability to understand or express speech, caused by brain damage).
During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 12/3/2023, the MDS indicated Resident 1 had severe cognitive impairment in attention, orientation, and ability to recall information. According to the MDS, Resident 1 required maximum assistance (helper does more than half the effort) during sit to stand activity and toileting transfer.
During an interview on 1/22/2024, at 3:00 p.m. with Resident 1's Responsible Party (RP), RP stated Resident 1 has had many falls because he gets up to go to the restroom and forgets to ask for help. The staff needs to anticipate Resident 1 will try to go to the restroom even if he denies help. RP stated, Resident 1 usually falls in the early morning when he needs to use the restroom for the first time during the day. RP stated she was not involved in discussing care plan interventions for Resident 1 to prevent further falls and it made her feel frustrated.
During a concurrent interview and record review on 1/23/2024 at 2:00 p.m., with the Licensed Vocational Nurse (LVN) 1, Resident 1's Change of condition (COC) notes dated December 2023 through January 2024 were reviewed. The COC notes indicated Resident 1 had falls on the following dates 12/12/2023, 12/18/2023, 1/10/2024 and 1/16/2024. LVN 1 stated the COC notes indicated Resident 1 falls occurred during the hours of 4am to 8am when Resident 1 was attempting to get up to use the bathroom without assistance.
During a concurrent interview and record review on 1/23/2024 at 2:10 p.m., with the Licensed Vocational Nurse (LVN) 1, Resident 1's Change of condition (COC) notes dated 1/13/2024 was reviewed. The COC indicated on 1/10/2024 at 4 a.m., a loud thump was heard, and Resident 1 was found on the floor trying to get to the restroom. Resident 1 sustained a right elbow laceration and red mark above the right eyebrow. LVN 1 stated Resident 1 frequently forgets to ask for help to get up when trying to use the restroom.
During a concurrent interview and record review on 1/23/2024 at 2:15 p.m., with LVN 1, Resident 1's care plan initiated on 11/28/2023 was reviewed. The care plan indicated Resident 1 was at risk for falls. The care plan goals indicated Resident 1 will be free from falls through the review date of 2/26/2024. The care plan intervention indicated to monitor for unsafe behavior communicate with the interdisciplinary team to discuss new and updated interventions as needed. The care plan interventions did not indicate the pattern of needing to use the restroom early in the morning or his forgetfulness to ask for help. LVN 1 stated there were no interventions revised to reflect Resident 1's pattern of needing to use the restroom early in the morning or his forgetfulness to ask for help.
During a concurrent interview and record review on 1/23/2024 at 3:05 p.m., with the Assistant Director of Nursing (ADON), Resident 1's Fall incident report dated 1/16/2024 was reviewed. The incident report indicated LVN 2 found Resident 1 lying on the bathroom floor with limited range of motion on his right arm, right elbow noted with abrasion (skin cut) and slight bleeding. The incident report indicated Resident 1 had the following predisposing factors, confusion, gait imbalance, impaired memory, resident with poor safety awareness, ambulates without assistance. The ADON stated on 1/16/2024, Resident 1 had an unwitnessed fall at approximately 08:15 a.m. The ADON stated, Resident 1 was found in the bathroom attempting to use the restroom and did not ask for assistance. The ADON stated staff must anticipate Resident 1's pattern of getting up to use the restroom without assistance. The ADON stated, Resident 1's care plan should have been updated to reflect resident specific interventions to direct staff to anticipate Resident 1's needs to use the bathroom in the early morning hours especially if Resident 1 did not void during the night.
During an interview on 1/24/2024, at 11:00 a.m. with Certified Nurse Aide (CNA) 1, CNA 1 stated Resident 1 usually tries to get up in the morning to walk to the restroom. CNA 1 stated, if staff does not know Resident 1's bathroom routine patterns, staff will not know to anticipate he will try to get up on his own even after he denies the need to urinate.
During a concurrent interview and record review on 1/24/2024 at 2:15 p.m., with the ADON, the facility's Policy and Procedure (P&P) titled, Fall Management system dated June 2018 was reviewed. The P&P indicated It was the policy of this facility to provide an environment that remains as free of accident hazards as possible. It was also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and minimize complications if a fall occurs. The P/P indicated a review of the fall incident will include investigation to determine probable causal factors, the investigation will be reviewed by the interdisciplinary team and resident's care plan will be updated. The ADON stated, based on the P&P, Resident 1's probable cause of fall was the resident's need to use the restroom in the morning. The ADON stated, the care plan should have reflected specific resident interventions to address Resident 1's voiding (urination) patterns needs. The ADON stated failing to update the care plan put Resident 1 at risk for further falls that could lead to injury and or death.
Based on interview and record review, the facility failed to revise the comprehensive resident centered care plan interventions for one of three sampled residents (Resident 1), who had a history of frequent falls between the hours of 4 am and 8 am due to the need to urinate.
This failure resulted in Resident 1 sustaining multiple falls on 12/12/2023, 12/18/2023, 1/10/2024, and 1/16/2024 which had the potential to injury.
Findings:
During a review of Resident 1's admission Record (face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] with difficulty walking, muscle weakness and aphasia (loss of ability to understand or express speech, caused by brain damage).
During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 12/3/2023, the MDS indicated Resident 1 had severe cognitive impairment in attention, orientation, and ability to recall information. According to the MDS, Resident 1 required maximum assistance (helper does more than half the effort) during sit to stand activity and toileting transfer.
During an interview on 1/22/2024, at 3:00 p.m. with Resident 1's Responsible Party (RP), RP stated Resident 1 has had many falls because he gets up to go to the restroom and forgets to ask for help. The staff needs to anticipate Resident 1 will try to go to the restroom even if he denies help. RP stated, Resident 1 usually falls in the early morning when he needs to use the restroom for the first time during the day. RP stated she was not involved in discussing care plan interventions for Resident 1 to prevent further falls and it made her feel frustrated.
During a concurrent interview and record review on 1/23/2024 at 2:00 p.m., with the Licensed Vocational Nurse (LVN) 1, Resident 1's Change of condition (COC) notes dated December 2023 through January 2024 were reviewed. The COC notes indicated Resident 1 had falls on the following dates 12/12/2023, 12/18/2023, 1/10/2024 and 1/16/2024. LVN 1 stated the COC notes indicated Resident 1 falls occurred during the hours of 4am to 8am when Resident 1 was attempting to get up to use the bathroom without assistance.
During a concurrent interview and record review on 1/23/2024 at 2:10 p.m., with the Licensed Vocational Nurse (LVN) 1, Resident 1's Change of condition (COC) notes dated 1/13/2024 was reviewed. The COC indicated on 1/10/2024 at 4 a.m., a loud thump was heard, and Resident 1 was found on the floor trying to get to the restroom. Resident 1 sustained a right elbow laceration and red mark above the right eyebrow. LVN 1 stated Resident 1 frequently forgets to ask for help to get up when trying to use the restroom.
During a concurrent interview and record review on 1/23/2024 at 2:15 p.m., with LVN 1, Resident 1's care plan initiated on 11/28/2023 was reviewed. The care plan indicated Resident 1 was at risk for falls. The care plan goals indicated Resident 1 will be free from falls through the review date of 2/26/2024. The care plan intervention indicated to monitor for unsafe behavior communicate with the interdisciplinary team to discuss new and updated interventions as needed. The care plan interventions did not indicate the pattern of needing to use the restroom early in the morning or his forgetfulness to ask for help. LVN 1 stated there were no interventions revised to reflect Resident 1's pattern of needing to use the restroom early in the morning or his forgetfulness to ask for help.
During a concurrent interview and record review on 1/23/2024 at 3:05 p.m., with the Assistant Director of Nursing (ADON), Resident 1's Fall incident report dated 1/16/2024 was reviewed. The incident report indicated LVN 2 found Resident 1 lying on the bathroom floor with limited range of motion on his right arm, right elbow noted with abrasion (skin cut) and slight bleeding. The incident report indicated Resident 1 had the following predisposing factors, confusion, gait imbalance, impaired memory, resident with poor safety awareness, ambulates without assistance. The ADON stated on 1/16/2024, Resident 1 had an unwitnessed fall at approximately 08:15 a.m. The ADON stated, Resident 1 was found in the bathroom attempting to use the restroom and did not ask for assistance. The ADON stated staff must anticipate Resident 1's pattern of getting up to use the restroom without assistance. The ADON stated, Resident 1's care plan should have been updated to reflect resident specific interventions to direct staff to anticipate Resident 1's needs to use the bathroom in the early morning hours especially if Resident 1 did not void during the night.
During an interview on 1/24/2024, at 11:00 a.m. with Certified Nurse Aide (CNA) 1, CNA 1 stated Resident 1 usually tries to get up in the morning to walk to the restroom. CNA 1 stated, if staff does not know Resident 1's bathroom routine patterns, staff will not know to anticipate he will try to get up on his own even after he denies the need to urinate.
During a concurrent interview and record review on 1/24/2024 at 2:15 p.m., with the ADON, the facility's Policy and Procedure (P&P) titled, Fall Management system dated June 2018 was reviewed. The P&P indicated It was the policy of this facility to provide an environment that remains as free of accident hazards as possible. It was also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and minimize complications if a fall occurs. The P/P indicated a review of the fall incident will include investigation to determine probable causal factors, the investigation will be reviewed by the interdisciplinary team and resident's care plan will be updated. The ADON stated, based on the P&P, Resident 1's probable cause of fall was the resident's need to use the restroom in the morning. The ADON stated, the care plan should have reflected specific resident interventions to address Resident 1's voiding (urination) patterns needs. The ADON stated failing to update the care plan put Resident 1 at risk for further falls that could lead to injury and or death.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their policy to notify the physician for one of three sampled residents (Resident 2), when the facility did not have Resident 2's ordered medications available and did not administer Amiodarone (drug that works to keep heart rhythm regular), Apixaban (drug used to prevent blood clots), Doxazosin (drug used to keep heart rhythm regular) and Metoprolol (drug used to treat high blood pressure) as ordered.
This failure had the potential to cause a delay in needed assessments, services, and treatments for Resident 2.
Findings:
During a review of Resident 2's admission Record (face sheet), the face sheet indicated Resident 2 was admitted to the facility on [DATE] with difficulty walking, muscle weakness and atrial fibrillation (condition when heart beats irregularly).
During a review of Resident 2's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 1/1/2024, the MDS indicated Resident 2 was cognitively intact (able to recall and register information). According to the MDS, Resident 2 required was dependent (helper does all the effort) on staff during sit to stand activity and toileting transfer.
During a concurrent interview and record review on 1/23/2023 at 11:45 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 2's Medication Administration Record (MAR), dated 12/1/2023 through 12/31/2023 was reviewed. The MAR indicated the following:
1.Amiodarone Tablet 200 milligrams (mg-unit of measure), give 1 tablet (pill) by mouth two times a day for atrial fibrillation, the MAR indicated on 12/30/2023 the 5pm Amiodarone dose was not administered.
2.Apixaban oral tablet 5 mg, Give one tablet by mouth two times a day for atrial fibrillation, the MAR indicated on 12/30/2023, the 5pm Apixaban dose was not administered
3.Doxazosin Mesylate tablet 4mg, give one tablet by mouth two times a day for atrial fibrillation, the MAR indicated on 12/30/2023, the 5pm Doxazosin dose was not administered.
4.Metoprolol Succinate Extended Release (ER-drug designed to slowly release in the body) 24 hours, 25 mg give one tablet by mouth two times a day for hypertension (blood pressure), the MAR indicated on 12/30/2023 the 5pm Metoprolol dose was not administered. LVN 1 stated Amiodarone, Apixaban, Doxazosin and Metoprolol were not administered on 12/30/2023 as indicated in the MAR.
During a concurrent interview and record review on 1/23/2023 at 12:00 p.m., with LVN 1, Resident 2's eMAR medication progress notes dated 12/30/2023 was reviewed. The progress notes indicated the following: on 12/30/2023 at 7:14 p.m., Amiodarone tablet 200mg was pending pharmacy delivery, on 12/30/2023 at 7:15 p.m., Apixaban tablet 5mg was pending pharmacy delivery, on 12/30/2023 at 7:15p.m., Doxazosin Mesylate tablet 4 mg was pending pharmacy delivery, on 12/30/2023 at 7:16 p.m., Metoprolol Succinate ER Tablet 25 mg was pending pharmacy delivery. LVN 1 stated Resident 2 was not administered four medications ordered by the physician to be given at 5pm on 12/30/2023 because pharmacy did not delivery them yet.
During a review of the facility's policy and procedure (P/P) titled Medication Administration Policy, undated, the P/P indicated medications are administered within 60 minutes of scheduled time (one hour before and one hour after).
During an interview on 1/24/2024, at 2:30 p.m. with the Assistant Director of Nursing (ADON), the ADON stated Resident 2's physician was not notified Resident 2 did not receive four medications orders. The ADON stated the physician should have been notified per facility policy to ensure Resident 2 does not receive a delay in care or services. The ADON stated failing to notify the physician put Resident 2 at risk for further declines in health and had the potential to delay assessments and therapies.
During a review of the facility's policy and procedure (P/P) titled Miscellaneous Special Situations, Unavailable medications, dated August 2019, the P/P indicated nursing staff shall notify the attending physician of the situation and explain the circumstances, expected availability and optional therapies available, obtain a new order and cancel/discontinue the order for the non-available medication.
Based on interview and record review, the facility failed to implement their policy to notify the physician for one of three sampled residents (Resident 2), when the facility did not have Resident 2's ordered medications available and did not administer Amiodarone (drug that works to keep heart rhythm regular), Apixaban (drug used to prevent blood clots), Doxazosin (drug used to keep heart rhythm regular) and Metoprolol (drug used to treat high blood pressure) as ordered.
This failure had the potential to cause a delay in needed assessments, services, and treatments for Resident 2.
Findings:
During a review of Resident 2's admission Record (face sheet), the face sheet indicated Resident 2 was admitted to the facility on [DATE] with difficulty walking, muscle weakness and atrial fibrillation (condition when heart beats irregularly).
During a review of Resident 2's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 1/1/2024, the MDS indicated Resident 2 was cognitively intact (able to recall and register information). According to the MDS, Resident 2 required was dependent (helper does all the effort) on staff during sit to stand activity and toileting transfer.
During a concurrent interview and record review on 1/23/2023 at 11:45 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 2's Medication Administration Record (MAR) , dated 12/1/2023 through 12/31/2023 was reviewed. The MAR indicated the following:
1.Amiodarone Tablet 200 milligrams (mg-unit of measure), give 1 tablet (pill) by mouth two times a day for atrial fibrillation, the MAR indicated on 12/30/2023 the 5pm Amiodarone dose was not administered.
2.Apixaban oral tablet 5 mg, Give one tablet by mouth two times a day for atrial fibrillation, the MAR indicated on 12/30/2023, the 5pm Apixaban dose was not administered
3.Doxazosin Mesylate tablet 4mg, give one tablet by mouth two times a day for atrial fibrillation, the MAR indicated on 12/30/2023, the 5pm Doxazosin dose was not administered.
4.Metoprolol Succinate Extended Release (ER-drug designed to slowly release in the body) 24 hours, 25 mg give one tablet by mouth two times a day for hypertension (blood pressure), the MAR indicated on 12/30/2023 the 5pm Metoprolol dose was not administered. LVN 1 stated Amiodarone, Apixaban, Doxazosin and Metoprolol were not administered on 12/30/2023 as indicated in the MAR.
During a concurrent interview and record review on 1/23/2023 at 12:00 p.m., with LVN 1, Resident 2's eMAR medication progress notes dated 12/30/2023 was reviewed. The progress notes indicated the following: on 12/30/2023 at 7:14 p.m., Amiodarone tablet 200mg was pending pharmacy delivery, on 12/30/2023 at 7:15 p.m., Apixaban tablet 5mg was pending pharmacy delivery, on 12/30/2023 at 7:15p.m., Doxazosin Mesylate tablet 4 mg was pending pharmacy delivery, on 12/30/2023 at 7:16 p.m., Metoprolol Succinate ER Tablet 25 mg was pending pharmacy delivery. LVN 1 stated Resident 2 was not administered four medications ordered by the physician to be given at 5pm on 12/30/2023 because pharmacy did not delivery them yet.
During a review of the facility's policy and procedure (P/P) titled Medication Administration Policy , undated, the P/P indicated medications are administered within 60 minutes of scheduled time (one hour before and one hour after).
During an interview on 1/24/2024, at 2:30 p.m. with the Assistant Director of Nursing (ADON), the ADON stated Resident 2's physician was not notified Resident 2 did not receive four medications orders. The ADON stated the physician should have been notified per facility policy to ensure Resident 2 does not receive a delay in care or services. The ADON stated failing to notify the physician put Resident 2 at risk for further declines in health and had the potential to delay assessments and therapies.
During a review of the facility's policy and procedure (P/P) titled Miscellaneous Special Situations, Unavailable medications , dated August 2019, the P/P indicated nursing staff shall notify the attending physician of the situation and explain the circumstances, expected availability and optional therapies available, obtain a new order and cancel/discontinue the order for the non-available medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident, who was in severe back pain and was at the facility for pain management, received Hydrocodone-Acetaminophen ([Norco] a combination medication used to relieve moderate to severe pain) 10/325 milligram ([mg] a unit of weight measurement), for severe pain, for one of three sampled residents (Resident 1). The facility failed to:
1. Ensure licensed nurses ordered a refill of Norco 10/325 mg for Resident 1's moderate to severe pain management before its quantity was depleted, leaving Resident 1 in severe pain.
2. Ensure Registered Nurse Supervisor (RNS 1) contacted Resident 1's physician or the facility's Medical Director for authorization to take Norco 10/325 mg from the facility's emergency kit ([E-Kit] a kit that contains a small quantity of medications that can be dispensed when pharmacy service is not available) where six Norco 10/325 mg tablets were available, to administer to Resident 1 for severe back pain.
3. Ensure Resident 1 was medicated to control her severe pain as ordered by the physician and care planned.
4. Ensure licensed nurses followed the facility's Policy and Procedure (P&P) titled, Medication Orders, Controlled Substance Prescriptions, to refill Norco and send the request form to the pharmacy five (5) days in advance to assure an adequate supply of Norco was on hand for administration to Resident 1.
These deficient practices resulted in Resident 1 experiencing uncontrolled severe back pain for approximately 22 hours without a relief. Resident 1 was eventually transferred to a General Acute Care Hospital (GACH) on 12/25/2023 at 10 a.m., for evaluation of uncontrolled back pain where she was administered intravenous ([IV] in the vein) Morphine (a medication used for severe pain) to relieve her uncontrolled
severe pain.
Findings:
A review of Resident 1's admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included orthopedic (a medical specialty that deals with the treatment of bones that did not grow correctly or sustained damaged) aftercare (care provided following a surgical procedure), arthrodesis status (orthopedic surgery in which two or more bones in a joint are fused (joined together) to become one larger bone), and difficulty in walking.
A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care planning tool), dated 12/19/2023, indicated Resident 1 was able to make independent decisions that were reasonable and consistent and was able to understand and be understood by others. The MDS indicated Resident 1 experienced severe pain frequently over the last five days making it hard to sleep.
A review of Resident 1's Care Plan, dated 12/14/2023, indicated Resident 1 had acute/chronic pain related to lumbar stenosis (a narrowing of the spinal canal in the lower part of the back) with five prior lumbar surgeries with misplaced plates, rods, and screws, removal of hardware decompression (a release of physical pressure from plates, rods, and screws used to keep spine stable), laminectomy (a surgical procedure to relieve pressure on the nerves by removing the arched back piece of the vertebrae [backbone]) and fusion (surgery to connect two or more bones together) of the thoracic 11 (the middle section of the spine) vertebrae through the sacrum bone 1 (a triangle shaped bony structure at the base of the lumbar vertebrae). The care plan goal for Resident 1 was to verbalize adequate pain relief or the ability to cope with incompletely relieved pain. The Care Plan interventions included to anticipate Resident 1's need for pain relief and respond immediately to any complaint of pain and administer analgesics (pain medications) as ordered by the physician.
A review of Resident 1's Physician's Orders indicated the following:
1. On 12/14/2023 - an order for Tylenol 325 mg, give two tablets by mouth every four hours as needed for mild pain (from 1 to 3) rated on a zero to 10 pain rating scale (a subjective [personal view] measure in which individuals rate their pain on an 11 point scale; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain).
2. On 12/24/2023 - Norco 10/325 mg one tablet every four hours as needed for moderate pain (4-6) to severe pain (7-10).
A review of Resident 1's Progress Note, dated 12/14/2023 and timed at 12:52 p.m., indicated Resident 1 was admitted to the facility from a GACH after an elective surgery to remove misplaced back hardware with severe stenosis, had hardware decompression with a history of multiple back surgeries. The Progress Note indicated Resident 1 was transferred to the facility (12/14/2023) for observation and management of physical condition/symptoms, and medication management for pain.
A review of Resident 1's Controlled Medication Count Sheet, dated 12/23/2023 and timed at 9:20 a.m., indicated Resident 1 had one tablet of Norco 10/325 mg left.
A review of Resident 1's Pharmacy Medication Order form, dated 12/23/2023 indicated, Resident 1's refill order for Norco 10/325 mg was faxed to the pharmacy on 12/23/2023 at 11:56 p.m., when Resident 1 had only one tablet (for one time dose) of Norco remaining available.
A review of Resident 1's Medication Administration Record (MAR), dated 12/2023 indicated Resident 1's last (available at the facility) dose of Norco10/325 mg was administered at 1:01 p.m., on 12/24/2023. The MAR indicated Resident 1's pain level was a 10 on a pain scale of 1 to 10 and was administered Tylenol 650 mg (usually given for mild pain rating 1-3) on 12/25/2023, at 8:36 a.m.
A review of Resident 1's Change in Condition Evaluation (COC), dated 12/25/2023 and timed at 10:05 a.m., indicated at 9:30 a.m., Resident 1 had an uncontrolled severe pain rated at 10. The COC indicated Resident 1 was tearful and had decreased mobility. The COC indicated there was no pain medication available, and the facility was waiting for Resident 1's pain medication (Norco 10/325 mg) to be delivered. The COC indicated Resident 1's physician was notified of Resident 1's pain level and an order was obtained to transfer Resident 1 to the GACH ' s emergency room (ER) for uncontrolled severe back pain.
A review of Resident 1's physician order dated 12/25/2023, indicated to transfer Resident 1 to the GACH ER for uncontrolled severe back pain.
A review of Resident 1's Transfer Form, dated 12/25/2024 indicated Resident 1 was transferred to the GACH on 12/25/2023 at 10 a.m. for uncontrolled severe back pain.
A review of Resident 1's Narcotic Prescription Form Long Term Care Facility Patient, indicated a fax confirmation indicating the order for Norco (Hydrocodone-Acetaminophen) refill was faxed to the pharmacy on 12/25/2023 at 3:59 a.m.
A review of Resident 1's GACH ER records, dated 12/25/2023 and timed at 11:13 a.m., indicated Resident 1's chief complaint was uncontrolled severe back pain that started on 12/24/2023, and radiated down Resident 1's right leg. The ER record indicated Resident 1 received IV Morphine to relief her uncontrolled severe pain.
During a concurrent interview and record review, on 1/11/2024, at 3:34 p.m., with Registered Nurse Supervisor (RNS 1) Resident 1's MAR dated 12/2023 was reviewed. The MAR indicated on 12/25/2023 Tylenol 650 mg was given at 8:36 a.m., for a pain level of 10 out of 10. RNS 1 stated Tylenol 650 mg was administered to Resident 1 because Norco was not available. RNS 1 stated Norco had been ordered (12/24/2023) and was expected to be delivered to the facility at any time. RNS 1 stated there were six tablets of Norco available in the facility's E-Kit but because Resident 1 was being transferred to the GACH, she (RNS 1) did not think to call the Medical Director to obtain an order to retrieve Norco from the E-Kit and instead gave Resident 1 Tylenol 650 mg. RNS 1 stated she should have called the Medical Director to get authorization to access the Norco from the E-Kit earlier so that Resident 1's pain could have been under control sooner.
During an interview on 1/11/2024 at 4:25 p.m., the Assistant Director of Nursing (ADON) stated, when medications are close to running out and get down to approximately 7-10 tablets, a medication order should be placed to refill the medication. The ADON stated in order to obtain a refill for a narcotic, the licensed nurse has to call the physician, the physician then calls the pharmacy to authorize the refill. Then ADON stated if the medication needed to be retrieved from the E-Kit, the licensed nurse has to call the physician, the physician then calls the pharmacy to authorize the medication to be taken from the E-Kit, then the pharmacy calls the facility to authorize the licensed nurse to retrieve the medication from the E-Kit. The ADON stated the nursing staff should have ordered Resident 1's pain medication before it was completely out of stock and called the physician and/or the Medical Director to get access to the Norco in the E-Kit so that Resident 1's pain could be controlled by preventing a delay in Resident 1's pain medication administration and transfer to the GACH.
During an interview on 1/12/2024 at 4:24 p.m., a Certified Nurse Assistant (CNA 1) stated Resident 1 was in a lot of pain, (12/24/2023 during the night), she (Resident 1) was moaning, crying, and had shooting pain down both of her hips. CNA 1 stated he (CNA 1) approached the charge nurse (CN 1) three to four times during her shift (11 p.m.-7 a.m.) to ask if Resident 1's pain medication had been approved, and the charge nurse told him no it had not.
During an interview on 1/12/2024 at 12:59 p.m., Licensed Vocational Nurse (LVN 2) stated, it was important to order the pain medication before its quantity became too low, so they did not run out of it, leaving Resident 1 in severe pain. LVN 2 stated she did not realize Resident 1's pain medication was running out.
During an interview on 1/16/2024 at 3 p.m., the Director of Nursing (DON) stated the nurse should have sent the refill order for Norco at least three days ahead, so there was no delay in Resident 1 receiving pain medication.
A review of the facility's P&P, titled Medication Orders, Controlled Substance Prescriptions, dated 8/2019 indicated emergency pharmacy service is available on a 24-hour basis. Emergency needs for medication are met by using the facility's approved emergency medication supply or by special order from Med-Plus Pharmacy LTC. Med-Plus Pharmacy LTC supplies emergency medications including emergency drugs, antibiotics, controlled substances, products for infusion in limited quantities in portable, sealed containers in compliance with applicable State regulation. To access medication from the emergency kit secondary to a new order or when medication for which there is a current prescription is not readily available, the nurse confers with the prescriber to determine whether the order is a true emergency., i.e., order cannot be delayed util the scheduled pharmacy delivery. If the medication is a controlled substance, the prescriber either faxes a complete prescription to the facility and pharmacy or communicates the verbal order to both the nurse and directly to the pharmacist along with details about the situation to verify that it meets the criteria of an emergency situation.
A review of the facility's P&P, titled, Medication Orders, Controlled Substance Prescriptions, dated 8/2019, indicated, if a partial fill quantity of schedule II ([CIIs] drugs that require additional care because of the potential for the patient to intentionally or unintentionally abuse the drug) medication remains, refills are written on a medication order form or ordered by peeling the top label from the label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose and requested from the pharmacy five (5) days in advance of need to assure an adequate supply is on hand.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who had a history of back surgery, and was admitted to the facility for pain management with an order for Hydrocodone-Acetaminophen ([Norco] a combination medication used to relieve moderate to severe pain)10-325 milligrams ([mg] a unit of measurement) for severe pain, had the order for Norco refilled in time enough to ensure its availability for 1 of 3 sampled residents (Resident 1). The facility failed to:
1. Ensure licensed nurses ordered a refill of Norco 10/325 mg for Resident 1's moderate to severe pain management before its quantity was depleted, leaving Resident 1 in severe pain.
2. Ensure Registered Nurse Supervisor (RNS 1) contacted Resident 1's physician or the facility ' s Medical Director for authorization to take Norco 10/325 mg from the facility's emergency kit ([E-Kit] a kit that contains a small quantity of medications that can be dispensed when pharmacy service is not available) where six Norco 10/325 mg tablets were available, to administer to Resident 1 for severe back pain.
3. Ensure Resident 1 was medicated to control her severe pain as ordered by the physician and care planned.
4. Ensure licensed nurses followed the facility's Policy and Procedure (P&P) titled, Medication Orders, Controlled Substance Prescriptions, to refill Norco and send the request form to the pharmacy five (5) days in advance to assure an adequate supply of Norco was on hand for administration to Resident 1.
These deficient practices resulted in Resident 1 experiencing uncontrolled severe back pain for approximately 22 hours. Resident 1 was eventually transferred to a General Acute Care Hospital (GACH) on 12/25/2023 at 10 a.m., for evaluation of uncontrolled back pain where she was administered intravenous ([IV] in the vein) Morphine (a medication used for severe pain) to relieve her uncontrolled severe pain.
Findings:
A review of Resident 1's admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included orthopedic (a medical specialty that deals with the treatment of bones that did not grow correctly or sustained damaged) aftercare (care provided following a surgical procedure), arthrodesis status (orthopedic surgery in which two or more bones in a joint are fused (joined together) to become one larger bone), and difficulty in walking.
A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care planning tool), dated 12/19/2023, indicated Resident 1 was able to make independent decisions that were reasonable and consistent and was able to understand and be understood by others. The MDS indicated Resident 1 experienced severe pain frequently over the last five days making it hard to sleep.
A review of Resident 1's Care Plan, dated 12/14/2023, indicated Resident 1 had acute/chronic pain related to lumbar stenosis (a narrowing of the spinal canal in the lower part of the back) with five prior lumbar surgeries with misplaced plates, rods, and screws, removal of hardware decompression (a release of physical pressure from plates, rods, and screws used to keep spine stable), laminectomy (a surgical procedure to relieve pressure on the nerves by removing the arched back piece of the vertebrae [backbone]) and fusion (surgery to connect two or more bones together) of the thoracic 11 (the middle section of the spine) vertebrae through the sacrum bone 1 (a triangle shaped bony structure at the base of the lumbar vertebrae). The care plan goal for Resident 1 was to verbalize adequate pain relief or the ability to cope with incompletely relieved pain. The Care Plan interventions included to anticipate Resident 1's need for pain relief and respond immediately to any complaint of pain and administer analgesics (pain medications) as ordered by the physician.
A review of Resident 1's Physician's Orders indicated the following:
1. On 12/14/2023 - an order for Tylenol 325 mg, give two tablets by mouth every four hours as needed for mild pain (from 1 to 3) rated on a zero to 10 pain rating scale (a subjective [personal view] measure in which individuals rate their pain on an 11 point scale; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain).
2. On 12/24/2023 - Norco 10/325 mg one tablet every four hours as needed for moderate pain (4-6) to severe pain (7-10).
A review of Resident 1's Progress Note, dated 12/14/2023 and timed at 12:52 p.m., indicated Resident 1 was admitted to the facility from a GACH after an elective surgery to remove misplaced back hardware with severe stenosis, had hardware decompression with a history of multiple back surgeries. The Progress Note indicated Resident 1 was transferred to the facility (12/14/2023) for observation and management of physical condition/symptoms, and medication management for pain.
A review of Resident 1's Controlled Medication Count Sheet, dated 12/23/2023 and timed at 9:20 a.m., indicated Resident 1 had one tablet of Norco 10/325 mg left.
A review of Resident 1's Pharmacy Medication Order form, dated 12/23/2023 indicated, Resident 1's refill order for Norco 10/325 mg was faxed to the pharmacy on 12/23/2023 at 11:56 p.m., when Resident 1 had only one tablet (for one time dose) of Norco remaining available.
A review of Resident 1's Medication Administration Record (MAR), dated 12/2023 indicated Resident 1's last (available at the facility) dose of Norco10/325 mg was administered at 1:01 p.m., on 12/24/2023. The MAR indicated Resident 1's pain level was a 10 on a pain scale of 1 to 10 and was administered Tylenol 650 mg (usually given for mild pain rating 1-3) on 12/25/2023, at 8:36 a.m.
A review of Resident 1's Change in Condition Evaluation (COC), dated 12/25/2023 and timed at 10:05 a.m., indicated at 9:30 a.m., Resident 1 had an uncontrolled severe pain rated at 10. The COC indicated Resident 1 was tearful and had decreased mobility. The COC indicated there was no pain medication available, and the facility was waiting for Resident 1's pain medication (Norco 10/325 mg) to be delivered. The COC indicated Resident 1's physician was notified of Resident 1's pain level and an order was obtained to transfer Resident 1 to the GACH ' s emergency room (ER) for uncontrolled severe back pain.
A review of Resident 1's physician order dated 12/25/2023, indicated to transfer Resident 1 to the GACH ER for uncontrolled severe back pain.
A review of Resident 1's Transfer Form, dated 12/25/2024 indicated Resident 1 was transferred to the GACH on 12/25/2023 at 10 a.m. for uncontrolled severe back pain.
A review of Resident 1's Narcotic Prescription Form Long Term Care Facility Patient, indicated a fax confirmation indicating the order for Norco (Hydrocodone-Acetaminophen) refill was faxed to the pharmacy on 12/25/2023 at 3:59 a.m.
A review of Resident 1's GACH ER records, dated 12/25/2023 and timed at 11:13 a.m., indicated Resident 1's chief complaint was uncontrolled severe back pain that started on 12/24/2023, and radiated down Resident 1's right leg. The ER record indicated Resident 1 received IV Morphine to relief her uncontrolled severe pain.
During a concurrent interview and record review, on 1/11/2024, at 3:34 p.m., with Registered Nurse Supervisor (RNS 1) Resident 1's MAR dated 12/2023 was reviewed. The MAR indicated on 12/25/2023 Tylenol 650 mg was given at 8:36 a.m., for a pain level of 10 out of 10. RNS 1 stated Tylenol 650 mg was administered to Resident 1 because Norco was not available. RNS 1 stated Norco had been ordered (12/24/2023) and was expected to be delivered to the facility at any time. RNS 1 stated there were six tablets of Norco available in the facility's E-Kit but because Resident 1 was being transferred to the GACH, she (RNS 1) did not think to call the Medical Director to obtain an order to retrieve Norco from the E-Kit and instead gave Resident 1 Tylenol 650 mg. RNS 1 stated she should have called the Medical Director to get authorization to access the Norco from the E-Kit earlier so that Resident 1's pain could have been under control sooner.
During an interview on 1/11/2024 at 4:25 p.m., the Assistant Director of Nursing (ADON) stated, when medications are close to running out and get down to approximately 7-10 tablets, a medication order should be placed to refill the medication. The ADON stated in order to obtain a refill for a narcotic, the licensed nurse has to call the physician, the physician then calls the pharmacy to authorize the refill. Then ADON stated if the medication needed to be retrieved from the E-Kit, the licensed nurse has to call the physician, the physician then calls the pharmacy to authorize the medication to be taken from the E-Kit, then the pharmacy calls the facility to authorize the licensed nurse to retrieve the medication from the E-Kit. The ADON stated the nursing staff should have ordered Resident 1's pain medication before it was completely out of stock and called the physician and/or the Medical Director to get access to the Norco in the E-Kit so that Resident 1's pain could be controlled by preventing a delay in Resident 1's pain medication administration and transfer to the GACH.
During an interview on 1/12/2024 at 4:24 p.m., a Certified Nurse Assistant (CNA 1) stated Resident 1 was in a lot of pain, (12/24/2023 during the night), she (Resident 1) was moaning, crying, and had shooting pain down both of her hips. CNA 1 stated he (CNA 1) approached the charge nurse (CN 1) three to four times during her shift (11 p.m.-7 a.m.) to ask if Resident 1's pain medication had been approved, and the charge nurse told him no it had not.
During an interview on 1/12/2024 at 12:59 p.m., Licensed Vocational Nurse (LVN 2) stated, it was important to order the pain medication before its quantity became too low, so they did not run out of it, leaving Resident 1 in severe pain. LVN 2 stated she did not realize Resident 1's pain medication was running out.
During an interview on 1/16/2024 at 3 p.m., the Director of Nursing (DON) stated the nurse should have sent the refill order for Norco at least three days ahead, so there was no delay in Resident 1 receiving pain medication.
A review of the facility's P&P, titled Medication Orders, Controlled Substance Prescriptions, dated 8/2019 indicated emergency pharmacy service is available on a 24-hour basis. Emergency needs for medication are met by using the facility's approved emergency medication supply or by special order from Med-Plus Pharmacy LTC. Med-Plus Pharmacy LTC supplies emergency medications including emergency drugs, antibiotics, controlled substances, products for infusion in limited quantities in portable, sealed containers in compliance with applicable State regulation. To access medication from the emergency kit secondary to a new order or when medication for which there is a current prescription is not readily available, the nurse confers with the prescriber to determine whether the order is a true emergency., i.e., order cannot be delayed util the scheduled pharmacy delivery. If the medication is a controlled substance, the prescriber either faxes a complete prescription to the facility and pharmacy or communicates the verbal order to both the nurse and directly to the pharmacist along with details about the situation to verify that it meets the criteria of an emergency situation.
A review of the facility's P&P, titled, Medication Orders, Controlled Substance Prescriptions, dated 8/2019, indicated, if a partial fill quantity of schedule II ([CIIs] drugs that require additional care because of the potential for the patient to intentionally or unintentionally abuse the drug) medication remains, refills are written on a medication order form or ordered by peeling the top label from the label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose and requested from the pharmacy five (5) days in advance of need to assure an adequate supply is on hand.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the call light device was within reach for one of eight sampled residents (Resident 1).
This deficient practice had the potential to delay Resident 1 from receiving necessary care and services.
Findings:
During a record review of Resident 1's admission record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including aphasia (loss of ability to understand or express speech, caused by brain damage), rheumatoid arthritis (chronic autoimmune inflammatory disease that affects the joints) and dementia (decline in mental ability severe enough to interfere with daily life).
During a record review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment and care-screening tool) dated 9/4/2023 indicated the resident had impaired vision, difficulty hearing, and severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 1 required extensive assistance for bed mobility (moving in bed to and from different positions such as side to side), dressing, eating, toilet use and personal hygiene. The MDS indicated Resident 1 had functional limitations in range of motion (full movement potential of a joint) of both arms (shoulder, elbow, wrist, hand) and both legs (hip, knee, ankle, foot).
During a record review of Resident 1's Fall Risk Evaluation dated 10/27/2023 indicated Resident 1 had fallen one to two times in the past three months and received a total score of 17, indicating high fall risk.
During an observation on 11/7/2023 at 11:49 am, in the resident's room, Resident 1 was lying in bed. Resident 1's call light cord was plugged into the wall behind Resident 1's bed. The call light device was not visible in or around Resident 1's bed.
During an observation and interview on 11/7/2023 at 11:51 am, in the resident's room, Certified Nursing Assistant 2 (CNA 2) entered Resident 1's room and tried to look for Resident 1's call light device. CNA 2 looked in and around the bed but could not find the call light device. CNA 2 followed the call light cord from the wall, untangled the cord which was wrapped around the bottom of the bed frame, and found the call light device inside the closed drawer of the bedside table to the left of Resident 1's bed. CNA 2 confirmed Resident 1's call light was out of reach and the resident would not be able to call for nursing assistance if needed. CNA 2 stated Resident 1 was dependent in mobility and was unable to move her arms and legs well - especially the left side of the body because of pain with movement. CNA 2 stated Resident 1's call light should have been clipped onto the bed sheet and always in or near Resident 1's left hand to ensure it was accessible.
During an interview on 11/9/2023 at 10:57 am, the Director of Nursing (DON) stated call lights should always be accessible and within the resident's reach. The DON stated that if the call light was not within the resident's reach, the resident would be unable to call for assistance to get his or her needs met.
During a review of the facility's undated policy and procedure titled, Answering the Call Light indicated the call light was to be within easy reach of the resident when a resident was in bed or in a chair to ensure the resident's needs and requests were met.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain and calibrate (process that ensures the reading and functionality of a device is accurate and in full working order) the sit to stand lift (a mechanical device used to assist a resident move from a seated position to a standing position) for resident use in accordance with manufactures guidelines.
This deficient practice had the potential to cause injury to any resident who used this equipment as part of their therapy treatment.
Findings:
During an observation on [DATE] at 9:44 am, in the therapy gym, a sit to stand lift was sitting in the left corner of the rehabilitation gym with a calibration sticker dated 2/2022.
During an observation and interview on [DATE] at 10:52 am, in the therapy gym, the Director of Rehabilitation (DOR) confirmed the sit to stand lift in the corner of the therapy gym was last calibrated in 2/2022. The DOR stated she was unsure how often the sit to stand lift was supposed to be calibrated. The DOR stated the sit to stand lift was scheduled to be calibrated last week but was not. The DOR stated the sit to stand lift was used to assist residents who needed help moving into a standing position. The DOR stated the importance of calibrating the sit to stand lift was to ensure the equipment worked properly and was safe for resident use.
During an interview on [DATE] at 12:39 pm, the Maintenance Supervisor (MS) stated the sit to stand lift was last calibrated 2/2022 and was not calibrated in accordance with manufactures guidelines. The MS stated the facility forgot about the sit to stand lift and did not calibrate it. The MS stated the sit to stand lift should be calibrated yearly according to manufacturer's guidelines. The MS stated that it was important to calibrate equipment to ensure the lift worked properly and was safe for resident use.
During an interview on [DATE] at 1:40 pm, the Administrator (ADMN) stated the sit to stand lift in the therapy gym was last calibrated in 2/2022 and was past due for the yearly calibration. The ADMN stated the sit to stand lift calibration expired and should have been calibrated yearly per manufacturers guidelines but was not.
A review of the manufacturer's user manual, dated 10/2002, titled Arjo Encore Operating and Product Care Instructions indicated the manufacturer recommended the scale be calibrated every 12 months for accuracy.
A review of the facility's policy and procedure, dated 1/2023, titled Rehab Equipment Maintenance indicated inspection would include the general condition of equipment and calibration according to manufacturer's specifications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship for one of two sampled residents (Resident 428). Resident 428 was prescribed antibiotic drug without meeting the criteria, after being screen for urinary tract infection ([UTI]an infection in any part of the urinary system).
This deficient practice had the potential for resident to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use.
Findings:
During a review of Resident 428's admission Order (Face Sheet) indicated Resident 428 was initially admitted on [DATE] and re-admitted on [DATE] with diagnoses including essential hypertension (high blood pressure), dysphagia (difficulty of swallowing), anemia (a condition in which the body does not have enough healthy red blood cells) and chronic obstructive pulmonary disease ([COPD] a group of diseases that cause airflow blockage and breathing-related problems).
During a review of Resident 428's physicians order dated 11/07/2023 indicated to start levofloxacin (an antibiotic that may be used to treat different types of bacterial infections) oral tablet 750 mg (unit of measurement): administer one tablet by mouth daily for UTI for five days.
During a review of the Infection Report Surveillance form indicated that Resident 428 was screened for UTI and urine analysis (U/A) was done on 11/07/2023 through collection of urine and was sent to the laboratory and have not received the results and there was no specific micro-organism targeted yet, but physician already ordered levofloxacin 750 mg for UTI for five days.
During an interview on 11/07/2023 at 02:31 p.m., with Infection Preventionist (IP) stated that Resident 428 had altered level of consciousness (ALOC), encephalopathy (any disturbance of the brain's functioning that leads to problems like confusion and memory loss), low blood pressure and asymptomatic of UTI.
During an interview on 11/08/2023 at 10:21 a.m., with IP admitted that when she spoke to the physician but did not challenge the physician about the order of levofloxacin oral 750 mg for five days and admitted that it was a mistake and Resident 428 should have not been prescribed with Levofloxacin because Resident 428 did not meet the criteria for antibiotic. IP stated resident can develop resistance to antibiotics if inappropriately used.
During a review of the facility's [policy and procedure titled, Antimicrobial Stewardship Policy dated 04/01/2018 indicated It is the policy of Alamitos [NAME] Health and Rehabilitation to implement an Antimicrobial Stewardship Program (ASP) which will promote appropriate use of antimicrobials while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antimicrobial use. This policy has the potential to limit antimicrobial resistance in the post-acute care setting, while improving treatment efficacy and resident safety. Facility may consider protocols to address: Improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection, Optimizing the use of diagnostic testing, Optimize the use and duration of antimicrobial therapy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure standard infection control practices were followed by staff for five of eight sampled residents (Residents 59,71,15, 131 and 279) by failing to:
1.
Ensure Resident 59's a gastrostomy tube (G-tube), a tube inserted through the belly that brings nutrition directly to the stomach and dressing (a pad applied to a wound to promote healing and protect from future harm) were applied as indicated in the care plan and physician's order.
2.
Ensure Resident 71's and Resident 15's nebulizer (a device used to administer medication in the form of a mist inhaled into the lungs) mask and nasal cannula (a device used to deliver supplemental oxygen placed directly on the resident's nostrils) was properly stored or changed as indicated in the facility's policy and procedure (P&P).
3.
Ensure Resident 131's drainage tubes dressing (tubes placed near surgical incisions in the post-operative patient, to remove pus, blood, or other fluid, preventing it from accumulating in the body), were changed to prevent the development of infection.
4. Ensure staff perform hand hygiene in between residents care.
These deficient practices had the potential to increase the risk for infection for Residents 59, 71, 15, 131 and 279.
Findings:
1. A review of Resident 59's admission Record (Face Sheet), the admission Record indicated, Resident 59 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including, dysphagia (swallowing difficulties), aphasia (difficulty speaking) and muscle weakness (a lack of strength in the muscles)
A review of Resident 59's Minimum Data Set (MDS), a comprehensive standardized assessment and care-screening tool, dated 8/2/2023, indicated Resident 59 was totally dependent on staff for dressing, toilet use, personal hygiene, bathing, and walking.
A review of Resident 59's Order Summary Report dated 9/12/2023, indicated instructions, G- tube site: Cleanse with normal saline (NS), pat dry, apply dry dressing daily and PRN (as needed) if soiled (not clean) or dislocated (separation of two ends).
During an observation on 11/7/2023 at 9:25 a.m. in Resident 59's room, Resident 59's G-tube site was observed without a dressing.
During a concurrent observation and interview on 11/7/2023 at 9:28 a.m. in Resident 59's room with Licensed Vocational Nurse (LVN 1), LVN 1 stated the G-tube site should have dressing. LVN 1 stated G-tube site without dressing could put Resident 59 at risk for infection.
During an interview on 11/8/2023 at 12:09 p.m. with Infection Preventionist Nurse (IPN), the IPN stated Resident 59's G-tube site should be cleaned, and dressing applied as per physician ordered. IPN stated if Resident 59's G-tube site was left without a dressing, that could lead to an infection, and Resident 59 could get sepsis (infection) and result in death.
2. A review of Resident 71's admission Record, indicated Resident 71 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included, dysphagia, and muscle weakness.
A review of Resident 71's History and Physical (H&P), dated 10/18/2023, the H&P indicated, Resident 71 alert with episodes of confusion.
A review of Resident 71's Minimum Data Set (MDS), a comprehensive standardized assessment and care-screening tool, dated 10/12/2023, the MDS indicated Resident 71 was totally dependent on staff for dressing, toilet use, personal hygiene, bathing, and walking.
During an observation on 11/6/2023 at 10:52 a.m. in Resident 71's room, nebulizer mask was observed on top of Resident 71's bedside table. The mask not stored in the plastic bag and the plastic bag was undated.
During an interview on 11/6/2023 at 10:58 a.m. with Licensed Vocational Nurse (LVN 2), LVN 2 stated the Resident 71's nebulizer mask should be stored in the plastic bag and dated. The mask was changed every seven (7) day to prevent contamination (infection). LVN 2 stated if the nebulizer mask was not stored properly in the bag and changed every 7 days Resident 71 could get an infection.
During an interview on 11/06/2023 at 1:51 p.m. with Registered Nurse (RN 1), RN 1 stated Resident 71's nebulizer mask should be changed every 7 days and as needed. RN 1 stated Resident 71's nebulizer mask should be stored in the plastic bag and dated at Resident 71's bedside. RN 1 stated if Resident 71's nebulizer mask not stored properly in the plastic bag places Resident 71 at risk for infection.
A review of Resident 15's admission Record dated, 10/20/2023, the admission Record indicated Resident 15 was admitted to the facility on [DATE] with diagnosis that included, difficulty in walking, muscle weakness and hypertension (high blood pressure).
A review of Resident 15's MDS, dated [DATE], the MDS indicated Resident 15 needed maximal assistance from staff for dressing, toilet use, personal hygiene, bathing, and walking.
During an observation on 11/6/2023 at 11:00 a.m. in Resident 15's room, oxygen tubing and nebulizer mask was observed on Resident 15's bedside table not stored in a bag and plastic bag undated.
During an interview on 11/06/2023 at 10:58 a.m. with LVN 2, LVN 2 stated Resident 15's oxygen tubing and nebulizer mask should be changed every week and stored in the plastic bag at the Resident 15's bedside to prevent contamination. LVN 2 stated if Resident 15's oxygen tubing and nebulizer mask not stored properly in the bag or changed every week Resident 15 could get infections. Resident 15 could get sepsis and result in death.
During interview on 11/08/2023 at 12:09 p.m. with the IP, the IP stated respiratory treatment-tubing and masks should be stored in the bag at the Resident 15's bedside and changed once a week. IP stated if Resident 15's oxygen tubing and nebulizer mask not stored properly in the bag, and not changed every 7 days as per facility's P&P put Resident 15 at risk for infection.
3. A review of Resident 131's admission Record, dated 10/29/2023, the admission Record indicated Resident 131 was admitted to the facility on [DATE] with diagnosis that included, sepsis (blood borne infection), difficulty walking and hypertension (high blood pressure).
A review of Resident 131's History & Physical (H&P), dated 10/30/2023, the H&P indicated, Resident 131 was alert and has capacity to make decisions.
A review of Resident 131's MDS, dated [DATE], the MDS indicated Resident 131 was totally dependent on staff for dressing, toilet use, personal hygiene, bathing, and walking.
During an observation on 11/07/2023 at 10:10 a.m., in Resident 131's room, Resident 131 was observed with two drainage tubes on the right-side abdomen. Resident 131's drainage tubes dressings were dated 10/18/23 and 10/24/23.
During concurrent observation and interview on 11/08/2023 at 12:09 p.m. with IP, the IP stated nursing staff should check Resident 131's dressing site when passing medications every shift. The IP observed and confirmed drainage tubes dressings dated 10/18/2023 and 10/24/23. The IP stated Resident 131was admitted to the facility on [DATE]. The IP stated Resident 131's drainage tubes dressings should be changed daily or as specified by the physician order. The IP stated if Resident 131's dressings not changed Resident 131 could get an infection.
4.
A review of the admission record indicated Resident 279 was admitted to the facility on [DATE] with a diagnoses including but not limited to, muscle weakness, dysphagia ,oropharyngeal phase (swallowing problems occurring in the mouth and /or the throat), depression, unspecified (a period of depressed mood for two weeks or more).
During a review of Resident 279 's history and physical (H&P) report dated,11/6/2023 the H&P indicated resident 279 had fluctuating capacity ( situations where a person's decision- making ability varies.
During a review of Resident 1's Minimum Data Set (MDS-comprehensive screening tool) dated 11/6/2023 indicated the resident is able to make herself understood and understand others. The resident is totally dependent on staff for Activities of Daily Living.
During an observation on 11/8/2023, at 8:13 a.m., Certified Nurse assistant (CNA) 6, walked into Resident 279's room washed her hands with alcohol-based hand rub (ABHR) put gloves on fixed residents' clothes and repositioned him in bed. CNA 6 then took her gloves off and walked out of the room into the hallway went inside another residents room( room [ROOM NUMBER]) to answer residents call light. CNA 6 then step out of the room and walked into hallway and came back to Resident 279's room to continue helping him.
During an interview on 11/8/2023 at 09:53 a.m. with CNA 6,,. CNA 6 stated I must wash my hands when taking off gloves and going on another residents room. CNA 6 stated it does not matter if your hands are visibly clean. CNA 6 stated it is most important that you wash your hands between residents because you can spread infection.
During an interview on 11/8/2023 at 09:53 a.m., Registered Nurse 1 (RN 1, RN1 stated when working in between residents, staff must wash their hands because not providing proper handwashing can spread infection.
During an interview on 11/8/2023 at 12:23 p.m., CNA 6 stated she later realized she did not wash her hands when leaving Resident 267's room , she stated she was in a hurry and forgot. CNA 6 stated she should have washed her hand immediately after taking off her gloves to prevent the spread of germs.
A review of the facility's Policy and Procedure (P&P) titled, Infection Control dated 2/2023, indicated to: Assess sites with dry dressings by gently palpation, Investigate complaints of discomfort. Visually assess sites with transparent dressings daily for redness, swelling, heat, pain, and drainage and document actions and findings, as appropriate.
During a review of the facility's P&P titled Oxygen Administration Mask, Cannula, Catheter dated 2/2023, indicated Oxygen tubing is to be replaced every seven (7) days. Oxygen masks or nasal prongs are to be replaced every seven (7) days.
A review of the facility's P&P titled, Resident Assessment, Skin Management dated 2/2023, indicated, Residents will have a head-to-toe skin evaluation by a licensed nurse at the time of admission. Any skin lesions will be documented on the Initial admission Record. A treatment order will be obtained from the Attending Physician for areas requiring treatment. i.e., surgical wounds, open skin tears, abrasions, lacerations etc. Surgical wound sites will be checked for signs and symptoms of infections until areas have healed. When observed with signs and symptoms of infection, the licensed nurse will be responsible for notifying the resident's physician regarding assessment.
During a review of the facility's policy and procedure (P/P) titled Hand Hygiene updated 12/2022 the P/P indicated the facility promotes safety and quality of care to the residents by reducing the transmission of pathogens within the facility through the practice of hand hygiene .
1.Within a single encounter with a resident , there can be several times when hand hygiene should be performed.
2.World Health Organization (WHO) 5 Moments of Hand Hygiene:
Before patient contact
Before aseptic procedure
After patient contact
After body fluids, secretions contact.
After environment contact

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide one out of eight sampled residents (Resident 15) with meals that accommodated their food preferences.
This deficient practice had the potential to result in decreased meal intake, lead to weight loss and malnutrition.
Findings:
During a review of Resident 15's admission Record (AR), the AR indicated Resident 15 was admitted to the facility on [DATE] with diagnoses of hypertension (high blood pressure), cervical myelopathy (compression of the spinal cord in the neck) and vitamin D deficiency (not enough vitamin D in your body affecting your bones).
During a review of Resident 15's physician order (PO) dated 10/20/23, the PO indicated Resident 15's diet was no added salt regular texture (not cut up or blended).
During a review of Resident 15's Nutrition Evaluation dated 10/20/23, the Nutrition Evaluation indicated Resident 15 did not have any chewing or swallowing problems.
During a review of Resident 15's care plan (CP) dated 10/22/23, the CP indicated Resident 15 diet was changed from regular texture to mechanical soft (designed for people who have trouble chewing and swallowing) due to right arm weakness, not the resident preference. The CP indicated that the facility would honor resident rights to make personal dietary choices and help (set-up) with meals as needed.
During a review of Resident 15's progress notes (PN) dated 10/22/23 at 3:18 p.m., the PN indicated the dietary assistant requested to change Resident 15's diet due to right arm weakness.
During a review of Resident 15's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 10/24/23, the MDS indicated Resident 15 had completely intact cognition (mental process of thinking and understanding) and has no swallowing disorders. The MDS indicated that Resident 15 could eat independently and only needed assistance to set up (open cartons and cut food) at mealtimes.
During a review of Resident 15's speech therapy evaluation (STE) dated 11/8/23, the STE indicated Resident 15 could swallow solids safely and the recommended diet was regular texture.
During an interview on 11/6/23 at 2:52 p.m. with the Speech Therapist (ST), the ST stated she would never downgrade a diet because the resident needed assistance to set up with meals and could not cut up certain foods. The ST stated the resident could lose weight if their diet was downgraded without their request and they didn't eat it.
During a concurrent observation and interview on 11/7/23 at 12:50 p.m. with Resident 15, Resident 15 was observed being served a mechanical soft diet of spaghetti and meatballs by Certified Nurse Assistant (CNA 3). Resident 15 told CNA 3 to take the tray back because the meat was ground like it was chewed before. Resident 15 stated she did not like her meal and often sends her meal trays back to the kitchen and doesn't eat. Resident 15 stated she knows that she lost weight but does not know how much. Resident 15 stated she does not know why her diet is mechanical soft because she has never choked or had any swallowing problems. Resident 15 stated that she felt angry and horrible that her request to change her diet to many staff members went unheard and that there is no reason her food should be served like it had been chewed already because looks disgusting.
During an interview on 11/8/23 at 12:57 p.m. with CNA 3, CNA3 stated Resident 15 was upset and flipped out on her because the meatballs were chopped because she wanted her meatballs were whole. CNA3 stated Resident 15 requested to talk to the dietician because she didn't want a mechanical soft diet.
During an interview on 11/8/23 at 4:45 p.m. with Registered Nurse 2 (RN 2), RN 2 stated she did not ask Resident 15 if she wanted her diet changed. RN 2 stated she was informed by the dietary staff to change Resident 15 diet and got an order to change the diet without asking her. RN 2 stated she should have assessed Resident 15 prior to changing her diet. RN 2 stated Resident 15 diet was changed because she had difficulty cutting her food. RN 2 stated Resident 15 did not have trouble swallowing.
During an interview on 11/9/23 at 12:01 p.m. with the Registered Dietician (RD), the RD stated she has not seen Resident 15 since admission. The RD stated she is not familiar with the resident.
During an interview on 11/9/23 at 2:19 p.m. with the Director of Nurses (DON), the DON stated if a resident diet is changed, and the resident does not like it they should be referred to the Registered Dietician (RD) for diet recommendations. The DON stated if a resident needs assistance to cut their food that is not a reason to change their diet. The DON stated the CNA should help the residents cut their food if they don't have swallowing issues. The DON stated Resident 15 does not have any swallowing issues.
During a review of the facility policy and procedure (P&P) titled, Food Preferences, undated, the P&P indicated that resident's food preferences will be adhered to within reason. The P&P indicated that updating of food preferences will be done as residents' needs change.
During a review of the facility P&P titled Resident Rights dated 2/2023, the P&P indicated the resident has the right to be treated with consideration, respect, and full recognition of his or her dignity and individuality.

Based on observation, interview and record review, the facility failed to ensure staff followed food production recipes and fortified diet (diet to increase caloric intake) guidelines during lunch preparation and tray line observation when:
1.Potatoes and onions prepared for Mechanical soft diet (food texture modified for residents who have chewing or swallowing difficulties) were cut into large pieces and not chopped according to recipe and spreadsheet (food portion and service guide) instruction and mechanical soft diet guidelines.
2.Fortified diets (diet enhanced to increase caloric content) were not prepared and were not served to residents who were on fortified diet.
These failures had the potential to result in decreased caloric intake and lead to undesirable weight loss for 15 residents requiring a fortified diet and increased choking risk for the 30 residents required a mechanical sot diet.
Findings:
1.During a concurrent observation and interview with Cook1 on 11/6/23 at 12:24PM, Cook1 said potatoes and onions are served as side dish. Cook1 said the potatoes served for the residents on mechanical soft diet doesn't have skin and is soft, and the potato for the regular diet is with skin.
During the same observation there were large pieces of onions in the potatoes and onion dish served for the mechanical soft diet. The onions were not fully cooked or translucent, they were hard when pierced with fork. Cook1 agreed that the onions were cut into large pieces, and some were not cooked thoroughly. Cook1 said the onion pieces are large because it was prepared for the regular diet. Cook1 said she used the cooked onions for the regular diet and added them to the potatoes that are for the mechanical soft Diet. [NAME] 1 said she didn't prepare onions separately for the mechanical soft diet. Cook1 said the onions must be chopped into small pieces and cooked until soft for the mechanical soft diet. Cook1 said residents who are on mechanical soft diet have problem chewing and swallowing and big pieces is difficult to eat. Cook1 said she was rushing and forgot to chop onions small.
During an interview and concurrent review of the recipe for potatoes and onions with Registered Dietitian (RD1) on 11/6/23 at 12:45PM, RD1 said the cooks should follow the mechanical soft diet recipe and the recipe indicates the onions should be chopped. RD1 said the recipe asks for chopped onions but it doesn't indicate the size of onions. When asked if the size of the onions is acceptable for residents on the mechanical soft diet, RD1 said the recipe indicated chopped onions and speech therapist approves the menus for texture.
During an interview with Speech Therapist (ST) on 11/6/23 at 2:40pm, ST stated she does not review or approve the menu and diets in the kitchen. ST said she expects the kitchen to prepare food following the menu. ST said when the menu and food production recipe indicates chopped for the mechanical soft diet this means the pieces should be between ¼ to ½ inch size unless it is specified to be finally chopped then it is smaller.
During the same interview and observation of food served on the mechanical soft diet 11/6/23 at 2:40pm, a penny (1 cent which is ¾ inches) was placed next to the onion pieces for size comparison. ST said the onion pieces are larger than the penny and larger than ½ inch. ST also said many residents who are on the mechanical soft diet have chewing and swallowing problems and they will require chopped and soft food. ST said there is always risk for choking with residents on texture modified diets.
A review of the spreadsheet (food portion and serving guide) for 11/6/23 indicated mechanical soft potatoes and onions are served chopped.
A review of the recipe for Potatoes and Onions, indicated for mechanical soft diet, to chop or finely chop the portions needed from regular prepared recipes.
A review of facility Diet Manual titled Mechanical Soft (dated 2022) indicated, intended use to provide a nutritionally adequate diet that requires a reduced amount of mastication .for residents who have limited chewing ability and intact swallowing ability. Vegetables should be soft- cooked and tender in texture. Some cooked vegetables may need to be chopped. Chopped is ¼ inch - ½ inch pieces.
A review of facility Policy titled Menu Planning (dated 2023) indicated, Menus are written for regular and modified diets in compliance with the diet manual, The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, physician's orders.
2.During the tray line observation on 11/6/23 at 12:08pm, residents who were on fortified diet cook2 did not communicate the fortified diet orders written on the meal tickets during tray line for lunch service. A review of resident's tray or meal tickets on the cart indicated the orderesorders for fortified diets. However, Cook2 did not read out loud the fortified diet and Cook1 did not add any additional food items.
During a concurrent interview with Cook1 and Cook2 on 11/6/23 at 12:15pm regarding diet fortification process, Cook1 said I don't have anything special for the resident on fortified diet they get the same food as everyone else. Cook2 said that she does not read the fortified section of the meal tickets or meal cards and does not ask for fortified, because there is nothing special that the residents receive. Cook2 said they all get the same food.
During an interview with Registered Dietitian (RD1) and Dietary Supervisor (DS) on 11/6/23 at 12:40PM ,RD stated that resident on fortified diets receive additional item to increase caloric intake. RD stated that Cook2 should communicate the fortified diets to cook1 during service. DS said that there is a recipe for fortified soup that should be given to residents who are on fortified diet. DS said that this increases calories for resident who need more calories for weight loss.
A review of facility Diet Manual titled Fortified /high calorie diet (dated 1/2022) indicated, this diet is used when additional amounts of protein and or calories are needed. This diet is also used to help prevent weight loss and tissue wasting, this diet includes fortification of two menu items per day. This adds 16grams of protein and 750 additional calories per day. The diet features a super cereal given at the breakfast meal and a super soup at the noon meal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accommodate and evaluate the food preferences for one of eight sampled residents (Resident 71).
This deficient practice had the potential for Resident 71 to have insufficient food intake and significant weight loss.
Findings:
During a review of Resident 71's admission Record (Face sheet), the admission Record indicated Resident 71 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), muscle weakness (lack of muscle strength), and difficulty walking.
During a review of Resident 71's History and Physical (H&P), dated 10/18/2023, the H&P indicated, Resident 71 was alert with episodes of confusion.
During a review of Resident 71's Minimum Data Set (MDS), a comprehensive screening and assessment tool, dated 10/24/2023, the MDS indicated Resident 71 can be understood and can understand others sometimes. Resident 71 was totally dependent on staff for Activities of Daily Living (ADL).
During a review of Resident 71's Care Plan dated 10/19/2023, indicated Resident 71 had potential nutritional problem due to diagnosis dysphagia. The goal was that Resident 71 will maintain adequate nutritional status as evidence by maintaining weight with no sign and symptoms of malnutrition through. Diet was No Added Salt (NAS), puree texture, thin liquids consistency. The facility will honor Resident 71's rights to make personal dietary choices.
During a review of Resident 71's Order Summary Report (OSR) dated 10/19/2023, the OSR indicated diet with no added salt (NAS), puree texture, thin liquids consistency, and family may bring in mechanical soft items for resident.
During a review of Resident 71's Daily Meal Percentage (%) Eaten, dated 10/2023, indicated:
1.
10/19/2023 at 7:30 a.m. 51-75%,
2.
10/19/2023 at 12:00 p.m. 26%-50%
3.
10/19/2023 at 5:30 p.m. 26%-50%
4.
10/23/2023 at 7:30 a.m. 51%-76%
5.
10/23/2023 at 12:00 p.m. 51%-76%
6.
10/23/2023 5:30 p.m. 51%-76%
7.
10/25/2023 at 7:30 a.m. 25%
8.
10/25/2023 at 12:00 p.m. 51%-75%
9.
10/25/2023 at 5:30 p.m. 25%
10.
10/30/2023 at 7:30 a.m. 0%
11.
10/30/2023 at 12:00 p.m. 25%
12.
11/01/2023 at 7:30 a.m. 26%-50%
13.
11/01/2023 at 12:00 p.m. 76%-100%
14.
11/01/2023 at 5:30 p.m. 51%-75%
During a review of Resident 71's Weight Summary, dated 10/18/2023-11/7/2023, indicated:
1.
10/19/2023 128.5 pounds (lbs, unit of weight)
2.
10/23/2023 120.5 lbs
3.
10/29/2023 117 lbs
4.
11/5/023 114.5 lbs
During a concurrent observation and interview on 11/7/2023 at 12:45 p.m. with Resident 71, Resident 71 was observed sitting in wheelchair in the dining room with family member present. Resident 71's lunch tray plate was observed with mushed potato, puree meat and vegetables. Resident 71 only ate the mashed potato from the lunch tray. Resident 71 stated he likes mashed potato but does not like puree vegetables or meat.
During an interview on 11/07/2023 at 1:02 p.m. with Restorative Nurse Assistant (RNA), RNA 1 stated Resident 71 does not like the puree food. RNA 1 stated Resident 71's family brings food from home. RNA 1 stated Registered Dietitian (RD) was aware that Resident 71 does not like puree food and family was allowed to bring food from home.
During an interview on 11/08/23 at 12:01 p.m. with Registered Dietician (RD), the RD stated Resident 71 was not evaluated for a different diet. RD stated was aware that Resident 71's family was bringing food from home. RD stated the resident could have benefited from a mechanical soft diet.
During an interview on 11/08/23 at 3:50 PM with Speech Therapy (ST). ST stated was aware that Resident 71 does not like the puree food. ST stated no mechanical soft diet trials done. ST stated if Resident 71 does not like the puree food, the resident can become malnourished, lose weight, and muscle atrophy (loss of muscle tissue).
During a review of facility's Policy and Procedure (P&P) titled, Nutrition Assessment and Documentation, dated 12/2013, the P&P indicated Observation of the resident during mealtimes. Interview and observation to determine food tolerances, likes, dislikes. Eating ability (chewing or swallowing problems).
During a review of facility's Policy & Procedure titled 'Food Preferences, undated, the P&P indicated Food preferences will be obtained as soon as possible through the initial resident screen. Food preferences can be obtained from the resident, family, or staff members. Updating of food preferences will be done as residents' needs change .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** FACILITY
Based on observation, interview, and record review, the facility failed to ensure
a. that its medication error rate was less than five (5) percent (%) due to four (4) errors observed out of 25 total opportunities (error rate of 16 %). The medication errors were as follows:
1. Resident 44 received both medications carvedilol (a medication that works by slowing down the heart rate and making it easier for your heart to pump blood around your body) 3.125 milligram (mg a unit of measurement of weight) one tablet every twelve hours and nifedipine extended release (a medication used to treat high blood pressure) 90 mg one tablet by mouth daily and Licensed Vocational Nurse (LVN) 6 did not check blood pressure readings and apical pulse (AP- a pulse point on your chest that gives the most accurate reading of your heart rate) before administering the medications.
2. Resident 50 received Digoxin (a medication used to manage and treat heart failure and certain irregular heartbeats) 125 micrograms (mcg a measurement of weight) one tablet by mouth daily and Diltiazem (a medication that relaxes the blood vessels, lower blood pressure, and increases the supply of blood and oxygen to the heart while reducing its workload) 120 mg one tablet twice daily.
3. Resident 72 received calcitonin (a prescription medicine used to treat osteoporosis [fragile and brittle bones] in women ) one spray to both nostrils instead of the right nostril only.
These failures had the potential to result in Residents 44, 50 and 72 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents 44's, 50'S and 72's health and well-being to be negatively impacted.
b. to prevent a significant medication error for one out of eight residents (Resident 131), by not safely administering 11 medications, including Digoxin (medication used to treat heart failure and arrhythmias [abnormal heart rhythm]) as ordered by the physician and leaving the medications at Resident 131's bedside to be administered by a family member.
This failure jeopardized resident safety and increased potential for unintended effects due to medication administration unsupervised by a licensed nurse.
c. ensure the resident was free from significant medication errors for three of three sampled Residents by administering that are scheduled as needed, outside of physician ordered parameters as follows.
1.
Resident 45 received Doxazosin mesylate tablet (medication used to treat high blood pressure) tablet 1 mg by mouth on 9/19/2023, and Resident 45's blood pressure was 107/50 mmhg.
2.
Resident 17 received benazepril HCL 20 mg, by mouth on 10/1/2023 and Resident 17's blood pressure was 92/55 mmhg.
3.
Resident 34 received carvedilol tablet 6.25 mg by mouth on 11/9/2023 with no documented evidence of a physician's order for parameters to check the apical pulse before administering.
This failure had the potential to cause unintended complications from taking the medications, such as hypotension (low blood pressure, dizziness, fainting which leads to falls) and bradycardia (low heart rate ).
Findings:
a.During a review of Resident 44's admission Record, the admission record indicated Resident 44 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including hypertensive heart and chronic kidney disease with heart failure, atrioventricular block (a slow heartbeat that occurs because of a malfunction with the heart's electrical system) and cardiomyopathies (problems with your heart muscle that can make it harder for your heart to pump blood).
During a review of Resident 44's Minimum Data Sheet (MDS- a comprehensive assessment and care planning tool) dated 09/20/2023, the MDS indicated Resident 44 had no cognitive (ability to make decisions daily living) impairment.
During a review of Resident 44's Medication Administration Record (MAR) Nifedipine ER 90 mg was ordered on 08/03/2023 to administer one tablet by mouth daily for hypertension with the following parameters (a fixed limit that establishes how something should be done): hold the medication for systolic blood pressure (SBP a measure of the hearts contractions while it pumps blood) less than 110 millimeters of mercury (mmHg unit of measurement of pressure) or apical pulse below 60 beats per minute.
During a review of Resident 50's admission Record, the admission record indicated Resident 50 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (high blood sugar), atrial fibrillation (an irregular and often very rapid heart rhythm) and heart failure (a condition that develops when your heat doesn't pump enough blood for your body's needs).
During a review of Resident 50's MDS dated [DATE], the MDS indicated Resident 50 had no cognitive impairment.
During a review of Resident 50's MAR Nifedipine ER 90 mg was ordered on 10/10/2023 to administer one tablet by mouth daily for CHF (congestive heart failure) with the following parameters: hold the medication if apical pulse below 60 beats per minute.
During a review of Resident 72's admission Record, the admission record indicated Resident 72 was admitted on [DATE] with diagnoses including essential hypertension (high blood pressure), occlusion and stenosis of left carotid artery (a condition that happens when your carotid artery, the large artery on either side of your neck, becomes blocked), malignant neoplasm of bone (a rapidly growing mass on a bone that can be life threatening).
During a review of Resident 72's MDS dated [DATE], the MDS indicated Resident 72 had no cognitive impairment.
During a review of Resident 72's physicians order dated 10/26/2023, the order indicated to administer Calcitonin Salmon 200 unit/act (unit of measurement) one spray alternating nostrils one time a day on odd days for bone supplement left nostril and one spray on even days for right nostril.
During a medication pass observation on 11/08/2023 at 9:07 a.m., with Licensed Vocational Nurse (LVN) 6, observed LVN 6 administer medications to Resident 50 without checking the identification band prior to giving the medications and did not check both the blood pressure readings and apical pulse prior to giving medications Digoxin 125 mcg one tablet daily and Diltiazem 120 mg one tablet twice daily.
During a medication pass observation on 11/08/2023 at 9:17 a.m., with LVN 6, observed LVN 6 administer medications to Resident 72 without checking identification band prior to giving the medications and administered calcitonin-salmon one spray to both nostrils instead of right nostril only.
During a medication pass observation on 11/08/2023 at 9:46 a.m., with LVN 6, observed LVN 6 administer medications to Resident 44 without checking identification band prior to giving the medications and did not check both the blood pressure readings and apical pulse prior to giving medications carvedilol 3.125 mg one tablet every twelve hours and nifedipine ER 90 mg one tablet by mouth daily.
During an interview on 11/08/2023 at 10:31 a.m., with LVN 4, LVN 4 stated that the apical pulse must be checked first prior to administering the medication or the resident may go to further bradycardia (an abnormally slower than normal heart rate) that can be life-threatening.
During an interview on 11/08/2023 at 10:45 a.m., with LVN 4, LVN 4 stated that if the nasal spray is given to both nostrils instead of one nostril only, as ordered it can lead to an overdose.
During an interview on 11/08/2023 at 12:02 p.m., with LVN 6, LVN 6 stated that prior to giving medications the licensed nurse must check the proper identity by checking the resident's wrist band and or the picture of the resident in the medication administration record to prevent medication error for giving it to the wrong residents' that can result in a life-threatening situation that can lead to coma or death.
b.During a concurrent observation and interview on 11/8/2023 at 12:32 p.m. in Resident 131's room with the Infection Preventionist (IP), 11 medications in two pill cups were observed on the bedside table unattended. Resident 131 stated Licensed Vocational Nurse (LVN 1) had left the medications at the bedside and said it was safe because Resident 131's daughter could help her take the medications.
During a review of Resident 131's admission Record the admission record indicated Resident 131 was admitted to the facility on [DATE], with diagnoses including, sepsis (the body's extreme response to an infection), difficulty walking, muscle weakness (decreased muscle strength), and dysphagia (swallowing difficulties).
During a review of Resident 131's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 11/4/2023, the MDS indicated Resident 131 was alert and oriented and able to make independent decisions about her activities of daily living. The MDS indicated Resident 131 needed assistance when eating and performing oral hygiene.
During a review of Resident 131's Order Summary Report, dated 10/29/2023, the order summary report did not indicate any current order for Resident 131 to self-administer her medications or for her medications to be left at Resident 131's bedside.
During a review of Resident 131's care plans, dated 10/29/2023, there was no specific care plan in the medical record for Resident 131's self-administration of medications.
During a review of Resident 131's Medication Administration Record (MAR) dated 11/1/2023-11/30/2023, the MAR indicated physicians orders for the following medications to be administered at 9 a.m. on 11/8/23:
1.
Norvasc (for high blood pressure) 5 milligrams (mg unit of measurement of weight) by mouth daily
2.
Cardizem LA Extended Release (used for high blood pressure and chest pain) 240 mg by mouth daily.
3.
Vitamin B12 (vitamin supplement) 500 micrograms (mcg unit of measurement of weight) by mouth daily
4.
Digoxin (used to treat heart failure and arrhythmias [abnormal heart rhythm]) 125 mcg by mouth daily.
5.
Iron (used to treat low blood levels) 325 mg by mouth daily.
6.
Fluconazole (used for antifungal infections) 200 mg 2 tablets by mouth daily.
7.
Lasix (diuretic) 40 mg by mouth daily.
8.
Modafinil (used to treat excessive daytime sleepiness) 100 mg 3 tablets by mouth daily.
9.
Multivitamin (vitamin supplement) one tablet by mouth daily
10.
Potassium Chloride (vitamin supplement) 20 milliequivalent (mEq unit of measurement of weight) by mouth daily
10.
Sertraline Hydrochloride (antidepressant) 50 mg by mouth a daily
11.
Spironolactone (used to get rid of excess fluids in the body) 25 mg by mouth daily
12.
Vitamin C (vitamin supplement) 500 mg by mouth daily
13.
Apixaban (blood thinner) 5 mg by mouth twice a day at 9 am and 5 p.m.
During a concurrent observation and interview on 11/8/2023 at 12:30 p.m. with the IP, the IP confirmed there were 11 medications left on Resident 131 bedside table unattended by a nurse. The IP stated medications should not be left at the Resident's bedside unattended. The IP stated Resident 131's daughter was in the room visiting and for supervision, so the medications were safe on the bedside table. The IP stated it was important for Resident 131 to take her medications so she would benefit from taking the medications.
During an interview on 11/8/2023 at 12:36 p.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated he was aware that Resident 131's morning medications were left at the bedside. LVN 1 stated medications should not be left at the bedside because it is unsafe for the resident or someone else could come in and take the medications. LVN 1 stated he gave the medications to Resident 131's daughter to administer to her mother.
During an interview and record review on 11/8/2023 at 4:09 p.m. with LVN 1, LVN 1 stated it is not Resident 131's daughter's job to administer medication, it's the nurse's job. LVN 1 stated the medications were due to be administered at 9 a.m., but Resident 131 was still sleeping so he left the medications at her bedside at 10:00 a.m. LVN 1stated the medications were still at the bedside at 1230 p.m., and past due, when he documented he gave them at 9 a.m. and that was false. LVN 1 stated that it is not a safe practice that he left the medications at the bedside and signed that the medications were given at 9 a.m. LVN 1 stated if a medication is administered late, and the next dose is administered on time, or early the resident could overdose and die. LVN 1 stated if the medications are not administered on time, it should be documented in the medical record and the doctor should be notified
During an interview on 11/9/2023 at 11:01 a.m. with Registered Nurse (RN 1), RN 1 stated if a resident doesn't want to take medications at the scheduled time the nurse should explain the risk and benefits and call the doctor to see if the meds can be given at a different time. RN 1 stated medications should not be left at the bedside because there are a lot of unsafe things that could happen like another resident could take it or the resident could not take the right dose. RN 1 stated the nurse should watch to make sure the resident takes their medications. RN 1 stated digoxin should never be left at the bedside. RN 1 stated medications should be signed at the time it was administered and if given late the correct time should be written. RN 1 stated it is falsification if you put that you gave a medication at a different time on the MAR than when you actually gave the medication.
During an interview on 11/9/2023 at 2:19 p.m. with the Director of Nurses (DON), the DON stated medications cannot be left at the bedside unattended because it's a safety issue and another resident could get the medications and take them. The DON stated if medications are due at 9 a.m., the latest you can give the medications is 10 a.m. The DON stated if the medications are given more than an hour later you need to notify the doctor that they were given late and document the reason. The DON stated it is falsification to document a different time than when you gave the medication. The DON stated a family member cannot administer a resident's medication without a nurse's supervision. The DON stated if a resident takes blood pressure medications without checking the blood pressure first, the resident can become hypotensive (blood pressure gets abnormally low), or any cardiac problem may arise, and they could even die.
c.1. During a review of Resident 45's admission record, the admission record indicated Resident 45 was admitted to the facility on [DATE] with diagnoses of hypertension, muscle weakness and depression ( a medical illness that negatively affects how you feel the way you think and how you act).
During a review of the MDS dated [DATE], the MDS indicated Resident 45 had severely impaired cognition. Resident 45 requires some help with self-care, Substantial/maximal assistance (helper does more than half the effort) with eating and dependent (helper does all the work) with transferring to and from a bed to a chair or wheelchair).
During a review of Resident 45's Order Summary Report, the OSR indicated Resident 45 has an order for doxazosin mesylate 1 mg tablet by mouth at bedtime for hypertension hold for systolic blood pressure (SBP) less than 110 mmHg scheduled at 9:00 p.m.
During a record review of the medication administration record (MAR) dated 9/19/2023 at 9:00 p.m. Resident 45 's recorded blood pressure was 107/50 mmHg, and doxazosin was signed as given.
c.2 During a review of Resident 17's admission record, the admission record indicated Resident 17 was admitted to the facility on [DATE] with diagnoses of hypertension, anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells) and depression.
During a review of Resident's 17's H&P, the H&P indicated Resident 17 decision -making ability varied.
During a review of the MDS, dated [DATE], the MDS indicated Resident 17 requires limited assistance (the resident is highly involved in performing a given activity) ) with bed mobility, eating, personal hygiene and supervision ( oversite ,encouraging and cueing ) with locomotion on the unit.
During a review of the MAR dated 10/1/2023 at 9:00 a.m. Resident 17's recorded blood pressure was 92/55 mmHg and benazepril was signed as given.
c.3 During a review of Resident 34's admission record, the admission record indicated Resident 34 was admitted to the facility on [DATE] with diagnoses of hypertension chronic kidney disease (high blood pressure caused by the narrowing of your arteries that carry blood to your kidneys), muscle weakness, and diabetes (disease where there is too much sugar in the blood).
During a review of Resident 34's OSR, the OSR indicated an order for carvedilol tablet 6.25 mg, give 1 tablet by mouth two times a day for hypertension hold for SBP below 100, the date the order was started on 12/14/2022.
During a record review of the MAR) for carvedilol dated 11/9/2023 there was no parameters given by the prescribing physician for checking Resident 34's apical pulse.
During an interview 11/9/2023 at 11:34 a.m., with RN 1, RN 1 verified doxazosin mesylate 1 mg tablet was signed as given on 9/19/2023 at 9:00 p.m., benazepril tablet 20 mg tablet was signed as given 10/1/2023 at 9:00 a.m. and carvedilol had no parameters for checking the pulse rate. RN stated it is our duties as nurses to get an order to check Residents heart rate. RN stated in dealing with carvedilol it should be standard to monitor a Residents apical pulse and blood pressure before giving the medication. RN 1 stated carvedilol can lower the heart rate and the Resident can experience an abnormally slow heart rate, low blood pressure, dizziness, or the resident could have a fall.
During an interview on 11/9/2023 at 2:02 p.m. with the facility pharmacist, the pharmacist stated for medications that affect blood pressure or heart rate, the physician needs to include parameters for administering the medications, to prevent the resident getting the medication when it is not indicated. The pharmacist stated when giving carvedilol the blood pressure and heart rate must always be monitored that is our policy.
During a review of the facility policy and procedure (P&P) titled Medication Storage undated, the P&P indicated that medications are stored safely, securely, and properly and only accessible to licensed nursing personnels.
During a review of facility's policy and procedure (P&P) titled Medication Administration revised 07/2012, P&P indicated: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Residents are identified before medication is administered. Methods of identification include Checking identification band, If necessary, verifying resident identification with other facility personnel, Allowing a cognitively competent resident to identify self or confirm his/her name.
During a review of the facility P&P titled medication administration policy, the P&P indicated medications are prepared and administered only by a licensed nurse in accordance with written orders of the attending physician. The P&P indicated medications are administered at the time they are prepared. The P&P indicated medications are administered within 60 minutes of the scheduled time (1 hour before or 1 hour after). The P&P indicated if the medication cannot be administered on the scheduled time the license nurse will document in the clinical record. The P&P indicated the resident is always observed after administration to ensure that the dose was completely ingested. The P&P indicated that is a dose of regularly scheduled medication is given at any other time, refused, or withheld than the scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled and an explanatory noted is documented on the record.
During a record review of the facility's P/P titled Medication Administration Policy revised 7/12, the P/P indicated medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorize to do so. 1.Medications are prepared and administer only by a licensed nurse in accordance with written orders of the attending physician. 2. The licensed nurse will read the medication orders against the supply available. If there is an inconsistency between the order and supply, the licensed nurse will verify the order from the chart and clarification of order will be done as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%) due to four (4) errors observed out of 25 total opportunities (error rate of 16 %). The medication errors were as follows:
1. Resident 44 received both medications carvedilol (a medication that works by slowing down your heart rate and making it easier for your heart to pump blood around your body) 3.125 mg (unit of measurement) one tablet every twelve hours and nifedipine ER (a medication that works by affecting the movement of calcium into the cells of the heart and blood vessels) 90 mg one tablet by mouth daily and Licensed Vocational Nurse (LVN) 6 did not check blood pressure readings and apical pulse (AP- a pulse point on your chest that gives the most accurate reading of your heart rate).
2. Resident 50 received medication Digoxin (a medication used to manage and treat heart failure and certain arrhythmias) 125 mcg one tablet by mouth daily.
3. Resident 72 received a medication calcitonin-salmon (a prescription medicine used to treat osteoporosis in women more than 5 years after menopause) one spray to both nostrils instead of right nostril only.
These failures had the potential to result in Residents 44, 50 and 72 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents 44's, 50'S and 72's health and well-being to be negatively impacted.
Findings:
During a review of Resident 44's admission Record (Face Sheet) indicated Resident 44 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including hypertensive hear and chronic kidney disease with heart failure,
atrioventricular block (a slowed heart that occurs because of a malfunction with the heart's electrical system) and cardiomyopathies (problems with your heart muscle that can make it harder for your heart to pump blood).
During a review of Resident 44's Minimum Data Sheet (MDS- a comprehensive assessment and care planning tool) dated 09/20/2023 indicated Resident 44 had no cognitive impairment.
During a review of Resident 44's Medication Administration Record (MAR) Nifedipine ER 90 mg was ordered on 08/03/2023 and to administer this medication with one tablet by mouth daily for hypertension with the following parameters (a fixed limit that establishes how something should be done): hold the medication for SBP (systolic blood pressure) less than 110 mmHg (unit of measurement) or apical pulse below 60 beats per minute.
During a review of Resident 50's admission Record (Face Sheet) indicated Resident 50 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (high blood sugar), atrial fibrillation (an irregular and often very rapid heart rhythm) and heart failure (a condition that develops when your heat doesn't pump enough blood for your body's need).
During a review of Resident 50's MDS dated [DATE] indicated Resident 50 had no cognitive impairment.
During a review of Resident 50's MAR Nifedipine ER 90 mg was ordered on 10/10/2023 and to administer this medication with one tablet by mouth daily for congestive heart failure( CHF- a serious condition in which the heart doesn't pump blood as efficiently as it should) with the following parameters: hold the medication apical pulse below 60 beats per minute.
During a review of Resident 72's admission Record indicated Resident 72 was admitted on [DATE] with diagnoses including essential hypertension (high blood pressure), occlusion and stenosis of left carotid artery (a condition that happens when your carotid artery, the large artery on either side of your neck, becomes blocked), malignant neoplasm of bone (bone tumor that can occur almost at any age).
During a review of Resident 72's MDS dated [DATE] indicated Resident 72 had no cognitive impairment.
During a review of Resident 72's physicians order dated 10/26/2023 indicated to administer Calcitonin Salmon 200 unit/act (unit of measurement) one spray alternating nostrils one time a day on odd days for bone supplement left nostril and one spray on even days for right nostril.
During a medication pass observation on 11/08/2023 at 09:07 a.m., with Licensed Vocational Nurse (LVN) 6, observed LVN 6 administer medications to Resident 50 without checking identification band prior to giving the medications and did not check both the blood pressure readings and apical pulse prior to giving medications. LVN 6 administered Digoxin (a medication used to manage and treat heart failure and certain arrhythmias) 125 mcg (unit of measurement) one tablet daily and Diltiazem (a medication that relaxes the blood vessels, lower blood pressure, and increases the supply of blood and oxygen to the heart while reducing its workload)120 mg one tablet twice daily which is part of the order.
During a medication pass observation ON 11/08/2023 at 09:17 a.m., with LVN 6, observed LVN 6 administer medications to Resident 72 without checking identification band prior to giving the medications and administered calcitonin-salmon one spray to both nostrils instead of right nostril only.
During a medication pass observation ON 11/08/2023 at 09:46 a.m., with LVN 6, observed LVN 6 administer medications to Resident 44 without checking identification band prior to giving the medications and did not check both the blood pressure readings and apical pulse prior to giving medications carvedilol 3.125 mg one tablet every twelve hours and nifedipine ER (a medication that works by affecting the movement of calcium into the cells of the heart and blood vessels) 90 mg one tablet by mouth daily.
During an interview on 11/08/2023 at 10:31 a.m., with LVN 4 stated that it is not a good practice to give medications without checking residents' proper identity because of the possibility of giving the medications to the wrong residents that can lead to medication error and possibly life threatening as a result. LVN 4 stated that apical pulse must be check first prior to giving the medication before resident will go to further bradycardia (a slower than normal heart rate) that can be life-threatening.
During an interview on 11/08/2023 at 10:45 a.m., with LVN 4 stated that if the nasal spray is given to both nostrils instead of one nostril only as ordered it can lead to overdose.
During an interview on 11/08/2023 at 12:02 p.m., with LVN 6 , LVN6 stated that prior to giving medications the licensed nurse must check the proper identity by checking the resident wrist band and or the picture of the resident in the medication administration record to prevent medication error for giving it to the wrong residents' that can result to a life-threatening situation that can lead to coma or death.
During a review of facility's policy and procedure (P&P) titled Medication Administration revised 07/2012 indicated: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Residents are identified before medication is administered. Methods of identification include Checking identification band, If necessary, verifying resident identification with other facility personnel, Allowing a cognitively competent resident to identify self or confirm his/her name.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to treat one of two sampled residents (Resident 40) with a diagnosis and verbalizations of depression.
This deficient practice resulted in Resident 40 not receiving the proper assessment, necessary treatment and resources for her diagnosis of depression.
During a review of Resident 40's admission record, the admission record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses including bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to maniac highs), depression (a mood disorder that causes persistent feelings of sadness and loss of interests in activities such as sleeping, and eating) anxiety (condition that causes nervousness, worry, and dread), dementia (impaired ability to think or make decisions accompanied by behaviors such as agitation and depression), and cataracts (a condition that causes cloudy, blurry vision, double vision, and sensitivity to light).
During a review of Resident 40's Minimal Data Set (MDS a standardized assessment and care screening tool), dated 7/20/2023, the MDS indicated Resident 40 was exhibiting signs and symptoms of depression, hopelessness difficulty staying asleep, feeling tired, poor appetite, trouble concentrating, feeling bad about herself and moving or speaking slowly. The MDS indicated Resident 40 had active diagnoses of depression, and bipolar.
During a review of Resident 40's MDS dated [DATE], the MDS indicated Resident 40's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills were intact. The MDS indicated Resident 40 was exhibiting symptoms of feeling depressed and hopeless and feeling tired or having little energy for seven to 11 days over the last two weeks. The MDS indicated Resident 40 always felt lonely or isolated from those around her. The MDS indicated Resident 40 required supervision for most of her activities of daily living (ADL's: toileting, dressing, and personal hygiene). The MDS indicated active Diagnoses for Resident 40 included diagnoses of depression, anxiety, and bipolar. The MDS indicated Resident 40 used a walker and wheelchair for mobility and had no impairments on both the upper and lower extremities (arms and legs). The MDS's Medications section indicated Resident 40 was not taking antidepressant medications.
During a review of Resident 40's untitled Care Plan (CP) initiated on 4/28/2023, the CP indicated Resident 40 had a potential for mood problems related to diagnoses of bipolar disorder. The CP goal indicated Resident 40 will have an improved mood state (happier, calmer appearance, no signs and symptoms of depression, anxiety or sadness with a revised date of 10/26/2023. The CP intervention indicated for Resident 40 to have behavioral health consults as needed, encourage to express feelings, and monitor/record mood to determine if problems seem to be related to external causes (medications, treatments, concern over diagnosis).
During a review of the Physician's Order Summary Report dated 11/8/2023, the Physician Order Summary Report indicated Resident 40 had an active order dated 1/21/2022 for psychiatric consult (a meeting to discuss the type of treatment needed to meet mental health goals) related to depression manifested by verbalization of sadness on 1/21/2022.
During a concurrent interview and record review of the Progress Note and Medication Administration Record (MAR: an electrical document that reports the drugs administered) on 11/8/2023 at 3:40 p.m. with Licensed Vocational Nurse 4 (LVN) 4), LVN 4 stated Resident 40 got shingles (a painful rash with blisters that causes shooting pain on one side of the body caused by a viral infection that is contagious), and always verbalized how she is stuck at the facility and had no home go back to. LVN 4 stated on 7/12/2023, the progress note indicated Resident 40 felt off (not feel okay or normal self). LVN 4 stated if the resident is feeling sad, a Change of Condition (COC a detailed report of the resident's deviation from their normal state of being) would be initiated. LVN 4 stated not addressing the resident's depression can affect their overall health, rehabilitation potential, nutritional intake, and sleep.
During a review of the Psychologist's notes dated 9/25/2023, the psychologist's notes indicated Resident 40 had mild depression and shared emotions and cognitions regarding being at the facility. The note indicated Resident 40 had adjustment difficulties and social isolation and was coached regarding coping skills to increase resilience. Additionally, the note indicated Resident 40 continued to share depression related to issues that were discussed (being at the facility).
During an interview on 11/6/2023 at 10:40 a.m. with Resident 40, Resident 40 stated she had been at the facility for two years and was waiting to get her cataract eye surgery as it was delayed due to the shingles she had. Resident 40 stated she had told the nurses, that she was feeling depressed but no one did anything about it.
During a concurrent interview and record review on 11/8/2023 at 12:43 p.m. with the Assistant Director of Nursing (ADON), The ADON stated Resident 40 was not taking any antidepressant medications.
During a review of the Interdisciplinary Team (IDT Resident's health care team consisting of various specialties) care plan dated 10/19/2023, the activity plan of care section of the IDT care plan indicated Resident 40 refuses most invites to group activities and that Resident 40 had stated during the quarterly meeting she had not been feeling well. The Social Service (SS) section of the IDT care plan indicated Resident 40 had a history of depression, bipolar disorder, and dementia and SS will provide support as needed.
During an interview on 11/9/2023 at 9:53 a.m. with Resident 40, Resident 40 was sitting in her wheelchair watching a show and appeared to be a little disheveled. Resident 40 stated she does not go to activities. Resident 40 stated she never got to talk to a psychiatrist. Resident 40 stated she can get really depressed, excited, and then get depressed again. Resident 40 stated she has been feeling depressed for a while. Resident 40 stated she had shingles and was isolated (having minimal contact with others), and while she was taking Gabapentin (Neurontin: used to treat nerve pain and used off-label [other than the indication the medication was approved for] in psychiatry to treat patients with treatment-resistance mood disorders) for her nerve pain, which was a medication that made her feel better enough that she went to the dining room and played bingo. Resident 40 stated ever since gabapentin was removed, she had been feeling down and needs some medication for depression. Resident 40 stated that she had lost her home and her seven-year-old dog had to be adopted out because she could no longer take care of it. Resident 40 was visibly emotional as her eyes started to tear up and her voice started to crack, and stated she had nothing to go back to. Resident 40 stated all of her belongings were given to her neighbors. Resident 40 stated she has a hard time going to sleep and slept better when she had the Gabapentin. Resident 40 stated depression is a terrible feeling that you always want to cry, and thinking about her dog makes her sadder.
During an interview on 11/9/2023 at 11:37 a.m. with Activities Director (AD), the AD stated there are activities five days a week. The AD stated she keeps asking Resident 40 to come to activities but Resident 40 does not want to go stating she was not feeling well. The AD stated they had an IDT meeting and noted Resident 40 was still not up to participating in activities.
The AD stated when the staff ask Resident 40 if they can call her son, Resident 40 does not want to bother him. The AD stated Resident 40 has not been attending activities for about five months. The AD stated she has conversations, talks to Resident 40 every day and Resident 40 always states she does not feel good.
During an interview on 11/9/2023 at 2:26 p.m. with Resident 40 and the MD, Resident 40 stated before getting shingles, she was doing great, but after that she was feeling depressed. The MD stated this was the first time he had heard about Resident 40's mood. Resident 40 stated when she was on Gabapentin for her nerve pain from shingles, she remembers feeling a lot better, but she started feeling anxious and depressed when she stopped taking it. Resident 40 stated her situation was making her sad as she lost everything. MD stated he would request a psychiatric consult regarding Resident 40's verbalization of sadness. MD stated if he knew how Resident 40 was feeling he would have done something sooner.
During a review of the facility's P&P titled Abuse: Prevention of and Prohibition Against: Freedom from Abuse, Neglect, Exploitation revised on 10/2022, the P&P indicated neglect is 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. Assuring that residents are free from neglect by having the structures and processes to provide needed care and services to all residents .completion of a Facility Assessment to determine what resources are necessary to care for its residents competently.
During a review of the facility's P&P titled Behavioral Health revised on 2/2023, the P&P indicated it is the policy of this facility to provide residents with necessary behavioral health care and services to attain or maintain in the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes the prevention and treatment of mental and substance use disorders. Highest practicable physical, mental, and psychosocial well-being is defined as the highest possible level of functioning and well-being .highest practicable is determined through the comprehensive resident assessment and by recognizing competently and thoroughly address the physical, mental, or psychosocial needs of the individual. The Social Service designee will also meet with resident and/or resident representative and attempt to identify possible psychosocial issues and needs that may be causing the behaviors or having an impact on resident's function, mood, and cognition.
During a review of the facility's P&P titled Resident Assessment: Comprehensive Assessment revised on 2/2023, the P&P indicated the assessment shall include at least the following: mood and behavior patterns, psychosocial well-being, and documentation of participation in assessment. The assessment process shall include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts.
During a review of the facility's P&P titled Resident Rights revised on 2/2023, the P&P indicated the resident has the right to be treated with consideration, respect, and full recognition of his or her dignity and individuality and to be informed of any accident involving Resident resulting in injury or requiring physician intervention, any significant change in Resident's condition, or need to alter treatment significantly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of eight sample residents (Resident 70) with a history of urinary retention (a sudden inability to urinate) was provided services to meet the resident needs and make a necessary appointment to see an urologist ( a doctor who specializes in the study or treatment of the function and disorders of the urinary system) as ordered by the physician.
This failure put Resident 70 at risk for further urinary retention and had the potential to lead to further urinary complications like urinary tract infection (when bacteria enter the body and infects the urinary tract), benign prostate hypertrophy (enlarged prostate [ the top portion of the tube that drains urine from the bladder]), fever and pain.
Findings:
During an observation on 11/6/23 at 11:00 a.m., Resident 70 was observed sitting in a wheelchair in his room, with a foley catheter (medical device that helps drain urine from your bladder), draining yellow colored urine attached to the wheelchair.
During a review of Resident 70's admission Record (AR) dated 10/3/23, the AR indicated Resident 70 was admitted to the facility with diagnoses of retention of urine, history of falls and chronic kidney disease (condition in which the kidneys are damaged).
During a review of Resident 70's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 10/12/23, the MDS indicated that resident 70 had completely intact cognition (mental process of thinking and understanding). The MDS indicated Resident 70 had an indwelling catheter (catheter that stays in place to drain urine) and an active diagnosis of urinary retention.
During a review of Resident 70's General Acute Care Hospital (GACH) discharge summary (DS) dated 10/3/23, the DS indicated Resident 70 was discharge from GACH on 10/3/23 to the facility. The DS indicated that Resident 70 had urinary retention on 9/29/23 and that multiple foley catheter insertion attempts were made to relieve the urinary retention. The DS indicated a Urologist was consulted and placed a coude catheter (a curved tip catheter that is used when regular catheters are not easily inserted or has a blockage to drain urine). The DS indicated that Resident 70 was discharged with the coude catheter and needed to follow up as an outpatient with urology for urine retention management.
During a review of Resident 70's DS dated 10/3/23, the DS indicated that the facility should make a urology appointment as soon as possible for a visit in one week for Resident 70 for the indwelling foley.
During a review of Resident 70's progress note (PN) dated 10/24/23 at 10:10 a.m. (21 days after Resident 70 was discharged from GACH), the PN indicated that the urology office called the facility to get insurance information for Resident 70 to receive a urology appointment.
During a review of Resident 70's PN dated 11/8/23 at 10:02 a.m., the PN indicated to leave the foley catheter indwelling in Resident 70 until he is seen by the urologist.
During a review of Resident 70's OS dated 11/8/23 at 1:35 p.m., the OS indicated Resident 70 appointment with urology was changed to 12/21/23 at 8 a.m.
During an interview on 11/6/23 at 2:03 p.m. with Resident 70, Resident 70 stated he had the foley catheter in since he left the hospital. Resident 70 stated he was not able to urinate at the hospital.
During a concurrent interview and record review on 11/9/23 at 11:01 a.m. with Registered Nurse 1 (RN1), RN 1 stated Resident 70 was discharged to the facility on [DATE] with a diagnosis of urinary retention and had discharge orders to follow up with urology in one week. RN 1 stated she contacted the Urology office on 10/24/23. RN 1 stated the appointment should have been made sooner. RN 1 stated it is the primary responsibility of nursing to make follow up appointments and it is important to have the residents checked with their current condition. RN 1 stated is the follow up appointments are not done; the right treatment isn't given to the resident and Resident 70 urinary retention could get worse. RN 1 stated is hard to do everything on the job and make appointments.
During an interview on 11/9/23 at 6:02 p.m. with the Director of Nurses (DON), the DON stated if the resident has a follow up appointment, it is nursing responsibility to make sure the appointment is made. The DON stated if the follow up appointment stated to follow up in one week, the facility should get an appointment in one week. The DON stated nursing should have followed up right away for the appointment.
During a review of the facility job description (JD) for RN dated 12/17/21, the JD indicated the essential duties and responsibilities for the RN is to initiate requests for consultation and referral.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to review and revise the comprehensive care plan for one of eight sampled residents (Resident 1) to address decreased physical mobility and weakness when Restorative Nursing Aide services (RNA, nursing program that uses restorative nursing aides to help residents maintain their function and joint mobility) were discontinued.
This deficient practice had the potential to negatively impact the provision of necessary care, treatment, and services for Resident 1 and cause a decline range of motion (ROM, full movement potential of a joint), contracture (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) development, and overall decline in functional ability.
Findings:
During a record review of Resident 1's admission record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including aphasia (loss of ability to understand or express speech, caused by brain damage), rheumatoid arthritis (chronic autoimmune inflammatory disease that affects the joints) and dementia (decline in mental ability severe enough to interfere with daily life).
During a record review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment and care-screening tool) dated 9/4/2023 indicated the resident had impaired vision, difficulty hearing, and severely impaired cognition (ability to think,
understand, learn, and remember). The MDS indicated Resident 1 required extensive assistance for bed mobility (moving in bed to and from different positions such as side to side), dressing, eating, toilet use and personal hygiene. The MDS indicated Resident 1 had functional limitations in range of motion (full movement potential of a joint) of both arms (shoulder, elbow, wrist, hand) and both legs (hip, knee, ankle, foot).
During a record review of Resident 1's Order Summary Report dated 10/4/2023 indicated to discontinue the RNA program for PROM exercises to both arms and both legs.
During a record review of Resident 1's care plan initiated and revised on 9/8/2023 indicated Resident 1 had limited physical mobility due to weakness with a goal of maintaining the current level of mobility for both arms and both legs. The intervention of the care plan was for RNA to perform passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to Resident 1's both arms and both legs as tolerated, every day, five times a week.
During an observation on 11/6/2023 at 11:00 am, in the resident's room, Resident 1 was lying in bed with both knees bent and rotated to the left side of the body. Minimal movement was observed in both legs. Resident 1 was unable to fully open and close both hands and slowly bent the right elbow to touch the mouth. Resident 1 reached across the body with the right arm to lift the left arm and due to pain Resident 1 unable to lift left arm. Certified Nursing Assistant 5 (CNA 5) and a student nurse pulled Resident 1 up in bed and repositioned the resident for comfort.
During an interview on 11/6/2023 at 11:26 am, CNA 5 stated Resident 1 was dependent in mobility. CNA 5 stated Resident 1 had contractures on the left arm and left leg and did not move both arms and both legs well.
During an interview and record review of Resident 1's care plan and Order Summary Report on 11/9/2023 at 9:55 am, the Minimum Data Set Coordinator (MDSC) confirmed Resident 1's care plan to address limited physical mobility and weakness was inaccurate and not revised. The MDSC confirmed Resident 1 was not receiving RNA services and the RNA orders were discontinued on 10/4/2023. The MDSC stated there were no other interventions in place to address Resident 1's decreased physical mobility and weakness. The MDSC stated the interdisciplinary team should have re-assessed Resident 1 when RNA was discontinued, checked to see if the goal was still appropriate, and created other interventions if appropriate to address Resident 1's decreased mobility and weakness since RNA was the only intervention listed on the care plan. The MDSC stated the purpose of the care plan was to identify the resident's risks and problems and provide a plan of care and interventions for nursing to implement to address the identified issues. The MDSC stated Resident 1's care plan should have been revised when the physician discontinued the RNA order. The MDSC stated it was important for care plans to be accurate and up to date to ensure the residents received the correct and most current treatment and interventions.
During an interview on 11/9/2023 at 10:57 am, the Director of Nursing (DON) stated the purpose of the care plan was to identify the resident's goals, concerns, and problems and create interventions to address those issues to ensure the appropriate care was provided. The DON stated the care plan should be updated for any change of condition, change in a physician's order, upon discovery of any new concern, quarterly, and as needed. The DON stated it was important for care plans to be accurate and up to date to ensure staff know how to provide the appropriate care to the residents.
A review of the facility's Policy and Procedure (P/P) revised 1/2023, titled Comprehensive Resident Centered Care Plan indicated the resident's comprehensive care plan would include the minimum healthcare information necessary to properly care for a resident including physician's orders and therapy services. The P/P indicated the comprehensive care plan would be reviewed and/or revised by the Interdisciplinary Team (IDT) after each assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility's interdisciplinary team (IDT), a coordinated group of experts from several different fields who work together, failed to ensure one of eight residents (Resident 385) was allowed to keep medications at the bedside without a physician's order and without being assessed to determine if the resident was capable to self-administer medications.
These deficient practices placed Resident 385 at risk for medication errors and had the potential for unsafe medication administration for other residents.
Findings:
During a concurrent observation and interview on [DATE] at 11:54 a.m. with Resident 385 in the resident's room, there was a bottle of Refresh (a medication solution applied to the eyes for dryness) eyedrops at Resident 385's bedside table. Resident 385 stated the eyedrops were used when needed and were independently administered.
During an interview on [DATE] at 12:03 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated there should be a physician order for Resident 385 to self-administer medications at bedside. LVN 3 stated eye drops should not be in the resident room. LVN 3 stated medications in the resident room is a safety risk. Resident 385 could administer excessive dose of medication or the medication can be expired.
During an interview on [DATE] at 2:19 p.m. with Director of Nursing (DON), the DON stated residents can self-administer medications if they are first assessed by the Interdisciplinary Team (IDT), and needed a physician order. The DON stated if the assessment was not done, and physician order was not obtained the medication cannot be left at the bedside. DON stated medications cannot be left at the bedside, because it is a safety issue, and another resident could get a hold of the medication and take the medications.
During a review of Resident 385's admission Record (Facesheet), the admission Record indicated Resident 385's was admitted to the facility on [DATE], with diagnoses including hypertensive heart disease (high blood pressure), difficulty walking, and dysphagia (difficulty swallowing).
During a review of Resident 385's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 385 was alert and had the capacity to make decisions for herself.
During a review of Resident 385's Minimum Data Set (MDS), a standardized assessment and care screening tool), dated [DATE], the MDS indicated, Resident 385 was alert and oriented and able to make independent decisions about her activities of daily living.
During a review of Resident 385's Electronic Medical Record (EMR) there was no documentation to indicate Resident 385 was assessed by the IDT to determine if the resident was a candidate to self-administer medication and did not indicate there was physician order for Resident 385 to have Refresh eyedrops at the bedside.
During a review of facility's policy and procedure (P&P) titled, Self-administration of medication, undated, indicated Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the facility's interdisciplinary team has determined that the practice would be safe.